Volume 71, no. 11 November 2015
The phrase “Peak Oil”—forgotten since the shale revolution—implies that after the pinnacle, it is all downhill. We’ll either slide backward, into medieval sources of energy—sunlight, wind, and human muscle, or take a new path. More than 100 nuclear power reactors will start up in the next decade—in China. For a $1 trillion investment, China expects to have 400 new reactors by 2050. What about America?
At the October Casey Research Summit in Tucson, there were a number of sessions on how to move capital out of the U.S., while it is still possible. An entrepreneur might still succeed here—as by investing in junkyards. Having spent future income on a new car a few years ago, people will now have to keep it running. If you can buy a house at auction for 25% of the defaulted mortgage, you can profit by renting to a former homeowner.
American dominance is threatened from many sides: Russia, China, Islamists, and, arguably, American “progressives.” Deep in debt, the U.S. government’s main asset is its taxing authority.
Peak Capitalism?
Simon Black writes that the U.S. Federal Reserve has engineered the equivalent of a neutron star, whose gravity is so powerful it has collapsed the yields of just about every financial asset on the planet. Central banks of other nations are competing fiercely to outdo the others’ destructive interest rate policies, until each of them has produced its own neutron star of monetary policy. “What message does it send to markets that your economy is too fragile to raise interest rates by even a tiny 0.25%?” he asks. “And what do you get when neutron stars collide? A black hole of finance, brought to you by the very central bankers who were charged with maintaining stability” (http://tinyurl.com/p454tcq).
There are ominous signs of peak employment in the U.S., despite deceptive 5.1% unemployment (http://tinyurl.com/qal7u56).
Economic indicators are also dismal worldwide. Industrial bellwether Caterpillar has shown 34 consecutive months of declining global sales. It has zero orders for locomotives next year.
Or Peak Socialism?
The popularity of Democrat Presidential candidate Bernie Sanders, an avowed socialist, who promised $42 billion in give-aways per minute ($1 trillion total) at the first Democrat debate, suggests that the U.S. may at last fully capitulate to Marxism.
There are signs that we are running out of other people’s money, yet the hemorrhage continues, with a huge chunk of tax dollars—including one in three dollars for earned income tax credits—going “straight into the pockets of crooks,” writes Mike “Mish” Shedlock. According to the Government Accountability Office (GAO), the feds have made $1 trillion in fraudulent payments since 2003 (http://tinyurl.com/nqskouz).
Peak ObamaCare. Despite Administration claims that “it’s working,” HHS Secretary Sylvia Burwell said it would be “challenging” for the exchanges to enroll 10 million people, only a quarter of those eligible for subsidies. Enrollment may peak at 12 million, half of the Congressional Budget Office’s 2010 estimate, writes Avik Roy (http://tinyurl.com/p6uynos).
Insurers enrolled in the Affordable Care Act’s (ACA) risk corridor program may receive only 13% of the money they requested (Wash Post 10/2/15, http://tinyurl.com/oxq6a9u).
Only 13 of 23 ACA co-ops remain. The ten that have failed put $1 billion in government loans at risk and left 500,000 without coverage (NYT 10/16/15, http://tinyurl.com/nqwpov8).
A total repeal of ACA would cut federal spending by $1.7 trillion, said CBO (http://tinyurl.com/pgud6mp).
Peak Entitlements. Senior entitlements are the biggest expense of the federal government, nearing $1 trillion annually and consuming one-third of all tax revenues. The government reduces the burden by fudging numbers used to calculate the cost-of-living (COLA) adjustment (http://tinyurl.com/o33d55k). Some 30% of beneficiaries face a 50% increase in Part B premiums.
As John Goodman explains, the least important but most reported part of the Social Security/Medicare Trustees’ report is the date on which the “Trust Funds” are projected to run dry. Since 2009, outgo has exceeded revenue (not counting “interest” on nonexistent funds) in Social Security retiree, disability, and Medicare programs. If you don’t assume that cuts in spending are sustainable, the unfunded liabilities reach $100 trillion (Forbes 8/7/15, http://tinyurl.com/nd6wgad).
In the age of “peak debt, peak doubt, and peak double-down” (http://tinyurl.com/poc668o), is it time to consider “the road not taken” to constitutional liberty—and the end of legal plunder, socialism, and crony capitalism?
Needed: a Copernican Revolution
In 1943, Nicolaus Copernicus sparked a radical shift in humanity’s view of the universe by showing that the earth is not the center of the universe. Italian Prime Minister Matteo Renzi has called for a Copernican change in the Italian government-centric tax code, writes Simon Black. We need “a complete reset to start thinking that productive people, capital, and business are the real sources of wealth and progress” (http://tinyurl.com/osj6qld).
Joseph Sobran observes that this revolution was retarded for centuries, not by the ignorant but by Europe’s most learned men, who relied on Ptolemy and Aristotle (http://tinyurl.com/nrlygxh).
Beware of Progressive Nobel-prizewinning economists.
Flashback: Divorced from History
Charles Courtney writes: “Our age is the epitome of modernism, the total rejection of anything a keen study of the historical record has to teach.” He notes that the U.S. has been called the Land of the Applied Enlightenment, and that the Enlightenment ushered in Napoleon Bonaparte. He quotes Charles Schorske in Fin-de-Siècle Vienna (1979):
As early as the eighteenth century, the word “modern” acquired something of the ring of a war cry, but then only as an antithesis of “ancient”—implying contrast with classical antiquity. In the last one hundred years, however, “modern” has come to distinguish our perception of our lives and times from all that has gone before, from history as a whole, as such. Modern architecture, modern music, modern philosophy, modern science—all these define themselves not out of the past, indeed scarcely against the past, but in independence of the past. The modern mind has been growing indifferent to history because history, conceived as a continuous nourishing tradition, has become useless to it.
Courtney also reminds us of the danger in trying to create our own world. “The writers of the Federalist papers constantly emphasized that reason may mislead.” He quotes Friedrich Hayek’s The Use of Knowledge in Society (1945):
As Alfred Whitehead has said… “It is a profoundly erroneous truism…that we should cultivate the habit of thinking what we are doing. The precise opposite is the case. Civilization advances by extending the number of important operations which we can perform without thinking about them.” This is of profound significance in the social field. We make constant use of formulas, symbols, and rules…we do not understand and through the use of which we avail ourselves of the assistance of knowledge which individually we do not possess. We have…[built] upon habits and institutions which have proved successful in their own sphere and which have in turn become the foundation of [our] civilization.
How to Make Expertise Irrelevant
Rocky Bilhartz, M.D., describes the following experiment: flash images of chess pieces from an obscure game on a screen, and ask a grandmaster and an amateur to reconstruct the game on a blank board. From a five-second view, the grandmaster can accurately reconstruct the scenario. The amateur struggles, even after a 15-minute view. But if the images depict pieces in places they could not be in a real game (e.g. two red bishops), the grandmaster’s advantage vanishes. He is not necessarily better at memorizing randomness, but has a deep understanding of the game.
In medicine, “grandmasters are quitting the game or being forced out. Prohibited from doing this. Regulated from doing that. To the grandmaster, the game doesn’t even make sense anymore. Scenarios that should never exist have become the status quo.” Forced implementation of unproved electronic health records (EHRs). Bureaucratic coding schemes like ICD-10. “Patient safety” organizations. Third-party payers. Rules are being imposed from above by conflicted entities with no understanding of the game (http://bilhartzmd.com/?p=2471).
This Time Will Be Different
In 1789 it was recognized that France had unpayable debts. Although fiat money had failed catastrophically many times before, the money-printing [now called “quantitative easing”] faction won, stating that France, being now a constitutional republic controlled by enlightened, patriotic people, would not repeat the mistakes of the past. Even respected elder statesman Mirabeau, who had called the issuance of Assignats “a loan to an armed robber,” was persuaded by the argument of a stronger economy, writes Michael Lebowitz. In his 1896 pamphlet, “Fiat Money Inflation in France,” Andrew Dickson White discussed how “exceedingly difficult it is stopping a nation once in the full tide of a depreciating currency.” Eventually, “commerce was dead; betting took its place.” The resulting poverty and despair helped trigger the French Revolution (http://tinyurl.com/nbqpn5o).
Washington HOD Approves MOC Choice
The Washington State Medical Association House of Delegates passed a Resolution proposed by AAPS member Ken Lee, M.D., to “support alternative pathways for board recertification (i.e. NBPAS [National Board of Physicians and Surgeons]) and maintenance of certification” and to “propose this resolution to the AMA for consideration.” Dr. Lee had to extract his Resolution from committee for an open floor debate. Academic physicians opposed it, but younger members wore red “stop MOC” badges, and Dr. Lee won by a 66% majority.
Some Boards Modifying MOC
In response to physician pressure, the American Board of Anesthesiology is planning to replace its 10-year recertification exam with weekly on-line quizzes, for the same cost, $2,100 (Washington Post 9/9/15, http://tinyurl.com/oec5rsr).
Five Hopeful Trends
Tired of “chronicling the decline” of medicine into increasing centralization and reduced choice, Michel Accad, M.D., has identified five promising developments: direct patient care; cost-sharing ministries; medical tourism; the MOC rebellion; and social media, sharing items of professional interest with colleagues around the globe. Physicians need to encourage each other and support anyone who is doing the right thing, Dr. Accad writes (http://alertandoriented.com 10/8/15).
AAPS Calendar
Jan 29, 2016. Thrive, Not Just Survive XXIII
Jan 30, 2016. Board of Directors, Orlando, FL
Sep 22-24, 2016. 73rd annual meeting, Oklahoma City, OK
ACTION OF THE MONTH
Each day do something to send the message of freedom. Talk to a colleague, share and re-tweet messages, give out literature, write to editors or officials. Sign up for alerts at http://aapsonline.org.
War on Cash-Paying Patients
Globally, governments and central bankers are trying to eliminate cash, partly because with effectively negative interest rates, more people try to avoid banks. There is always a noble pretext, and in Wisconsin it is to get rid of “pill mills.”
Called to our attention by an AAPS member, Assembly Bill 366 contains an overly broad definition of “pain clinic,” which would even include facilities that never prescribe controlled substances. It denies patients the right to pay for their own legitimate medical care. Insured patients may only pay deductibles and coinsurance—care is restricted to what the third-party allows. Uninsured patients may pay for services, but not with cash. Patients who have no credit and no checking account cannot pay—everyone has to use a financial institution. Physicians have to take the risk, not only of nonpayment, but of incurring bank charges for bad checks. See AAPS alert (http://tinyurl.com/pequusg), and watch for similar legislation in your state.
Dred Scott Redux
In 1857, the U.S. Supreme Court issued a decision in the Dred Scott case, affirming the right of slave owners to take their slaves into the Western territories. The Supreme Court of the State of Wisconsin, however, refused to file the mandates requiring people to return fugitive slaves to their owners. It opined:
“The last hope of free, representative and responsible government rests upon the state sovereignties and fidelity of state officers to their double allegiance, to the state and federal government” (WND 10/4/15, http://tinyurl.com/q3ls73h).
Liberty Council quotes from this opinion in a brief supporting a case filed by several probate judges in Alabama asking the state Supreme Court to issue a protective order allowing them to exercise their right to decline to issue same-sex marriage licenses. Same-sex marriage is contrary to the Alabama State Constitution and to the expressed will of 81% of Alabama voters.
In an Oct 5 filing (http://tinyurl.com/nlxjp6b), Judge John Enslen suggested that the issue could be resolved by having an agency of the federal government issue licenses that were contrary to state law. He questioned whether the federal government could force states to issue other types of licenses, such as for “those who intend to acquire explosive materials” (WND 10/10/15, http://tinyurl.com/qh6kd5z).
Criminalizing Dissent
Sabrina Hout, a French city councilor of Islamic faith, was given a suspended sentence of 5 months in prison and must pay 2,400 euro to a lesbian couple she refused to marry and to several advocacy organizations who supported them. A few French mayors who oppose same-sex marriage have backed down under threat of criminal prosecution and administrative persecution (http://tinyurl.com/pevvfg5).
Kentucky county clerk Kim Davis was actually jailed, without a jury verdict. At a Harvard Law School meeting, Justice Anthony Kennedy did not say what should be done to dissenters, but suggested they should resign. He approves of the three judges who resigned rather than enforce the Nazi “rule of law”—but what of those who complied? (http://tinyurl.com/pauu262, at about 51 min).
Tip of the Month: If you have adopted an EHR to get “meaningful use” incentive payments, be aware that you may have to return them if the Office of the National Coordinator for Health IT (ONC) decertifies your system. Watch for evidence that your vendor is not keeping up. Make sure to have your data files backed up or that you have a sure way to access them if your vendor goes out of business (MPCA 9/28/15).
Compelled Speech
California’s AB 775 orders pro-life pregnancy clinics to hand out and prominently post messages that California has public programs that provide immediate free or low-cost access to comprehensive family planning services and abortion. The Pacific Justice Institute announced that lawsuits have been filed in both northern and southern California. In a similar New York case, the 2nd Circuit Court of Appeals held that the state could require crisis pregnancy centers to disclose whether they have a licensed medical provider on staff but not whether the center provides abortions or referrals, because that runs afoul of the First Amendment.
Constitutional attorney Herb Titus said, “It’s not the government’s business to force anybody to carry the message of anyone else” (WND 10/12/15, http://tinyurl.com/pkv6c47).
Medical Boards Subject to Antitrust Law
In response to the U.S. Supreme Court opinion in North Carolina Board of Dental Examiners v. FTC, the Federal Trade Commission has issued guidance (http://tinyurl.com/oxpxdml) on what constitutes “active state supervision” of licensing boards made up of practicing members of professions they regulate.
The state supervisor must review the substance of board decisions and have the power to veto or change the decisions to make sure they’re in line with state policy. The FTC says it will consider whether the supervisor has discovered the relevant facts, collected data, conducted public hearings, received public comment, investigated market conditions, conducted studies, and reviewed evidence. Merely “monitoring,” or rubber-stamping all board decisions is not sufficient. The vast majority of boards would not now meet the active supervision requirements, states Robert Fellmeth, a law professor at the University of San Diego and executive director at the Center for Public Interest Law (Modern Healthcare 10/14/15, http://tinyurl.com/p5p4u97).
Coroners Have Problems with Assisted Death
According to the new California law, “death resulting from the self-administration of an aid-in-dying drug is not suicide.” It is not clear how such a death is to be classified. The law is silent on how a physician records a cause of death. Insurance payouts to beneficiaries are expected to proceed unhindered, even though many policies exclude suicides (LA Times 10/7/15).
♦ ♦ ♦
The candid citizen must confess that if the policy of the government upon vital questions affecting the whole people is to be irrevocably fixed by decisions of the Supreme Court, …the people will have ceased to be their own rulers, having…resigned their Government into the hands of that eminent tribunal.Abraham Lincoln, First Inaugural Address, 1861
Correspondence
News from the Empire State. According to a promotional piece for a free webinar by Athenahealth, “Why EHRs Get in the Way and What You Can Do About It,” 50% of physicians want to dump their EHR and 72% say it distracts from patient care. Also, 59% of doctors wouldn’t recommend the field of medicine to their own children. Athenahealth is “a vetted MSSNY member benefit,” and the Medical Society of the State of New York is promoting the webinar. Athenahealth offers EHRs, “population health management,” “care coordination,” etc.
The hottest job opportunity in healthcare is for “utilization management” nurses. Large ads are appearing in the local newspaper by Fidelis Care, “one of the largest government programs-based health insurance plans in New York State.” It is New York State’s Catholic Health Plan.
Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY
The EHR Money Pit. After diligently researching options, a colleague purchased an EHR with an in-house server. The base cost: $100,000. This price was subsidized by a $72,000 grant towards the software fees. Once up and running, the system failed to provide the platform necessary to document encounters. A consultant, hired for $27,000 for one year, determined that the system required an updated server, for an additional $50,000. This required an additional air conditioner. Annual vendor fees are $26,000. Each “provider” license cost $16,000, and each device, $1,5000. My colleague could not pay herself for at least 3 months. Hours of chart completion in the evenings ensued until all staff learned the system. Besides money, EHRs steal time and other intangible value. The ultimate verdict on the system is still out.
Melinda Woofter, M.D., Granville, OH
Ideas Have Living Consequences. The result of same-sex marriage is discussed in the article “Surrogacy Gives Birth to an Unusual Alliance” (WSJ 9/4/14, http://tinyurl.com/oljxdyr). The Dartmouth Alumni Magazine of Sept-Oct 2013 told the story of an alumna whose surrogate pregnancy arising from artificial insemination by the sperm of a homosexual produced a baby girl, who was adopted by the sperm donor’s household. She asks, “Did I do something altruistic, or was it in some way monstrous? My birth daughter will create her own story” (http://tinyurl.com/pwqoo8u). Here’s your life, and good luck adjusting to what Mom has done. The birth arose from a woman using her own body with no regard for any law but her personal beliefs. Humans become like loaves of bread baked and delivered on demand.
Charles R. Courtney, Riverside, IL
No Exit. The Wisconsin legislature proposed to accept the Interstate Medical Licensure Compact, with a four-year sunset. There is, however, no way to sunset the Compact once a state has joined. The Compact is very specific about how exits can take place, and it would require reversal of the state legislation. Furthermore, it might open Wisconsin to litigation from the Interstate Compact, which also specifies those remedies for states found to not be in compliance with terms. It will be very difficult and expensive to exit this Compact.
Kenneth D. Christman, M.D., Dayton, OH
100% Carve-out Needed. Direct patient care needs to be completely uncoupled from government and private health plans. Whoever holds the purse strings holds the power. So we can’t allow any third party to take money from the patient and then pay the physician, because then the physician is beholden to that entity to collect payment.
Josh Umbehr, M.D., Wichita, KS
O.L.D. Age 2015 (ObamaCare Legislated Death). Physician-assisted death is the revived, rebranded, unholy grail in the Progressives’ quest for philosophical transformation of American medicine and usurpation of the patient-physician relationship. The Institute of Medicine’s Committee on Approaching Death recommends a paradigm shift: in the absence of an advance directive, the default option would change from providing life-sustaining care to “allow natural death.” The “right” to physician-assisted suicide implies the duty to prescribe lethal drugs.
Kristin S. Held, M.D., San Antonio, TX
Just Board the Train. For fiscal reasons, the government is nudging us to “less is more.” But its medical bureaucracy is expanding without bounds. The runaway bureaucratic train is blasting through walls hoping to justify its existence to further its power. It repeatedly broadcasts themes of “quality” and “patient safety” as it attempts to codify the human condition. (We have even medicalized “bizarre personal appearance,” coded R46.1.) Many physicians have become employees of large health systems, seeking an opportunity to improve care and efficiency. But this has resulted in complete surrender and acceptance of increased administrative loads. The train is less safe; quality is rapidly deteriorating. Every new government policy brings us one step closer to complete control by a central bureaucracy that’s gone insane. Yet no one thinks of stepping backwards. We maintain hope that one more step will free us from the zoo previous policies have put us in. This is the paradigm of perpetual decline.
Rocky D. Bilhartz, M.D., bilhartzmd.com
