Congressional Representative Tom Price (R-GA) Proves Having an MD Doesn't Guarantee an Understanding of Healthcare Reform

Congressional Representative Tom Price (R-GA) illustrates that having an M.D. after your name is no guarantee that you can understand or honestly represent the complexities of healthcare reform.

The Affordable Care Act is not perfect.  Parts of it annoy the hell out of me (as a provider).   But there is no question that it has given tens of millions of Americans access to healthcare who didn't have it before and made the policies everyone else has more robust (no lifetime caps, no pre-existing condition exclusions, copayment-free access to a list of essential medications, for starters).  

But Price is simply not being honest (or hasn't done his homework) when he repeats the rightwing talking point that "Many Americans lost ... health coverage."

Many Americans beg to differ.  The rate of uninsured has been roughly halved by the law:

So why the hell are Republicans so intent on aborting it?   And why did Trump just put the GOP's chief abortionist in charge of overseeing it?  

Price is an outlier since most physicians support healthcare reform.   Although they are either some surveys show a physician split along party lines on the Affordable Care Act others show as many as  59% in favor, as a 2015 survey of California physicians across different specialties indicated.

A begged question that the California researchers tried to answer was whether physicians knew what they were criticizing.  The ACA is a large, complex laws with many parts, so should we really assume that busy physicians are much more familiar with it than their patients, or that they see the entire elephant beyond the trunk, tail, leg, or other body part in front of their faces?

Not really.  The more specialized the physician, the less likely she is to be able to answer 8 questions about the ACA such as where it covers undocumented immigrants (it doesn't) where it affects Medicare coverage (it doesn't) and whether it increases Medicare payroll taxes (it does).   Another interesting finding:  the more one knew about the law, the more one was to support it (confirmed by other studies), and the more conservative politically physicians rated themselves, the lower their knowledge of the law they were criticizing:  

Support various inversely with income - those physicians in specialties making the most support the ACA the least.  Orthopedic surgeons ($443,000 per year in 2016) such as Price top the list of specialties ranked by income.  Primary care physicians whose responsibilities are broader and more continuous make far less.  Pediatricians ($204,000) and family medicine doctors ($207,000) earn less than half of the average orthopedic surgeon.  

Income after expenses but before income taxes, 2016 Medscape Physician Compensation Survey.  

Why might this be?  

Political affiliation drives Affordable Care Act support among physicians as much as among everyone else, and a high-earning physician ceteris paribus is more likely to gravitate to the party promising a reduction of income taxes.  They may come for the $100,000 tax bill reduction but stay for the ObamaCare-bashing.  

Also, specialists earning income many multiples of other physicians and 1,000% of the median family income are unlikely to see those deviantly high incomes continue in any sort of rational health care system.  Primary care physicians might earn more, although they would arguably have far less to lose, income-wise, and many aspects of the law, such as the expansion of the insured population base, make providing care to a diverse community less stressful (the uninsured not only cannot pay but often only present when a treatable or preventable condition has worsened to a crisis point, increasing the acuity of care that must be provided).  

Specialists, especially surgeons, only see patients after a "wallet biopsy" has been done by someone else.  Their concern about the uninsured might be lower since they rarely if ever deal face-to-face with the uninsured or marginally insured, whereas any primary care physician with a busy practice is reminded every day of the depth and breadth of the uninsured in America.

Indeed, surveys of physicians do indicate that support for the law is correlated with whether the provider believes the law will help his practice, and primary care physicians are far more likely to believe this.  

Absent from Price's resume is any public health experience.  I don't know if he ever took a course in healthcare economics or studied solutions to healthcare allocation developed overseas or in Canada for their pros and cons.

Yet the man feels confident enough in his abilities to offer his personal overhaul of our healthcare system.

In 250 pages.

The plan, which he introduced as a 2015 bill called the "Empowering Patients First Act of 2015" starts and ends with the idea that funneling as many dollars through the massively profitable giant American for profit health insurance companies is the way to go.  

It's unclear why Dr. Price believes this group needs such a boost.  They have thrived under the Affordable Care Act which the GOP said was socialism, a dastardly government takeover of the health care industry.   Yet last year (2015), UnitedHealth Group reported a profit of $11 billion (on revenues of more than $157 billion) up from $10.3 billion (on revenues of $131 billion) the year before.   And the CEO's of these companies certainly don't feel times are lean enough to cut back on their compensation - UnitedHealth’s CEO Stephen Hemsley made more than $66 million in 2014.  (In case you're wondering, since all UnitedHealth does is collect premiums and pay them out in claims, his salary represented $66 million of unpaid mammograms, cancer chemotherapy, and denied hospital days.)   

Back in March 2009 when President Obama was surely going to destroy the private health insurance industry (according to any Republican that wasn't too busy explaining why healthcare reform was going to ruin the overall economy), had you bet against those GOP Cassandra's, you would be very, very rich today.   You could have bought a basket of health insurance stocks for bargain basement prices.  Had you held them for exactly 7 years (through March 2016), you would have achieved returns that Peter Lynch or George Soros would envy:

Humana:   up 1,010 percent (a ten-bagger);

Cigna:   up 1,113 percent, over 400% the return of the Dow Jones Industrial Average;

Anthem:   up 469 percent;

Aetna:   up 628 percent;

UnitedHealth

 Group:   up 814 percent;

WellCare:   up 1,410 percent.

- source:  healthinsurance.org

Had you taken out a mortgage on your house, backed up the truck and bought $100,000 worth of each of these companies,  you would have over $5.4 million right now, excluding dividends.   

Here's a fun fact about WellCare - every penny they made is thanks to us, the US taxpayer.  Their revenue comes entirely from federal and state government customers (ain't free enterprise grand?).  

Another fun fact about WellCare:  they keep committing fraud, the sort of thing that would put you or me behind bars or certainly bar us from future government contracts.  But they just pay their fines and keep on making money.   Wouldn't you if you could?

Now health insurance is a complex solution to what is at its core a simple problem:  how do we pay for healthcare?  

Most sane societies (meaning every developed country except for the United States for some reason) decided to create an enormous risk pool of all of their citizens, most of whom would not need all that much health care, if any, if a given year.   A few would need a lot.  Since it's impossible to know for sure who will be in which group, everybody puts a small or modest amount of money (what are called premiums) into a big hat, understanding that most of those contributing in any given year will lose their premiums (that's a good thing).   The core idea of insurance that Republicans cannot seem to understand is that it involves an exchange of a low probability but catastrophic loss (getting cancer, struck by a car, having a stroke) for a small, high probability (guaranteed) loss (premiums paid as well as deductibles and copayments and other out of pocket expenses).  By definition, healthcare spending is other people's money since that is how insurance works!  If my house burns down but a thousand homeowners' homes don't, then it's the money of all those homeowners I never met that pays for me to rebuild mine.

I cannot understand how otherwise bright people - people who tell us what business geniuses they are - fail to understand this basic concept.  

Health insurance is a zero sum game, at least in the short term.  That means that every claim paid by an insurer must come out of premiums paid (plus returns on invested premiums collected but not paid out).   All an insurance company does is collects premiums and pays claims.  They don't provide health care, they don't contribute anything directly to your health.  They are a go-between.  In fact, they are a drag on the system, since their overhead reduces the amount available of your premiums paid to be paid for claims one day (imagine the guy in charge of the hat reaching in from time to time to take out a bill or some coins to pay himself for the trouble of collecting the money).

The real art of insurance is setting the premium right.  Too low and claims will swamp premiums collected and the company will either go bankrupt or have to turn to a reinsurer (or both).  Too high and no one will want to participate (or a competitor's premiums will seem more attractive if there is a transparent, competitive market).  

And the premiums, in turn, are driven by fiduciary responsibilities of for profit companies whose primary responsibility is not to you, dear policyholder, but to investors who are expecting to be enriched (and over the last half decade most certainly were).  

So let's say that actuarials hired by the insurance company tell the CEO that absolute lowest price they could charge and still keep the lights on is $10,000 a year for a family of 4.  The CEO might then calculate the mortgage on his fifth house, work out the minimum salary he can live on (the nearest $10 million), multiply by a fudge factor to take into account his buddies in top management, then add a healthy return he would like to be able to report to shareholders, so instead turns around and sets premiums at $12,000.

When policyholders complain, he can just blame ObamaCare.  

For the trouble of handling all your money (invested and generating a stream of income the actuarial works into his calculations, but always conservatively), your typical private company just added 20% overhead.  

Many countries reason that this system is too expensive and take over the business of collecting premiums and paying claims themselves.  In fact, our government already does this through Medicare, Medicaid, and a number of other federally-administered plans, except instead of premiums, the government collects a (much smaller) tax from a much larger risk pool (everyone).  And because their administrative overhead is 1.8%, because they don't have to advertise, and because the person administering the plan earn a few hundred thousand dollars rather than $100 million, right off the bat, hundreds of millions are available for healthcare claims.  

Private health insurance is an experiment that seems to have mostly failed.  It's unclear why we need to subsidize or make work for a group of smart people that no doubt would have no trouble finding real jobs.  

Price's plan would take the elements of the Affordable Care Act that helped the private health insurance industry grow so dramatically and add their own version of Miracle Grow.  They would make sure it's called something completely different to make sure they get the point across about how mad! mad! mad! they are that a black Democratic president did something that Nixon and Clinton failed to do:  systematically overhaul our healthcare system.   How about TrumpTraumaTriage or something?

But it's based on the same model of propping up a private health insurance industry.  Again:  why?  

The United States spends more on healthcare as a percentage of GDP (17.1%) or in per capita spending but we're the only developed country that doesn't cover all of our citizens - even after the massive improvements of Affordable Care Act, 10% of our citizens remain uninsured.  

But American taxpayers wouldn't subsidize this industry directly the way we must subsidize private defense contractors or agribusiness.  No, those subsidies would be sprinkled among Americans who could then use them to buy private policies which, once again, could suck.  Oh, but they would be affordable - low premiums in exchange for a deductible of as high as $20,000.

Everything is up in the air right now, which is no way to run a healthcare system.  Anyone who bought coverage through the exchanges or thanks to Medicaid expansion or because of the law's allowance of continuing on a parental policy through age 26 has no idea if she can get health care next year.  Or ever.   If the pre-existing conditions exclusions return, then anyone who left a group policy for a better policy on the exchange and actually used the insurance to get health care now has a pre-existing condition.  

Price is an extremist who does not represent the views of most physicians.  It's fair to say he doesn't represent the views of most Americans whose health care access he is threatening.  But Price, like so many in his party, never lets facts or lack of personal experience get in the way of personal opinion.  

He claimed back in 2010 when joining the tea people that he was trying to beat back a "vile liberal agenda."  (Vile?  Really?)

He wants to prohibit abortion, making pregnancy termination clandestine and dangerous.  Planned Parenthood rates him as zero.   He has voted to defund Planned Parenthood and helped pass on later debunked claims that the organization was operating a black market in "baby parts" [sic].

He is a homophobe, bemoaning the recent SCOTUS marriage equality ruling as a "a sad day for marriage" and a "further judicial destruction of our entire system of checks and balances."
Trump is clearly removing any hope that some of his apologists had that he really didn't mean all those nasty things he said on the campaign trail and would never carry them out.  

If the people he is picking are any indication, he did and he will.  

General Joseph E. Johnston's Bum Wrap - And How the Internet Can Set Things Straight…

by

Mike Victor

Nov 28, 2016

The Internet has made so many riches available for free and on demand anytime, anywhere.

Like this biography of Joseph Johnston, the confederate general Sherman drove back from Dalton, North Georgia, to the gates of Atlanta, where Confederate President Jefferson Davis, who never much liked Johnston, fired him in the summer of 64, replacing him with Hood, who launched an aggressive series of attacks collectively known as the Battle of Atlanta.

GENERAL JOSEPH E. JOHNSTON

AGE 83 YEARS

A MEMOIR

OF THE

LIFE AND PUBLIC SERVICE

OF

JOSEPH E. JOHNSTON,

ONCE THE QUARTERMASTER GENERAL OF THE ARMY OF THE

UNITED STATES,

AND

A GENERAL IN THE ARMY OF THE CONFEDERATE

STATES OF AMERICA.

EDITED BY

BRADLEY T. JOHNSON,

FORMERLY A SOLDIER IN THE ARMY OF NORTHERN VIRGINIA.

This delightful text is a gushing apology for Johnston, explaining that his careful, methodical retreats were part of a brilliant plan to draw Sherman deep into Georgia then destroy his army, far from his base of operations, tethered only by the thinnest of railroad supply lines. Hood's soft from defense to offense was all part of Johnston's plan that the poor general was fired right before he had a chance to execute it.  According to the author (Johnston writing in third person through cover of a biographer?), this plan would have succeeded were it not for the fatal blow to morale that Johnston's firing represented. Oh, and attacking north toward Tennessee not only failed buy destroyed the southern army.

Johnston was no doubt a capable general who managed to face McDowell, McClellan, then Sherman and hold his own at some level, playing the cards he was dealt as well as could be expected, but he was overshadowed by a fellow Virginian and West Point classmate (Class of 1829) who was also born in 1807.  This more aggressive classmate replaced him to command the Army of Northern Virginia after Johnston was badly wounded early in the war.  His name, of course, was Robert E. Lee.

There is a footnote to all this that falls under the heading  "You Can't Make This Stuff Up":

After the war, Johnston's conduct was praised by two unlikely men:  Grant and Sherman.  Sherman's commentary on his former adversary was so kind that the two men became good friends, such good friends that when Sherman died, Johnston served as pallbearer.

Unfortunately, the weather the day of the funeral was cold and wet and the elderly Johnston (13 years older than Sherman) fell ill and died shortly after the funeral.

In a very strange, indirect sense, Sherman killed his old adversary.  Even dead, Sherman was dangerous!

I have excerpted below the text summarizing the campaign against Sherman.  Enjoy.

The Georgia Campaign

[p. 115]

Johnston's plan was to strike Sherman as he was [fording the Chattahoochee River north of Atlanta] hoping to crush one of his columns before the other could aid him, and in case of disaster, he had the fortified position of Atlanta, which he had been preparing since June, for just such a contingency.

No one can now say that his whole campaign was not conducted on the best principles and with the highest generalship.

It was unjust in the extreme, to criticise his policy of retreat and fight, of fight and retreat. Lee in Virginia had been pursuing precisely the same plan since May, and had been forced back from the Rapidan to the James with no greater disparity of forces; and his movement met the entire sympathy and approval of the [Confederate] people and of the administration.

THE GEORGIA CAMPAIGN.

But for some inscrutable reason, by some logic even now unaccountable, there was a demand that Johnston should fight. He fought every day for seventy-four days.

That he should stop retreating. He did stop until his army was nearly surrounded.

That he should make a forward movement. That he should move around his adversary and throw himself on his communications.

Just at the point when he was about to declare decisive battle on his own terms, he was ignominiously relieved and Hood placed in command.

His removal was a shock to the military sense of the Confederacy. Lee, subordinate, patient, respectful, as he ever was, remonstrated in writing to the Secretary of War. He spoke openly, as he never spoke before or since, "That if General Johnston was not a soldier, America had never produced one. That if he was not competent to command that army, the Confederacy had no one who was competent." And he was firm in urging that Johnston be reinstated to command. He was relieved September 17, 1864.

Hood cut loose from Atlanta, carried out the programme directed by Bragg to Johnston in the preceding Spring, moved into Tennessee and lost his army.

On February 22, 1865, Johnston was directed by Adjutant-General Cooper to report by telegraph to Lee, at Petersburg, for orders. On the same day Lee ordered him to "Assume command of the Army of Tennessee and all troops in South Carolina, Georgia and Florida; assign General Beauregard to duty under you as you may select. Concentrate all available forces and drive back Sherman." ...

The Army of Tennessee, utterly broken up by the Tennessee Campaign, was coming into North Carolina by regiments and skeleton brigades, and there was hardly a vestige of the organization of an army left.  But Johnston did what was possible. He drew together the fragments from Charleston, Wilmington, and wherever they could be laid hold on, and concentrated them near Goldsboro, North Carolina, to delay Sherman and prevent his junction with Grant; while he hoped that Lee might disengage himself from Richmond, join him, and they together might defeat Sherman.

Desertion Executions - Shooting Free Citizens for the Crime of Freely Choosing Not to Fight. For Freedom Of Course

Mike Victor

While re-reading historian Lee Kennett's excellent 1995 history of Sherman's invasion of Georgia Marching Through Georgia, told mostly from the viewpoint of common civilians and soldiers patched together  from letters, diaries, and contemporary newspaper articles, I was struck by this haunting passage:  

The pattern of desertions that spring [1864] was sufficiently disturbing for General [Joseph] Johnston to make a severe example.  Just before the campaign opened he had fourteen North Carolinians executed as deserters.  They were shot sitting blindfolded on their coffins, while several thousand of their comrades watched.

- page 50

Shooting your own men has to be one of the cruelest aspects of any war, but it's particularly oxymoronic in a war that each side felt was being fought for "freedom."  How can you kill a man who freely signed up to serve if he freely decides not to serve any longer?  Had he never signed up in the first place, or had he been wealthy enough to buy a substitute to avoid conscription, he would have lived a long and happy life.  

In fact, the idea of forcing free men to fight a war (for freedom) against their will, shooting them if they don't, has to be one of the cruelest paradoxes of a modern democratic society.  There was a reason that our country survived 86 years from the Declaration of Independence before forced conscription appeared.  Compelling someone - even someone who once formed a contractual obligation - to work against his will, to risk his life, or to be shot for not following through on a contract seems at some level a patently anti-democratic idea.  

Ironically, the South, with all of its blather about freedom and a loose confederacy of sovereign states (as opposed to the type of strong federal government and coherent single country against which they fought) was the first to institute a draft (in 1862).  Conscription followed in the North and led to rioting in many citizens, most famously in New York City, where Irish immigrants rightly feared that they would be forced to disproportionately bear the burden of war in a country whose "freedoms" they had not yet had the opportunity to enjoy.  

In her book Team of Rivals, Doris Kearns Goodwin relates how disturbed Lincoln was by the sound of deserters being shot by firing squad in the nation's capital.  He tried to pardon as many as he could, saving 9 lives at one time, but his reach only extended to the Army of the Potomac and only when it was encamped around Washington.  Many men were just summarily shot or hanged.  

More soldiers were executed for desertion - perhaps almost 350 - during the Civil War than during all other American wars combined.  500 were shot or hanged for various reasons, mostly desertion, in both the Union and Confederate military.[1]    In all of World War II, only 1 soldier was executed for desertion although 21,000 were tried and convicted (48 of 49 death sentences were commuted).  [2]

Private Eddie Slovik, after his January 31, 1945, execution for desertion. He was the last American executed for desertion.

There is a reason why then 28-year-old Stanley Kubrick chose to focus on a mass execution of an allegedly mutinous French WWI unit in his 1957 Paths of Glory, arguably the first truly anti-war movie (and perhaps the most sarcastically titled).  The horror and immorality of a democratic country murdering its own free citizens, citizens who have often "borne the battle" to use Lincoln's phrase of an earlier generation of soldiers and veterans, highlights the imperative not to fight these damn things and certainly not to start them.  

Desertion is a strange crime if indeed it's a crime at all.  Commanders must be able to maintain unit integrity and count on having their left wing advance or their center to hold, but every commander also knows that battles are psychological affairs with every unit having a breaking point beyond which it will pull back or disintegrate into a rout.  At some level, such behavior is a vote of confidence in the commander and the cause, and although it is inconvenient, think of how many fewer wars we would have if the free citizens who chose (or were compelled) to participate got to literally vote with their feet.  

The popular history of war is often one of brave, glorious men closing on each other, accepting their fate like protagonists in some ancient Greek tragedy, but a wealth of data - from the low percentage of front line soldiers who ever fire their weapons in combat, to the pattern and distribution of wounds, the ratio of wounded to killed soldiers and the vast number of soldiers in any conflict who are neither killed nor wounded to psychological studies conducted by the US Army in World War II showing 10% of any unit will become psychiatric casualties during the first hours of combat and after between 180 and 200 days of combat, up to 100% are psychologically ineffective [3] - shows us that the story is far less glorious and much messier.  

Confederate General James Longstreet, no slouch of a commander, estimated early in the Civil War that over one-fifth of his men (7,000 out of 32,000) had deserted.

Of course, desertion in the Civil War was more complicated than desertion in more modern conflicts, especially in the South, where men saw themselves as fighting for their state, not for any country made up of states, so a North Carolinian (such as any of the 14 killed in the single mass 1864 execution cited above) fighting in Georgia would have seen himself not as deserting but as leaving a foreign country to go home.   And in an age when the absence of a military-age man to drive a plow or bring in a harvest could have meant hunger, even starvation, for relatives back home, the moral calculus was far more complex than for a soldier today who fails to report for a deployment.  
This situation was even cloudier in the 22 men that Confederate General George Pickett (yes, the same Pickett who graduated last in his class and led the disastrous Pickett's charge at Gettysburg) shot or hanged, 11 in one mass hanging. These men were North Carolinians who had signed up with a secessionist militia which they understood to be a Home Guard. When the militia was ordered to join the CSA, they fled north and ended up as Union soldiers. When captured, Pickett did not consider them POW's but deserters and hanged them all on February 15, 1864. It's such an awful business.  As Sherman put it best, "It is only those who have neither fired a shot nor heard the shrieks and groans of the wounded who cry aloud for blood, more vengeance, more desolation. War is hell.”

Notes: Millen Command Legacy:  A Tactical Primer For Young Leaders by Raymond A. Millen, page 343, citing Keegan, 328-9 and 335:  ""The first hours of combat disable 10 percent of the fighting force."  Combat exhaustion results from continuous combat exposure.  Psychiatric casualties could account for as many as 30 percent of the total casualties of a battle.  If handled immediately, 90 percent will return after a brief rest.  Most combat line soldiers are ineffective after 180 days of combat.  Their peak of effectiveness is 90 days.  After 200-240 days, they contribute little.  Doubler, 242-5.  From 1944 to 1945, psychiatric casualties accounted for one quarter of combat casualties.  A First Army report estimated that a soldier could endure only 200 days of combat before breaking down, 243.  Lindermann, 356.  According to some combat psychologists, the effectiveness of a soldier deteriorated after 30 days in continuous combat, and after 45 days the soldier becomes vegetative.  Total breakdown occurred between 200 and 245 days in continuous combat."