Benefits of sleep: "a nap that included REM sleep resulted in nearly a 40 percent improvement over the pre-nap performance."

Hyperphagia: It keeps you wanting more.

Looking good: "160,283 children 18 and under had cosmetic interventions in 2008."

On the Goal of Health Care Reform

Dr. David Blumenthal, a Harvard professor and key health advisor to President Obama: "The more people have, the more of it they tend to spend on healthcare." But as a nation's wealth increases and standards of medical care become higher and more costly, the lowest income groups get priced out. Government controls are needed to push down healthcare costs (and by inference, standard of care) to a level that everyone, including the poor, can afford, or to what government can afford to provide to everyone equally. The goal is not only universal coverage but also a similar healthcare experience for everyone, regardless of ability to pay (New England Journal of Medicine, March 8, 2001).

On the Rhetoric vs. the Reality of Reform

Dr. Ezekiel Emanuel, a health policy advisor in the Office of Management and Budget and brother of Rahm Emanuel, the president's chief of staff: "Vague promises of savings from cutting waste, enhancing prevention and wellness, installing electronic medical records, and improving quality are merely 'lipstick' cost control, more for show and public relations than for true change." (Health Affairs, February 27, 2008.) True change must include reassessing the promise doctors make when they enter the profession. The Hippocratic Oath is partly to blame for the "overuse" of medical care: Physicians take the "Hippocratic Oath's admonition to 'use my power to help the sick to the best of my ability and judgment' as an imperative to do everything for the patient regardless of the cost or effects on others." (Journal of the American Medical Association, June 18, 2008.)

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By some estimates, more than half of US health care spending is for patients with chronic conditions. As I have previously reported, this money is spent very wastefully. Care is often delivered in discrete, disjointed and disconnected ways. The most efficient form of therapy (drugs) is substantially underutilized. And many chronic patients are not receiving care at all.

Fundamentally, there are two ways to deal with chronic care. The current approach is a nonmarket approach, and it has the following 10 characteristics:

• Completely suppressing the market for every facet of medical care and every type of health insurance — so that no one ever faces a real price for anything;
• forcing health plans to take enrollees they don't want at premiums well below the cost of their care;
• forcing doctors to treat patients with complicated conditions for the same fees as easy-to-diagnose-and-treat patients;
• paying doctors in a way that encourages uncoordinated and unintegrated care;
• denying providers the opportunity to repackage and reprice their services in ways that would lower cost and raise quality;

Petition Signers: 170,000 and rising

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Why is Washington having so much trouble reforming health care?

Why, if they do pass a major overhaul, are the problems of cost, quality and access almost certain to get worse?

Answer: Because they don't understand health care. By that I mean, almost no one in Congress understands health care as a complex system. When they campaign, most politicians claim that health care problems could be solved with a few simple reforms. Now that it's time to legislate, they are discovering that health care is very, very complicated. In fact, there is no solution that even comes close to being simple or easy.

As Nobel Laureate Frederick Hayek taught us, a complex system is a structure that is so complicated, that no one person can even begin to grasp it in its entirety. The best each of us can hope for is to master the small part of it we interact with.

The economy, for example, is a complex system. To allow us to think about it — if only imperfectly — economists have developed a highly simplified model over a period of 200 years. In fact, the only reliable model that exists to understand complex social systems is the economic model. Yet we have completely suppressed normal market forces in virtually every aspect of health care. So what we are left with is almost certainly the most complicated market of all and no reliable model with which to understand it.

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A May 2009 report form the American Academy of Actuaries, summarizes the latest data on the performance of Consumer-Drive Health Plans (CDHPs). The authors conclude that CDHPs cut expenditures 4 to 15 percent in their first year. After the first year, the expenditure growth rate is 3 to 5 percent lower than in comparable PPO plans.

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It is remarkable in the current debate over health care reform how policymakers are ignoring the one thing that has been proven to work: consumer-driven health care.

This is an approach that has proven to work after six years of testing by many millions of people in real-world conditions all across the nation. Consumer-driven health plans empower individuals by taking money away from third-party payers and putting it in the hands of consumers to spend as they wish.

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After spending hundreds of millions of dollars in the last campaign election accusing John McCain of wanting to "tax the health insurance benefits" of ordinary Americans, President Obama now says he is open to the very same idea and it seems likely that the Congressional Democrats will themselves opt to tax health insurance benefits, as part of overall health reform.

Is this a complete flip flop? Yes. And other than Kimberley Strassel's Wall Street Journal editorial last Friday, the media is giving the President a free pass. But can the Democrats claim that Republicans have endorsed the same idea? If they are intellectually honest, I think not.

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The idea that patients receive about half of recommended care when they see physicians is the conclusion of a RAND Corporation study [gated, but with abstract], spearheaded by Elizabeth McGlynn and colleagues. In fact, not a single outcome of care (like death, infection, ability to walk, relief of pain, return to work) was analyzed. Instead, the study focused only on 439 inputs called "indicators." These inputs range from the serious and uncontroversial (giving a heart exam to patients with chest pain) to the unobjectionable but possibly trivial (counseling smokers to stop smoking, alcohol abusers to reduce their drinking, and patients with sexually transmitted diseases to practice safe sex).

Four questions immediately jump to mind: (1) What does it mean to say that a procedure is "recommended care?" (2) How do we know that the recommended care is actually good for patients? (3) How do we know whether the patients actually got the care? and (4) Does it make sense to combine the serious with the trivial in making a judgment about the overall quality of the US health care system?

Oh, the movie never ends
It goes on and on and on and on

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I have glimpsed at the future of U.S. health care and I am pleasantly surprised. Instead of continuing to rise at twice the rate of growth of income, health care spending will slow dramatically. Future prices will actually be lower than they are today. Providers will bundle their services into easily-understood packages with a single fee. They will compete against each other on price and quality and the data will be transparent. Health care will be provided in a free, competitive marketplace. Third-party insurance will be relied upon only for rare, very expensive events. Medical malpractice suits will be virtually unknown.

There is only one catch. All this will happen outside the United States.

We Like Guatemala

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The biggest mistake Hillary Clinton made 15 years ago was not endorsing Bob Dole's health bill, which had more than 40 Republican co-sponsors. The Dole bill would have given her 70% to 80% of everything she wanted anyway, to say nothing of creating a huge bipartisan lovefest. Democrats would have held the Congress in 1994….. and, well, you get the picture.

Barack Obama is about to repeat that same mistake. The smartest thing Obama could do is endorse a bill [summary] sponsored by Sens. Tom Coburn (R-OK) and Richard Burr (R-NC), along with Reps. Paul Ryan (R-WI) and Devin Nunes (R-CA), [hereinafter called the Coburn bill]. Here's why:

• Independent analyses estimate the Coburn bill would cut the number of uninsured in half, the same result that is expected under Obama's plan.
• The Coburn bill is revenue neutral — requiring no net increased taxes or spending; whereas Obama's plan will cost $1.5 trillion over 15 years and maybe more - even though they both achieve the same goal. (I'll explain this truly fascinating result in a future Alert.)
• The Coburn bill makes coverage more universal by shifting tax benefits from those who earn more to those who earn less — precisely what Obama has committed to from the get-go.
• The Coburn bill liberates millions of poor people from Medicaid rationing and gives them access to the same kind of insurance middle-income families have, whereas Obama's plan would do to reverse.
• The Coburn bill gives people strong incentives to control costs and they might actually work, whereas Obama's $150 billion a year in extra spending will almost certainly add to health care inflation.

In some ways, this is the most "liberal" proposal on the table made by the most conservative senator on Capitol Hill; and it achieves all of Obama's goals as well or much better than Obama's own plan!

Why Not Me?

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