by Betsy McCaughey, WSJ

The health bill that House Speaker Nancy Pelosi is bringing to a vote (H.R. 3962) is 1,990 pages. Here are some of the details you need to know.

What the government will require you to do:

• Sec. 202 (p. 91-92) of the bill requires you to enroll in a “qualified plan.” If you get your insurance at work, your employer will have a “grace period” to switch you to a “qualified plan,” meaning a plan designed by the Secretary of Health and Human Services. If you buy your own insurance, there’s no grace period. You’ll have to enroll in a qualified plan as soon as any term in your contract changes, such as the co-pay, deductible or benefit.

• Sec. 224 (p. 118) provides that 18 months after the bill becomes law, the Secretary of Health and Human Services will decide what a “qualified plan” covers and how much you’ll be legally required to pay for it. That’s like a banker telling you to sign the loan agreement now, then filling in the interest rate and repayment terms 18 months later.

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Associated Press

Protestors wave signs in front of the Capitol on Thursday.

On Nov. 2, the Congressional Budget Office estimated what the plans will likely cost. An individual earning $44,000 before taxes who purchases his own insurance will have to pay a $5,300 premium and an estimated $2,000 in out-of-pocket expenses, for a total of $7,300 a year, which is 17% of his pre-tax income. A family earning $102,100 a year before taxes will have to pay a $15,000 premium plus an estimated $5,300 out-of-pocket, for a $20,300 total, or 20% of its pre-tax income. Individuals and families earning less than these amounts will be eligible for subsidies paid directly to their insurer.

• Sec. 303 (pp. 167-168) makes it clear that, although the “qualified plan” is not yet designed, it will be of the “one size fits all” variety. The bill claims to offer choice—basic, enhanced and premium levels—but the benefits are the same. Only the co-pays and deductibles differ. You will have to enroll in the same plan, whether the government is paying for it or you and your employer are footing the bill.

• Sec. 59b (pp. 297-299) says that when you file your taxes, you must include proof that you are in a qualified plan. If not, you will be fined thousands of dollars. Illegal immigrants are exempt from this requirement.

• Sec. 412 (p. 272) says that employers must provide a “qualified plan” for their employees and pay 72.5% of the cost, and a smaller share of family coverage, or incur an 8% payroll tax. Small businesses, with payrolls from $500,000 to $750,000, are fined less.

Eviscerating Medicare:

In addition to reducing future Medicare funding by an estimated $500 billion, the bill fundamentally changes how Medicare pays doctors and hospitals, permitting the government to dictate treatment decisions.

• Sec. 1302 (pp. 672-692) moves Medicare from a fee-for-service payment system, in which patients choose which doctors to see and doctors are paid for each service they provide, toward what’s called a “medical home.”

The medical home is this decade’s version of HMO-restrictions on care. A primary-care provider manages access to costly specialists and diagnostic tests for a flat monthly fee. The bill specifies that patients may have to settle for a nurse practitioner rather than a physician as the primary-care provider. Medical homes begin with demonstration projects, but the HHS secretary is authorized to “disseminate this approach rapidly on a national basis.”

A December 2008 Congressional Budget Office report noted that “medical homes” were likely to resemble the unpopular gatekeepers of 20 years ago if cost control was a priority.

• Sec. 1114 (pp. 391-393) replaces physicians with physician assistants in overseeing care for hospice patients.

• Secs. 1158-1160 (pp. 499-520) initiates programs to reduce payments for patient care to what it costs in the lowest cost regions of the country. This will reduce payments for care (and by implication the standard of care) for hospital patients in higher cost areas such as New York and Florida.

• Sec. 1161 (pp. 520-545) cuts payments to Medicare Advantage plans (used by 20% of seniors). Advantage plans have warned this will result in reductions in optional benefits such as vision and dental care.

• Sec. 1402 (p. 756) says that the results of comparative effectiveness research conducted by the government will be delivered to doctors electronically to guide their use of “medical items and services.”

Questionable Priorities:

While the bill will slash Medicare funding, it will also direct billions of dollars to numerous inner-city social work and diversity programs with vague standards of accountability.

• Sec. 399V (p. 1422) provides for grants to community “entities” with no required qualifications except having “documented community activity and experience with community healthcare workers” to “educate, guide, and provide experiential learning opportunities” aimed at drug abuse, poor nutrition, smoking and obesity. “Each community health worker program receiving funds under the grant will provide services in the cultural context most appropriate for the individual served by the program.”

These programs will “enhance the capacity of individuals to utilize health services and health related social services under Federal, State and local programs by assisting individuals in establishing eligibility . . . and in receiving services and other benefits” including transportation and translation services.

• Sec. 222 (p. 617) provides reimbursement for culturally and linguistically appropriate services. This program will train health-care workers to inform Medicare beneficiaries of their “right” to have an interpreter at all times and with no co-pays for language services.

• Secs. 2521 and 2533 (pp. 1379 and 1437) establishes racial and ethnic preferences in awarding grants for training nurses and creating secondary-school health science programs. For example, grants for nursing schools should “give preference to programs that provide for improving the diversity of new nurse graduates to reflect changes in the demographics of the patient population.” And secondary-school grants should go to schools “graduating students from disadvantaged backgrounds including racial and ethnic minorities.”

• Sec. 305 (p. 189) Provides for automatic Medicaid enrollment of newborns who do not otherwise have insurance.

For the text of the bill with page numbers, see www.defendyourhealthcare.us.

Ms. McCaughey is chairman of the Committee to Reduce Infection Deaths and a former Lt. Governor of New York state.

The following set of videos basically documents the final vote and reactions to the passage of the Pelosi/Obamacare bill in the U.S. House.  Some details in the two thousand page document are hazy, but it appears it won’t take effect until 2013, so we may never actually see this.  Or it may pop up again as an option to be “fast-tracked” in next year’s Congress.  Assuming the Senate passes a similar measure here.

The vote and count:

Pelosi has her first orgasm and risks ruining thousands of dollars worth of plastic surgery in her on-air gyrations:

Representative Pete Sessions (R-TX) talks about what the bill really does:

Dale will be playing this portion on the air, where Sessions reads the portion that puts you in jail if you don’t join in on the new health care system.

by Thomas J. DiLorenzo

Some time ago I invented the phrase “fascialism” to describe the American system of political economy. Fascialism means an economy is part fascist, part socialist. Economic fascism has nothing to do with dictatorship, militarism, or bizarre racial theories. Fascism is a brand of socialism that was the economic system of Germany and Italy in the early 20th century. It was characterized by private enterprise, but private enterprise that was comprehensively regulated and regimented by the state, ostensibly “in the public interest” (as arbitrarily defined by the state).

Socialism started out meaning government ownership of the means of production, but it came to mean egalitarianism promoted by “progressive” taxation and the institutions of the welfare state, as F.A. Hayek stated in the preface to the 1976 edition of The Road to Serfdom. The problems of the American healthcare system are caused entirely by the fact that the government subjects the system to massive interventions, some of which are fascist in nature, while others are socialist.

In 1992, the Hoover Institution published an essay by Milton Friedman titled “Input and Output in Medical Care,” in which Friedman documented how, at the beginning of the 20th century, about 90% of all American hospitals were private, for-profit enterprises. State and local governments then began taking over the hospital industry. So, by the early 1990s only about 10% of all American hospitals were private, for-profit enterprises. Socialism characterizes at least 90% of all hospitals. Many other hospitals have received government subsidies, and with the subsidies come reams of regulation, making them fascist by definition.

The effect of this vast government takeover of the hospital industry, Friedman documented, is what any student of the economics of bureaucracy should expect: the more that is spent on hospital care, the worse the quality and quantity of care become, thanks to the effects of governmental bureaucratization. According to Friedman, as governments took over an ever-larger share of the hospital industry (being exempt from antitrust laws), hospital personnel per occupied hospital bed quintupled, as cost per bed rose tenfold.

Friedman concluded that “Gammon’s Law,” named after British physician Max Gammon, “has been in full operation for U.S. hospitals since the end of World War II.” Gammon’s Law states that “In a bureaucratic system, increases in expenditure will be matched by a fall in production.… Such systems will act rather like ‘black holes’ in the economic universe, simultaneously sucking in resources, and shrinking in terms of … production.” Dr. Gammon surely knew what he was talking about, having spent his career in the British National Health Service.

“The U.S. medical system, in large part, has become a socialist enterprise,” Friedman ended. Friedman also once suggested a syllogism to explain the bizarre spectacle on display today of responding to problems caused by healthcare socialism with even more healthcare socialism.

The syllogism goes as follows:

1. Socialism has been a failure everywhere it has been tried;
2. Everyone knows this; and
3. Therefore, we need more socialism.

Layers of regulation plague every aspect of medical care and health insurance in America. In the health-insurance industry, for instance, each state imposes dozens of regulatory mandates on health insurers, requiring them to include coverage of everything from massage therapy to hair implants. The reason for mandates is that the message-therapy and hair-implant industries (and many others) hire lobbyists to bribe state legislators to require insurers to cover their particular practice if they want to sell insurance within a state. Among the states with the largest number of mandates as of 2009 are Rhode Island (70), Minnesota (68), Maryland (66), New Mexico (57), and Maine (55). Idaho has the fewest mandates (13), followed by Alabama (21), Utah (23), and Hawaii (24).

Each mandate increases the cost of health insurance and probably increases the typical health-insurance policy by hundreds, or thousands, of dollars yearly. This is a good example of healthcare fascism.

Government policy in the health-insurance industry applies both the brakes and the gas at the same time. While imposing onerous and cost-increasing regulations, government also limits legal liability in some cases where an insurer refuses to pay for a particular procedure or treatment that costs a patient his life. The state also creates state-wide cartels with laws prohibiting the portability of some aspects of health insurance. (For example, my employer-provided health insurance covers pharmaceuticals in Maryland, where I reside, but not in other states.)

Getting back to pure socialism, Medicare, Medicaid, and the Veterans Administration hospitals socialize a very large portion of healthcare in America, with the same predictable results as the socialization of hospitals: runaway costs for decade after decade, coupled with massive fraud, as is often the case when politicians are enabled to spend other people’s money. Even the federal government admits that there is currently about $60 billion in Medicare fraud. Since government always understates the cost of everything it does, it is likely that the real number is at least two or three times that amount.

Having taken over most of the hospital industry, government-run or government-subsidized hospitals have created regional monopoly power for themselves with so-called “certificate-of-need” (CON) regulation. How this regulatory scam works is that an existing hospital in an area will give itself the legal “right” to decide whether there is a legitimate “need” for more hospitals. They have given themselves, in other words, the right to veto new competition in the hospital industry. It is as if the Microsoft Corporation had a legal right to veto new competition in the computer industry.

Not surprisingly, research has shown that CON regulation has increased hospital costs. CON regulation is also used to block competition in various healthcare professions as well, from nursing to home healthcare. (I was once asked to assist several nurses in obtaining a CON license from the Fairfax County, Virginia government so that they could start up their own home healthcare business. The county government was already in the business itself, and vetoed their application, naturally.)

Physicians have long enjoyed a degree of monopoly power derived from state legislatures that delegate to the American Medical Association (the doctors’ union) the “right” to limit entry into medical schools through accreditation. Only graduates of accredited (by the AMA) medical schools are licensed to practice medicine. The AMA has used these state-granted privileges to limit both the number of medical schools and the number of medical-school graduates. The reduced supply of doctors drives up the price of medical care and the income of AMA members. Hundreds of other health professions limit entry with the help of occupational licensing regulation, the primary effect of which is to create monopoly profits, not to ensure quality of care.

Government regulation of pharmaceuticals and medical devices, primarily by the Food and Drug Administration (FDA), increases healthcare costs, denies the benefits of myriad helpful drugs and devices, and creates monopoly power. It has literally been responsible for the premature death of thousands of Americans who have been deprived of drugs that were long available to people in other countries.

FDA bureaucrats are extremely risk averse: On the one hand, it costs them nothing personally to delay a life-saving drug for years, if not decades, by demanding test after test. On the other hand, if they permit a drug to enter the marketplace that turns out to be dangerous, it is a public-relations disaster for the agency, which it does not want to be associated with. Consequently, the entrance of new drugs and medical devices onto the market is often delayed by years, costing many lives and inflicting much needless pain on those already suffering, while driving up prices.

The FDA also makes the market for pharmaceuticals less competitive by restricting what advertising may say for myriad drugs — even aspirin. New drugs do consumers no good if they do not know about them. Advertising restrictions imposed by the FDA, therefore, prop up the profits of incumbent drug marketers at the expense of newcomers in the industry and of consumers.

The government’s legal system is also responsible for what used to be called “the liability crisis.” The genesis of this crisis began in the 1960s. The government courts began accepting the Chicago School Law and Economics argument that assigning all liability in product-liability cases to manufacturers would be a good way to minimize the “social costs” of accidents. Manufacturers know more about products such as medical devices than anyone else, the argument went, so contract law and shared responsibility for accidents with the users of the products were thrown out the window.

So, when accidents occur, slick trial lawyers have had an easy time convincing dumbed-down juries to award millions, or hundreds of millions, of dollars in liability lawsuits. These lawsuits have bankrupted the manufacturers of many medical devices, while convincing others that the devices are too risky to make. The effect on the healthcare consumer is poorer healthcare and higher prices.

There are thousands of other government regulations and controls on all aspects of healthcare, even (or especially) the nursing-home industry. Like most regulation, it has little or no beneficial effect for the public. More often than not, it is part of a cartel arrangement by some group of medical practitioners who are in cahoots with federal, state, or local politicians who are always more than willing to sell their “constituents” down the river for a generous campaign “contribution.”

The only sensible approach to healthcare “reform” would be massive privatization of America’s socialized hospitals, combined with deregulation of the medical professions to introduce more competition, and deregulation of the health-insurance industry. Free-market competition would produce medical “miracles” the likes of which have never been seen, while dramatically lowering the cost of healthcare, just as it has done in every other industry where it is allowed to exist to any large degree.

This is not likely to happen in the United States, which at the moment seems hell-bent on descending into the abyss of socialism. Once some states begin seceding from the new American fascialistic state, however, there will be opportunities to restore healthcare freedom within them.

by Jeff Jacoby

It was a perfectly straightforward question. The answer was anything but.

by Stephanie R. Murphy

I was shocked, surprised, and flabbergasted to hear it. I’m sure that you’ll never believe it, either. The federal government is – get this, readers – butting into your most personal and private business.

OK, you’ve caught me in a rare moment of sarcasm. Maybe I wasn’t really that surprised. After all, government bureaucrats attempt to control what types of substances you put into your body, what kind of work you do with your body, and even how you can legally dispose of your body after death; it makes perfect sense that they would also scramble for power over what parts of your body should remain attached. Yes, that’s right. The CDC is now considering a campaign for universal circumcision in the US.

The reason for pushing this one-size-fits-all policy stems from the results of several studies, all done in Africa, which have demonstrated the benefits of male circumcision for reducing the transmission of HIV.

The studies on circumcision and HIV transmission are very interesting. They are large, randomized, controlled trials; the methodology is solid. They show, on average, a 40–60% reduction in the risk of a circumcised, HIV negative man contracting the virus from an HIV positive woman, as compared to an uncircumcised man. The precise mechanism of circumcision’s protective effect is unknown. There are many potential explanations, none of which are mutually exclusive. First, the foreskin has a relatively high population of cells that are receptive to being infected by HIV. Second, it acts as a reservoir which may trap infected secretions. Third, the foreskin has a higher propensity to ulcerate (become scraped) and become infected with other sexually transmitted infections that cause open sores. It seems that removing the foreskin also removes several potential avenues for HIV entry into the body.

However, when considering the benefits of circumcision, there are some significant caveats. For one, circumcision is not a panacea; it does not completely prevent transmission of HIV, it just lowers the probability that a man will contract the virus during any given sexual encounter with an HIV positive woman. It should be noted that these studies only examined the effect of circumcision on transmission of the virus from an HIV positive woman to an HIV negative man. While this is a relatively common scenario in Sub-Saharan Africa, HIV epidemiology in the US is different. Overall rates of infection are lower. Also, HIV in the US is relatively more common among men who have sex with men (MSM). There is no evidence that circumcision protects against HIV acquisition in MSM. Circumcision also does nothing to protect anyone against acquiring HIV via bloodborne routes, such as sharing needles with an HIV positive person. It should go without saying that men can protect themselves from acquiring HIV in other ways besides getting circumcised, such as practicing safe(r) sex and avoiding intravenous drug use. These methods are much more reliable than the 40 – 60% risk reduction conferred by circumcision.

Circumcision also has risks and demerits. My personal philosophy on medicine leads me to look skeptically at any procedure that removes a part of the body which is not causing harm, pain, or annoyance to the patient; in other words, don’t mess with success. As with any surgical procedure, infections and pain after circumcision are both possibilities that should not be ignored. Medical errors should be considered as a legitimate risk during circumcision, too. There are rare case reports of penile amputation that have occurred during botched circumcisions. There are also many more reports of less extreme, but still real, consequences resulting from circumcision mishaps.

Of course, the question on the minds of many who are considering circumcision is that of whether the procedure impacts sexual enjoyment and satisfaction. That question is, in my opinion, impossible to answer accurately. To distill the immense debate surrounding this issue to its barest essence, choice seems to play a significant role in how men view their foreskins (or lack thereof). Men who choose to get circumcised tend to be happy that they did so; those who did not have a choice in the matter because they were circumcised at birth are more likely to lament it.

That brings me to my main point in writing about the prospect of universal circumcision: the issue of choice. If my patient asked me about circumcision, I would discuss with him the information above. I would also encourage him to do his own research about the procedure if he felt interested. He would make his own decision about whether he wanted to have the surgery.

By contrast, the CDC’s attitude demonstrates a lack of consideration for patient autonomy and consent, two essential elements in all medical decisions. The CDC would like every baby boy born in America to be circumcised, no matter the opinion of his parents and, more importantly, without the boy’s consent. If circumcision were a medically necessary and life-saving procedure with no possible ill effects, things might be different. In reality, it is a surgical procedure that is not essential for the health of a normal man; furthermore, it has both risks and benefits. The relative importance of those risks and benefits is subjective. Every man may value them differently. For that reason, it’s essential that each individual be afforded the choice about what to do with his own foreskin.

To be perfectly blunt, I do not see any justification for removing a part of a baby boy’s body without his consent. Men can always get circumcised as adults if they wish; by contrast, once the foreskin is gone, it’s gone forever. Most people will concede that the procedure is painful even for babies, but they insist that the pain is justified because the baby will not remember it. I wince at the thought of causing pain to a newborn boy. I say that even if he does not remember the physical pain as an adult, he may still suffer from the psychological sting of having had a body part removed without his permission.

Another argument from the advocates of universal circumcision is that it makes good hygiene easier. This is a typical government one-size-fits-all solution: parents are too stupid, in the minds of government agents, to teach their sons good hygiene, so instead we should just circumcise everyone. People are also too stupid to practice safe sex, so we should circumcise them all because they will gain a marginal reduction in the overall risk of contracting HIV. I’ve also heard arguments for circumcision based in religious tradition and cultural norms. Sure, circumcision is common – and a very old tradition in some religions and cultures. But does that make it right? I don’t think that’s for us to decide. I think that each individual, the owner of his own body, should make the call about whether or not circumcision is appropriate for him.

It’s difficult for me to assume the mindset of statists who advocate for this kind of thing, so I raised the issue of universal circumcision in conversation with a few people whose opinions I thought would be unencumbered by that pesky philosophy of leaving others alone and letting them make their own decisions. In addition to the religious and culturally based arguments that several people trotted out, one colleague had an interesting comment. He thought that universal circumcision was a good idea, envisioning a world where no more would awkward teens have to worry about getting teased in the locker room, because “everyone would look the same.” Oh really? The last time I checked, people came in all shapes, colors, and sizes, and that was a good thing! I guess that if everyone looked alike, wore the same clothes, and had the same hairstyles, nobody would ever have to worry about not fitting in. Would this egalitarian also propose to redistribute the wealth from the best-endowed men to those who are not quite as blessed by Mother Nature? Ridiculous.

I certainly cannot agree with the CDC’s move toward making a blanket recommendation that all boys should undergo a medical procedure at birth, without their consent. I want each man to have the opportunity to make his own decision about what to do with his foreskin when he reaches an age at which he is capable of doing so, based on his understanding of the risks and benefits, and how much he personally values each. The bloated, overreaching federal government apparently does not want the same.