by Russ Roberts on February 9, 2009

in Uncategorized

Betsy McCaughey appears to have actually read the spending bill (HT: Drudge) and finds (page numbers from the pdf of HR1):

The bill’s health rules will affect “every individual in
the United States” (445, 454, 479). Your medical treatments
will be tracked electronically by a federal system. Having
electronic medical records at your fingertips, easily
transferred to a hospital, is beneficial. It will help avoid
duplicate tests and errors.

But the bill goes further. One new bureaucracy, the
National Coordinator of Health Information
Technology, will monitor treatments to make sure your doctor is
doing what the federal government deems appropriate and cost
effective. The goal is to reduce costs and “guide” your
doctor’s decisions (442, 446). These provisions in the stimulus
bill are virtually identical to what Daschle prescribed in his
2008 book, “Critical: What We Can Do About the Health-Care
.” According to Daschle, doctors have to give up autonomy
and “learn to operate less like solo practitioners.”

Keeping doctors informed of the newest medical findings is
important, but enforcing uniformity goes too far.

Hospitals and doctors that are not “meaningful users” of
the new system will face penalties.  “Meaningful user” isn’t
defined in the bill. That will be left to the HHS secretary, who
will be empowered to impose “more stringent measures of
meaningful use over time” (511, 518, 540-541)

What penalties will deter your doctor from going beyond the
electronically delivered protocols when your condition is
atypical or you need an experimental treatment? The vagueness is
intentional. In his book, Daschle proposed an appointed body
with vast powers to make the “tough” decisions elected
politicians won’t make.

The stimulus bill does that, and calls it the Federal
Coordinating Council for Comparative Effectiveness Research
(190-192). The goal, Daschle’s book explained, is to slow the
development and use of new medications and technologies because
they are driving up costs. He praises Europeans for being more
willing to accept “hopeless diagnoses” and “forgo
experimental treatments,” and he chastises Americans for
expecting too much from the health-care system.

This is a bad idea. (Check out this podcast with Steve Lipstein for the basics on the idea. It's near the end. He likes it. I don't.) But if you think it's a good idea, fine. Just don't bury it in a bill that's supposed to save the economy. Put it out in the daylight and let people debate it.

Are there only 36 Senators willing to oppose this bill?

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Zachary Kurtz February 9, 2009 at 11:56 pm

that is so corrupt… as someone who's planning on entering the medical profession, I am very disturbed by this.

TrUmPiT February 10, 2009 at 12:33 am

Instead of weeding out the bad stuff in the bill, the Republicans just want tax cuts for the wealthy – more trickle down. The 36 Senators that oppose the bill just operate on auto-pilot. They are looking out for the interests of the "majority of the majority," as one Republican leader put it. They would vote "no" no matter what was in a Democrat bill. They get no credit for being evil Dr. No.

Flash Gordon February 10, 2009 at 12:51 am

Obama and Daschle have brought back Richard Lamm's idea that after a certain age we have a duty to die.

Lee Kelly February 10, 2009 at 2:02 am


Poorer people tend to spend almost all of their income on consumption (which is mostly why they are poor). Wealthier people tend to spend more of their income on invesmtnet (which is mostly why they are wealthy).

When wealthy people invest, it is usually in techniques and technologies to provide poorer people with consumer goods at lower prices. A flat tax would be better. People tend to discount the future for immediate gratification anyway. If tax codes incentivise anything, it should be investment, not consumption. So tax cuts for those who invest most would generally be a good idea for long term prosperity.

vikingvista February 10, 2009 at 3:15 am

EMR is far from a new idea. There are numerous software companies providing packages, and hospitals small and large across the country have employed it to some degree. It isn't so much that doctors are technophobes as that practical experience has shown in many cases that EMR results in lost efficiency and MORE errors. There are even examples of hospitals reverting back to their pre-EMR systems.

For one thing, those of you used to using Microsoft products, or actively developed software with millions of users are spoiled. Medical software is, for the most part, AWFUL. They are bug-ridden, frequently with an interface that nowhere even resembles the Windows or MAC GUI you are used to, and updates are few and far between, often because any change requires expensive reapproval by the FDA.

The idea that EMRs eliminate errors couldn't be further from the truth. Sure, you no longer have to struggle to read handwriting–which is an improvement. Instead, however, users find themselves trying to navigate a highly confusing interface to find the orders they want, only to select orders that seem close enough but are wrong. Rarely an EMR will spare the tedious waste of time required to search for the desired options, and allow the user to just type it in. But then you lose the uniformity, have to deal with typing errors, and force docs to waste their time typing–assuming a terminal is even available when they need one. And don't even get me started on voice recognition.

Don't get me wrong. I used to be a medical software developer. I love high tech. I'm quite sure EMR is the future. Wherever it significantly improves efficiency, it usually gets employed. Its areas of usefulness vary from hospital to hospital, within a hospital, and across different types of practices and practice communities. EMR is moving as fast as it possibly can already. And there is a great deal of high quality health informatics research and standards development.

Instead of improving efficiency and reducing mistakes, government mandates will short-circuit the natural technological development of EMR, increase health care costs, and trade one source of medical errors for a whole slate of new ones. Further government intrusion would likely be bad even for the future of EMR.

Morgan February 10, 2009 at 3:19 am

In a previous post, the Cafe referred to rationing of medical services in Canada by increasing wait time. Removal of the physician's authority to treat as he and the patient deem best – in favor of an explicit "cost effectiveness" criteria – is another kind of rationing.

The problem is, once you accept that all medical care will be paid for out of a common pool, you accept that the pool's rules about what is worth paying for are paramount. And given that there will always be some people who feel that a particular treatment is worth paying for, and some who feel that it is not, one group or the other will always be unhappy.

You can minimize the problem by making coverage frugal but allowing people to pay the difference between the "accepted treatment" and the treatment they feel is most appropriate for themselves. Strangely, though, there is a pattern of governments that have adopted nationalized systems rejecting this kind of voluntary upgrade of treatment. Apparently, it's unfair to the rest of us that some people can afford to do so on their own dime.

With regard to the specific provision in the stimulus bill, it seems to me that if we're looking for a measure of the cost effectiveness of treatments, the UK's NICE would probably be willing to sell us their data for a lot less than it would take to replicate their work – but then I guess that wouldn't be stimulative.

indiana jim February 10, 2009 at 8:42 am

Remember: "Some animals are more equal than other animals." (From Orwell's "1984" for the uninfomred)

For guys like Teddy Kennedy, who has been kept out of the grave at great medical expense to be able to cast his vote for socialized medicine, the doctors will never be "meaningful users" of the "new systems." But for the doctors of Joe Sixpack (and Joe the Plumber) penalties will be vigorously applied in the future for equivalent "use" of the same "systems."

indiana jim February 10, 2009 at 11:01 am

"Animal Farm" not "1984"; my bad


colson February 10, 2009 at 11:50 am

vikingvista – I don't think you'll catch any argument that such systems are, for better or worse, good on the whole. But government mandated and government controlled systems continue to bridge the needed gap between citizens and government.

It also breaks the old rule that you should have no single points of failure. Decentralized, market-oriented services effectively provide this type of stop-gap by decentralizing data.

In much the same way that credit card breaches through various means over the past decade have led to thousands, if not millions, of stolen card numbers, the real success was that the entire system could not be brought down because because thieves could only access a narrow set of card numbers. It would be an interesting study in how markets naturally mitigate risk through decentralization of information…

Now if you think medical software is bad, you should see some of the clunkers running in the card processing industry. There are companies out there still running legacy COBOL applications and much of the industry is still running everything in batches. The only thing missing from this industry is the shag carpeting and avocado green appliances.

RickC February 10, 2009 at 6:21 pm

Dr. Roberts and all,

Further reading into Daschle's book will show you that the Dems are following his plan to a T. He actually writes in the book that the health care provisions should be hidden within a spending bill to prevent debate and resistance. And remember, he was probably planning on being the health care dictator when he outlined this plan.

So the provisions have nothing to do with stimulus or health care, but instead, are just the standard power grab. Who was it that spoke of Daschle's unquestionable and well-known integrity?

indiana jim February 10, 2009 at 8:20 pm

Per RickC's post: Remember the Trojan Horse? It was a "gift" that brought death to the recipients because of what was hidden within it. However absurd, the spending bill is being touted as "stimulus", a sort of gift from the gods to "jump start" the American economy. Who says history doesn't repeat itself?

Ray G February 11, 2009 at 12:42 am

I'm amazed at how many people were outraged to find out that our government was tracking phone calls to/from a foreign country but they're perfectly okay with the government having our medical records in such a fashion.

Even if the spooks were tracking all of our phone calls, no foreign connection needed, which holds the potential for personal risk; transcripts of my wife and I talking about picking up a DVD on the way home from work, or my complete medical history in digital form?

Charles N. Steele February 11, 2009 at 1:01 pm

After spending a couple of hours trying to read H.R. 1 (ugh), I don't believe the account cited by RR is correct. The cited pages in question don't really say what is claimed.

For example, the Federal Coordinating Council for Comparative Effectiveness Research is tasked with organizing medical research, not defining permitted treatments. Sure, the research could be used for such, but H.R.1 doesn't call for it.

The discussions on and around pp. 511 and 518 concern making Medicare payments to users & nonusers of EHR. The penalties in and around 540-1 are for leaking individuals' EHR.

None of this is to defend H.R. 1; it's a dreadful mess, loaded with nonsense and built on bad economics. But our attacks on it ought to be accurate.

Tudorman February 19, 2009 at 9:41 pm

According to the HHS website, the National Coordinator for Health Information Technology was created in 2004 under Bush.

Of course, that doesn't make it any less offensive.

Andrew E Plaisted February 20, 2009 at 7:22 pm

So we are adding new crap and organizations which costs $$. These new turds and organizations are now supposed to monitor and things and thus save us money. Is that not illogical? Sounds to me, like we would be better off leaving things as they are.

Why not just cut crap off the current spending sheets like some of the duplicate crap listed here: (Top 10 Examples of Government Waste)
I think we could live just fine without 341 of the 342 economic development programs. They obviously have failed.

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