The Clare Spark Blog

November 21, 2010

Dr. James Pagano on ObamaCare (2)

Filed under: Uncategorized — clarelspark @ 3:24 am
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Rembrandt: The Anatomy Lesson of Doctor Tulp, 1632

Two weeks have passed since the midterm elections.  The anxiety, anticipation, and exhilaration they inspired have had time to dissipate and now a clearer picture of where we stand, and what we have to do to move forward, is beginning to emerge.  While there are many fronts on which battles should, and will, be fought I will confine my comments to the one issue I am most qualified to critique—ObamaCare.

 It was crafted in secret with no bipartisan support.  It is monstrous in its scope.  It is being touted by those who created it as being about ‘healthcare for all’, and yet to get it passed, with supermajorities in both the House and Senate, votes had to be bought outright.  It has to go.

 While everyone agrees that there are problems with the cost and delivery of healthcare in this country I can guarantee you this law will not solve them.  It will make them worse and the cost for this ‘de-provement’ will be an American public indentured to the Federal government for the foreseeable future.

 This country was founded on the principle that individuals have value and rights.  Nowhere is this more apparent than in our system of healthcare.  Doctors are trained to treat patients as individuals, each with his own problems and circumstances, and patients have come to expect their doctors to make decisions regarding their care based on what is best for them.  Period.

 The architects of ObamaCare see things differently.  Our president, a self-proclaimed ‘progressive’, believes what all progressives believe.  Namely, that the welfare of society is more important than the welfare of any individual.  Individuals don’t matter in general, and when they cease to be ‘productive’ members of that society, they matter even less.  The fact that a society is nothing more than a collection of individuals working to achieve some common goals is somehow lost on these people.

 This belief in the primacy of ‘society’ underlies the key element of ObamaCare—stripping half a trillion dollars from MediCare to pay for thirty-some million people soon to be enrolled in various forms of Medicaid.  This is a disaster on a few different levels.

First, patients on MediCare are by definition older, sicker, and more in need of medical services, services that by and large they have earned during their ‘productive’ years by paying large amounts of money into the system via MediCare taxes. 

 Second, Medicaid is not what people think it is.  Specifically, it is not ‘insurance’ but merely a free pass for those who have it who will then never face a premium payment, a deductible, or a co-payment.  This creates a class of healthcare consumer with no skin in the game.  This is exactly what we don’t need if we want to control overuse of services and spiraling costs.

When I say it isn’t insurance I’m referring to the fact that very few physicians accept Medicaid patients.  They can’t afford to.  This is true for most primary care physicians and even more so for the great majority of specialists and subspecialists.  So when the Medicaid patient comes to the ER with a broken arm, we see him, do the exam, take the x-rays, make the diagnosis, and apply the splint.  But if that broken arm needs to be reduced, or operated on, we can’t get the orthopedist to take the case. 

 Some have suggested that a physician’s license to practice be dependent on his willingness to care for these patients.  I hope we’re not considering bringing back slavery. 

 The true goal of ObamaCare is to squeeze out private insurance companies and force everyone into a single-payer, government-run healthcare system.  Why seemingly intelligent people think this is a good idea baffles me.  In countries where this is being practiced, notably Canada and England, there is widespread acknowledgement that it doesn’t work very well.  Private clinics are popping up in Canada and doctors in border cities are doing a brisk business caring for Canadians who feel they can’t wait six months to a year for their joint replacement or their MRI.  My British friends are equally unenthusiastic about their system.

If we want to reform healthcare in this country then that’s what we should do.  Identify the specific problems that need to be addressed, the recisions, the denials for pre-existing conditions, the lifetime caps on benefits, and the availability of coverage for the great majority of people in this country, and then do the work of finding specific solutions in concert with physicians and insurers.

 We do not need the Federal government using healthcare as an excuse to commandeer a sixth of our economy.  We do not want bureaucrats deciding who gets what care and when.  We don’t need rationed care, we need rational care.  There’s a difference.


 If Obama succeeds in destroying the current private healthcare system his appointees, like Dr. Berwick, will be instituting a large number of ‘practice guidelines’ as a means of making healthcare delivery more homogeneous across geographic and social lines, and more affordable.  There are already such guidelines in place for certain diagnoses and they are referred to as ‘Core Measures’.  These guidelines are supposed to be the result of rigorous scientific study and are supposed to represent ‘best practices’ for the diagnoses they cover.

 In some instances they make sense, in others they seem arbitrary.  But even the most egregious of these guidelines—the one requiring us to obtain blood cultures on patients suspected of having pneumonia, which most physicians realize is a waste of time and money, remains in force.  Such is the inertia of government.

 The guidelines to come are not going to be anywhere near as pleasant as our current ‘Core Measures’.  My guess is that they will be closer to Draconian.  They will be designed to shift care, and the money it costs, away from the ‘non-productive’ members of society.  And yes, if this sounds like the ‘death panel’ stuff people were ranting about a year ago, well, it is.

 It is true that something like eighty percent or so of healthcare dollars are spent on the last 2-3 years of life.  We don’t need the government to fix this.  We need to promote rational care, where physicians feel free to discuss end-of-life issues with patients and families and where they do not have to live under the threat of being sued every time one of their patients has a bad outcome.  If you believe that death is a bad outcome, then we are all bound to have one.  It is not necessarily your doctor’s fault.

Educating the public about what we can and cannot do for the terminally ill, and having the courage to make decisions on that knowledge, will eventually save the dollars we are looking to save.  All without the government taking over, without Dr Berwick, without Obama.

 James Pagano, MD

Dr. Pagano’s first blog can be found here: Dr. Pagano has just published a novel, The Bleed, “about ER doctors, sleazy trial lawyers, ne’er-do-well patients, gangs and girls–and what happens when their worlds collide.”  I have just read the novel, and its detailed account of a medical malpractice case and the current administrative difficulties that discourage doctors from a one-to-one relationship with patients should alert us to the dangers to individual and public health being advanced by left-liberals today. In Pagano’s own words to me, it is a good airplane read.


  1. Pagano may be well-versed in medicine, but I think he needs to spend a little more time honing his political and economic analysis.

    We all have rights, we’re all individuals, and our American doctors have a long tradition of respecting that, Pagano says. What could be more natural? This is a nice patriotic preamble, but the fact of the matter is that without an insurance card in hand, that individual, or a complete collection of individuals for that matter, are not going to get treatment, or, if they do, they’re going to go into debt trying to pay for it. Political rights mean very little in the economic world. So don’t try and impress me with how red, white and blue our health care system is.

    Pagano says ‘The fact that a society is nothing more than a collection of individuals working to achieve some common goals is somehow lost on these people (progressives).’ I don’t think it’s lost on progressives any more than it’s lost on conservatives – they wouldn’t be working on a health care overhaul if they weren’t thinking in terms of a common goal. This is just a clumsy political jab.

    Pagano would probably find that what the terminally-ill patient (and their family) thinks is best for them as an individual is not necessarily what is best for the medicare bottom line – or any health insurance provider, private or public. You can’t have a system that caters to both the individual’s will to survive and the health insurance system’s drive to increase profits(and/or lower costs).

    I do also have a problem with stripping Medicare to pay for Medicaid, but I don’t agree that Medicare patients are ‘older and sicker’ by definition. Coming from a doctor, that’s a pretty unscientific conclusion.

    It works both way. Pagano’s take on Medicaid is true enough, that it’s essentially for a class of free riders with ‘no skin in the game’. But that’s a truism. Medicaid recipients are by definition unable to pony up to the health care table, specifically, their income is at or below poverty level. Pagano also doesn’t mention that medicaid recipients don’t become said recipients without the blessing of multiple doctors. Should these free riders be required to pay premiums, so that they’ll think twice about burdening our clinics and emergency rooms? Would that make us feel better?

    He also asserts that ‘In countries where this (government run health care?) is being practiced, notably Canada and England, there is widespread acknowledgment that it doesn’t work very well…my British friends are equally unenthusiastic about their system’. Widespread? He and I must have British friends from completely different social circles.

    Pagano wants us to identify the specific problems, and work on solutions in concert with insurers and physicians. And yet, every day, each accuses the other of driving up the cost of health care, both sides only coming together when it suits them politically (AHIP recently took out this ad ) Health insurance companies and physicians have had years to work in concert, and where has it gotten us? Right where we’re at now.

    Pagano ends by saying the way to cut costs is in ‘educating the public about what we can and cannot do for the terminally ill, and having the courage to make decisions on that knowledge, will eventually save the dollars we are looking to save. All without the government taking over, without Dr Berwick, without Obama.’ It’s interesting that Pagano is so vague about what he means by what physicians ‘can and cannot do’. But I get what he’s hinting at: confronting the difficult balance of medical ethics and economic efficiency. To me, this sounds an awful lot like a free-market version of the death-panel scenario.

    I don’t feel too badly, though. The system is broken, and those who have paid the most into it will lose the most.

    Comment by Juston Keefe — November 23, 2010 @ 5:05 am | Reply

    • [This comment is posted by Clare Spark on behalf of Dr. James V. Pagano:]

      People without insurance cards have been getting medical care all along. They get it from me in the ER and I’m happy to do it. It is my pro bono. In almost 30 years of practice I haven’t sent one person to the poor house. Where they have difficulty is getting care from other specialists once they have been stabilized. This will get worse with Obamacare as more and more people are moved into an insurance model that grossly underpays providers.

      I’m not sure how my depiction of the health care system got labeled red, white and blue or why you think I’m trying to impress you with anything. We had the best medicine in the world when I first went into practice. I think it’s a shame that the best our liberal friends can do to improve the system is to reduce it to some lowest common denominator.

      That progressives value society above the individual is their claim. I’m merely repeating it. It is also a dangerous position to take because when the system becomes more important than the people who comprise it bad things tend to happen.

      As for the terminally ill, we spend far more than we should sustaining the unsustainable. There does need to be an increased level of understanding among the public, and among physicians, of the negative impact this has not only on the bottom line, but on the lives of the patients and their family members as they go through expensive, painful, and futile treatments. However, that increased understanding needs to come from the ground up, and not from Washington on down. I do not have a lot of faith or trust in politicians and bureaucrats. The decision they make to deny the fourth round of chemo for the terminal pancreatic cancer patient, a good decision, can lead to the decision to delay a joint replacement or an important diagnostic procedure on someone who could truly benefit from it. That would be bad indeed. In my experience, doctors are not the ones who are likely to institute a free-market death panel. Those in government, with no real idea how medicine is practiced, are much more likely to make the bad decisions leading to the kind of rationing we would consider Draconian.

      That you would fault my comment about MediCare patients being in general older and sicker is just idiotic. They ARE older by definition, or they have illnesses like HIV or dialysis-dependant renal failure that make them sicker.

      MediCaid should be our safety net, not our default national insurance plan. We should be finding ways to improve the economy, create jobs, and make private insurance more competitive and thereby more affordable. If this sounds like a lot of scary right wing nonsense, I can’t help you. As the grandson of immigrants who came here with nothing I think I can honestly say that the majority of people who immigrate to this country do it for two things: Freedom and Opportunity. They don’t come for the food stamps and MediCaid. Obama’s policies have diminished both our freedom and our opportunity, and if left uncontested they will do more damage.

      As for the Brits and Canadians–I guess we do travel in different circles. [end response by Dr. Pagano]

      Comment by clarespark — November 24, 2010 @ 5:18 am | Reply

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