For years, I have been complaining about a system that pays for procedures but not care. Has someone heard me? I doubt it. It isn’t the need to improve care, unfortunately, that has brought this about. It is the need to contain costs. What an idea! With one central doctor to coordinate care, there would be more efficiency in that care, fewer mistakes, fewer duplicated and costly tests. Seems to me this used to be called family medicine.

As a patient, I try to take an active role in my care.. That can be difficult. Like the time I said that I didn’t need a battery of blood tests because I had had them just two months before and they were all normal. The looks that I got were interesting. This upstart patient trying to second guess her physician! It was like the time that I said I didn’t want a chest x-ray before surgery. If my lungs sounded clear, why did I need it? Or the time I demanded to see a faculty anesthesiologist rather than deal with residents who had had about one weeks training. I kept insisting (I have had reactions to anesthetics.) until it was obvious I was holding up the surgery schedule. No points gained there. Just some assurance for me that the original mistake would not be repeated. And there was the time I was reading my chart on the way to surgery when I found the lab results for two other people in my chart. Two absolute strangers were part of my medical record! That got their attention. And so it goes.

One very wise physician I used to work with told this story. His patient had broken her hip so he called in the orthopedic surgeons who in turn called in a cardiologist since she was of an age. He felt she was in good hands and left the care to others until he received a call from his patient’s daughter.

“Mother is having some problems with discomfort and with constipation,” she complained. “She has a surgeon to repair her hip, She has a heart doctor to care for her heart. But who is taking care of Mother?” Just who was taking care of all of her—the whole person?

If it takes a push for efficiency to bring about this return to old time medicine when your family doctor coordinated your care, I will applaud loudly. And all you patients out there, let your voice be heard. This is the best news from the field of health care in many a blue or any other colored moon.

http://www.nytimes.com/2008/07/21/business/21medhome.html?ref=health

What is too much and what is not enough? You are going to hear those questions often in the coming years. There are no studies on what is good medicine for the elderly. And now there are many of them with the number growing. According to the Census Bureau, there were 92, 422 centenarians as of June. It may be over a million by 2050.

http://www.nytimes.com/2008/07/18/health/18old.html?emc=tnt&tntemail0=y#

Have you ever talked to y our family about what kind of care you want as you age? Families have an attitude of, “Nothing but the best and the most for my parent.” Do you really want that? What should we as a society support? In Europe, the elderly are less likely to get cardiac repairs or implants. Who is right?

There are a number of reasons that doctors do every test imaginable on patients. There is always the threat of malpractice. But that only represents a small percentage of the health care dollar. They learned about the tests in medical school and no one questions when or where they are most appropriately used. Patients demand them. And what do patients know?The best practice concept has yet to permeate the medical society. Just look at statistics on what type of medicine is practiced in different area of the country.

http://www.aafp.org/fpm/20040200/51maki.html

https://www.ctnbestpractices.org/networks/nih-ctsa-awardees/mayo-clinic-college-of-medicine-rochester-mn

http://www.dartmouthatlas.org/

There are calls being heard for a streamlining of Medicare along rich and poor lines. Convincing some rich old geezer who made his millions through tough times and hard work that he is not entitled to his Medicare benefits may be a very hard sale.

Why are there no calls for taking welfare for insurance companies and drug companies who are reaping large profits on the current non-competitive system before we jump to the rich man, poor man scheme? It is discouraging that when political calls are made for change they do not include the health care system.

http://www.nytimes.com/2008/07/20/business/economy/20view.html?emc=tnt&tntemail1=y

Fred Kaplan of Slate reviews the candidates’ speeches on Iraq and Afghanistan from yesterday and highlights a disturbing tendency from John McCain.

It’s a happy coincidence that Barack Obama and John McCain both gave speeches on Tuesday about Iraq and Afghanistan. The big difference between the two is that Obama views the wars as problems, while McCain pretty much does not. In short, while Obama’s analysis has some lapses and holes, at least it is an analysis; McCain’s is a bit of a fantasy.

Here’s the problem: The U.S. Army is stretched so thin that, according to its own calculations, no extra combat units can be sent to Afghanistan unless the same number of units is pulled out of Iraq. There is no flexibility here. So if McCain wants to put three more brigades in Afghanistan, where is he going to get them?…If McCain wins the White House, the first thing the Joint Chiefs will tell him is that they don’t have the resources to fulfill his war aims.

McCain’s fantasy world is one in which there is an endless supply of troops and willingness of their families and our nation to sacrifice them for the heroic military crusades that he is sure will transform our world into a better place.  More broadly, it is a place where the numbers don’t have to add up.  He can extend the Bush tax cuts, eliminate the Alternative Minimum Tax, add new tax breaks for corporations, continue to spend $10 billion a month in Iraq indefinitely, hike our expenditures in Afghanistan and balance the federal budget by 2013.

McCain’s policies may differ from those of Bush in some areas (global warming, stem cell research, spending) but here he shows a frightening resemblance to Bush: he sees what he wants to see and dismisses credible evidence to the contrary.  He dumbs down our political discourse by offering nonsensical proposals that insult the intelligence of the electorate.  Faced with this absurdity, at least Kaplan actually digs into the candidates’ proposals and evaluates them rather than reporting them in a mindless "he said, she said" manner that fails to separate the wheat from the chaff.

Ezra Klein of the American Prospect nails the difference between the Obama and Bush/McCain approaches to Islamic extremism.

A few months back, Mitt Romney, who’s now on John McCain’s short list for the vice presidency, said, "I don’t want to buy into the Democratic pitch, that this is all about one person, Osama bin Laden. Because after we get him, there’s going to be another and another. This is about Shi’a and Sunni. This is about Hezbollah and Hamas and al Qaeda and the Muslim Brotherhood. This is the worldwide jihadist effort to try and cause the collapse of all moderate Islamic governments and replace them with a caliphate."

The Egyptian Brotherhood isn’t a terrorist group. al Qaeda, a Sunni terrorist group, hates Iran and is rivals with Hezbollah, a Shi’ite extremist sect. This statement, in other words, made no sense. It was a war against Arabs, and maybe some Persians. not a limited conflict against al Qaeda. As Obama says, one of the clear distinctions between the Left’s approach to terrorism and the Right’s approach to terrorism is that the Left wants to limit the scope of the conflict, while the Right wants to expand it. So though it was only al Qaeda who attacked us on 9/11, Romney and Giuliani and McCain and plenty of their colleagues want to zoom out from al Qaeda to terrorism, and from terrorism to Islamic extremism. Rather than this being an effort to hunt down al Qaeda, it becomes a war to hunt down al Qaeda, destroy Hezbollah, eradicate Hamas, overthrow Saddam Hussein, change the regime in Tehran, crush the Muslim Brotherhood, and confront Syria, and whatever else Bill Kristol thought of while eating his Cheerios that week. It is an incredibly dangerous and incoherent approach. And it marks a genuine difference between Obama and McCain.

Two perceptive writers point out lessons the Democrats need to learn in order to win in November.  Speaking specifically about the need to break from slavish support of antiquated teachers’ unions, Newsweek’s Jonathan Alter suggests a perspective with broad applications.

All the criticism of Obama’s moving to the center is misguided. General elections are won among moderate swing voters, many of whom would respond well to a Democratic candidate willing to show he can slip the ideological stranglehold of a retrograde liberal interest group.

Theda Skocpol delivers a similar message on TalkingPointsMemo.com.

I look back over an adult lifetime of this, of identity-oriented and single-issue groups undermining any chance for a convincing message relevant to all working middle class people. This lack of discipline and inability to sort out the fundamental from the partial is what has made it so hard for Democrats to win — and has cost the country terribly in terms of the undermining of middle class wellbeing. Why are we doing it again? Why are we playing along with all the diversions and distractions the media wants to pursue, rather than speaking loudly with one voice for Obama and in drumbeat criticism of McCain?

I have been kind of depressed ever since that morning at the diner, especially because the supposedly progressive blogs are full of similar kinds of diversions — and Obama’s campaign is clearly being hurt by the lack of unity and discipline, as well as by its own tentativeness. I am not so sure progressives are going to do what is necessary to win — even in this year when all the stars should be aligned. Unity and practical realism are the order of the day, and the fire must be directed outward, not inward. Can we do it?

Non-partisan web-site FactCheck.org nails John McCain on more false claims about Barak Obama’s tax policies.

McCain has repeatedly claimed that Obama would raise tax rates for 23 million small-business owners. It’s a false and preposterously inflated figure.

We find that the overwhelming majority of those small-business owners would see no increase, because they earn too little to be affected. Obama’s tax proposal would raise rates only on couples making more than $250,000 or singles earning more than $200,000.

McCain argues that Obama’s proposed increase is a job-killer. He has a point. It’s true that increasing taxes on those at the top would leave them less money for other purposes, including investment and hiring in the case of business owners. But the number of business owners who would see their rates go up would be only a small fraction of what McCain says. Many would see their taxes go down.

TSC’s unofficial fib tally (according to FactCheck) now stands at 10 for McCain to 4 for Obama.  All candidates fudge a little here and there but this is getting embarassing.  So much for "straight talk."

Chris Cillizza of the Washington Post provides some answers.

The fact that McCain trails by only four points in the poll of polls is somewhat remarkable given the developments of the last month or so.

Obama finally vanquished Hillary Rodham Clinton in the primary race, a win that provided him a huge amount of attention in the national media — coverage that seemed to suggest, albeit it subtly, that the hard part of the race was over for the Illinois senator.

McCain, on the other hand, has weathered a series of stumbles — his widely panned speech on June 3, an address that will forever be defined in political history by the lime green backdrop behind him, a staff shakeup, former Senator Phil Gramm’s "mental recession" comments — that have hijacked his message for weeks.

Cillizza believes that the strength of the McCain brand as a "straight talking reformer" seems to overcome the campaign’s stumbles (and his own flip-flops on multiple issues according to Glenn Beck).  Cillizza also suggests that independents in particular are not sold on Barack Obama, perhaps because of his so-called tack to the center.  He concludes that the race is still in its early stages and McCain must still overcome strong hostility to Bush and the GOP.

Repeat after me. “Private is not always better.” And, “Government regulation is not all bad.” These phrases represent the ideological thinking that has battered an already weak Medicare. Congress let the private insurers in and they are sucking life blood out of the system. Touch them, congress, and you risk a veto.

We pay the private insurers more than the cost of original Medicare We are subsidizing the insurance companies. Welfare for the insurers.

http://www.nytimes.com/2008/07/14/opinion/14mon1.html?tntemail1=y&_r=1&oref=slogin&emc=tnt&pagewanted=print

When will we learn that if we give money to people or compani3es, it has to come with rules. Take a long look at the German health care system. I has been in place for 125 years and the Germans like it. The doctors moan a bit. They earn one third less than American docs. They still earn more than lawyers and other professionals. What makes it work are the rules which govern how the money is spent. While there are some 250 private insurers, what they charge and what they spend is regulated. Workers and employers contribute but for the employer, it costs less than in the US. In Germany, 0.2% of people are Most of them are illegal aliens. In the US 18% or 47 million are uninsured.

Are we so short sighted and stubborn that we refuse to learn from those who seem to be doing it right? The only answer seems to be sadly, yes. When we bankrupt Medicare, where will we go from there?

http://www.npr.org/templates/story/story.php?storyId=91971406

So says US Army Lt. Col. Christopher Kolenda about the fight against the Taliban and al-Qaeda in the Afghan-Pakistani border region in a column by Nicholas Kristof in The New York Times.

Since 9/11, Westerners have tried two approaches to fight terrorism in Pakistan, President Bush’s and Greg Mortenson’s…Mr. Bush has focused on military force and provided more than $10 billion — an extraordinary sum in the foreign-aid world — to the highly unpopular government of President Pervez Musharraf. This approach has failed: the backlash has radicalized Pakistan’s tribal areas so that they now nurture terrorists in ways that they never did before 9/11.

Mr. Mortenson, a frumpy, genial man from Montana, takes a diametrically opposite approach, and he has spent less than one-ten-thousandth as much as the Bush administration. He builds schools in isolated parts of Pakistan and Afghanistan, working closely with Muslim clerics and even praying with them at times.

Mortenson, a US Army veteran from Montana, arrived at the idea after being nursed back to health in a remote Muslim village after a failed attempt to climb the famous Himalayan peak K-2.  In return, he built a school for the village and discovered a calling.  Mortenson’s best-selling book Three Cups of Tea describes his experiences.

He secures a commitment from a village to demonstrate "buy-in" by providing land and labor to build a school.  He provides funding and building materials through his aid group the Central Asia Institute.  Aside from being kidnapped for a week, Mortenson and his schools have largely been left alone by radical groups that have attacked other Western aid groups due to the stake in the schools by local people. 

The project has focused on including girls since finding that educated mothers are better able to restrain their sons from joining radical Islamic groups. The Pentagon has shown interest ordering a number of copies of Mortenson’s book and inviting him to speak.

Military force is essential in Afghanistan to combat the Taliban. But over time, in Pakistan and Afghanistan alike, the best tonic against militant fundamentalism will be education and economic opportunity.

So a lone Montanan staying at the cheapest guest houses has done more to advance U.S. interests in the region than the entire military and foreign policy apparatus of the Bush administration.

Much has been made about Barack Obama’s so-called move to the political center since becoming the presumptive Democratic nominee.  Criticism from the left was summed up by Bob Herbert in the New York Times.

One issue or another might not have made much difference. Tacking toward the center in a general election is as common as kissing babies in a campaign, and lord knows the Democrats need to expand their coalition.

But Senator Obama is not just tacking gently toward the center. He’s lurching right when it suits him, and he’s zigging with the kind of reckless abandon that’s guaranteed to cause disillusion, if not whiplash.

Other center-left commentators offer a different view.  Gail Collins followed Herbert’s column in the Times with one asking "what did you expect?"

Think back. Why, exactly, did you prefer Obama over Hillary Clinton in the first place? Their policies were almost identical — except his health care proposal was more conservative. You liked Barack because you thought he could get us past the old brain-dead politics, right? He talked — and talked and talked — about how there were going to be no more red states and blue states, how he was going to bring Americans together, including Republicans and Democrats.

Exactly where did everybody think this gathering was going to take place? Left field?

When an extremely intelligent politician tells you over and over and over that he is tired of the take-no-prisoners politics of the last several decades, that he is going to get things done and build a “new consensus,” he is trying to explain that he is all about compromise. Even if he says it in that great Baracky way.

Clarence Page of The Chicago Tribune, who may know Obama better than most pundits, said similar things in today’s column.

Much of Obama’s perceived shift in positions comes because he was not pressed on the issues that much earlier. He navigated the primaries as a Rorschach candidate, an inkblot test in which Democratic voters tended to see what they wanted to see, not always where he actually stood on various issues.

That’s why Obama appears to be following Nixon’s old dictum: Run toward your party’s base in the primaries, then move back to the center for the general election. Bill Clinton did the same, calling it "triangulation." Obama’s taking a risk by following the same strategy, but he’s smarter to lurch to the middle of the road in midsummer than to risk becoming road kill in the fall.

Obama’s shift on FISA has been particularly disappointing.  However, I am convinced that "the partisan fight" isn’t winnable by either side and that the collateral damage sustained in waging it is unacceptable.  I am willing to accept some less-than-ideal compromises in the name of moving forward with solutions over ideological posturing.