Is Insurance the Problem With Health Care?
Yesterday's Wall Street Journal (requires paid subscription) points the way to one possible element to better health care: cash. It is in a story titled "Pay-as-You-Go M.D.: The Doctor Is In, But Insurance is Out."

Dr. Robert S. Berry operates the Patmos EmergiClinic, which does not accept insurance. Patmos, it turns out, is an acronym of sorts for "Payment at Time of Service." Cash, please, in other words. No lengthy forms. No co-pays. No collecting receipts to turn into the insurance company. No lengthy waits to see if the insurance company will pay up, and if so, for how much. And for the doctor, no need to hire anyone to push paper.

While Berry's services are not for everyone, his idea has a place in the health care debate. Simply put, one problem with the health care system is that we spend too much on the system--a system of third party-payments, insurance regulations, and administrative review.

By taking out the "system," prices for actual services plummet. While a typical office visit in eastern Tennessee, where Berry works, is $55, Berry charges $35. A blood test that costs at least $100 elsewhere is $20.

The Journal story mentions another cash-only doctor, Todd Coulter, of Mississippi. "I was tired of being dishonored and disrespected [by insurance companies.]" Now, he says "I don't have to spend all day begging Blue Cross & Blue Shield for money." Since Coulter went all-cash, he dropped the fee for his office visits from $60 to $40; his expenses have dropped 35 percent.

Is this a realistic model? It works well for people who must, for whatever reason, pay cash. For example, some of Berry's patients are Mennonites, who shun insurance for religious reasons. Without insurance, they have had a hard time finding doctors willing to see them.

But even the general public may find this kind of arrangement worthwhile for some services. One of Berry's patients has to pay a $20 co-pay when she charges her visits (elsewhere) to her insurance company. That's nearly 60 percent of the way to what she pays Berry out-of-pocket. "For the extra $15," she says, "it's worth coming down the street." Combined with Medical Savings Accounts (MSAs), which allow people to accumulate money for out of pocket expenses, cash-for-service could make a valuable contribution to health care.

One group that is connecting doctors and patients in a return to the cash society is the American Association of Physicians and Providers, which promotes cash-only services under the name of SimpleCare.
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Michigan Schools Could See Less Money
The Lansing State Journal says that schools could receive $196 per pupil less than expected. It's the fallback position if the state can't find other ways to make up a deficit. Don't feel too bad for the schools, though: they already get state aid ranging anywhere from $6,700 to $11,000 per student.

In response to the challenges facing the state, the Michigan Education Association (MEA) takes a courageous and innovative stand. Uhm, No. It wants to raise taxes. You'd think that a teachers' group could come up with a smarter, more responsive response than that.

HOLD THE PRESSES. The Detroit Free Press tells us that the MEA does have a better idea after all. They say that government school districts have $1.8 billion stored away. They want schools that have the funds to spend them before getting more state aid. The idea is to make the state money go farther. And, of course, to increase pay rates for MEA members.
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States Freezing CHIPS
A number of states have stopped enrolling new beneficiaries in CHIP, a government-run heath care program for children whose parents are not poor enough to qualify for Medicaid. The reason: tight budgets.

This story from Stateline teaches several lessons. Here is the first: the existence of a government program does not mean that the people who are supposed to benefit actually do. Would you like your children's health to be the hostage of the political process, in which one program competes against another for limited dollars?

What states (and the federal government) need to do is make the cost of health care more affordable for all. This starts with curbing lawsuit abuse, which drives up medical costs. Another goal should be to promote the use of true insurance, rather than what we have, which is an expensive form of pre-paid services. True insurance will be cheaper, and won't drive up health care costs as much as the current system does.

Another lesson from this story is the need to promote charity care. The director of the CHIP program for Alabama said "“We get daily requests from folks who have children who are having crises, who need medical care and don’t know how they are going to wait until they come off the waiting list. They’re very, very concerned."

It's too bad that these people think they have to wait for government care rather than charity care. Charity care is not the complete answer to these situations, of course. But perhaps there would be more of it if people got to keep more of their own money, and spent less of it on government programs, including CHIP.
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Conceal Carry Measure Falls Short in Wisconsin
The Wisconsin General Assembly a shall-issue provision yesterday. However, the vote is two members short of that required to override an expected veto. Nearly all Republicans voted in favor of the bill, while only a handful of Democrats did.
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Illinois Proposal to Tax Hospital Beds is a Bad Idea
This policy brief from the Illinois Policy Institute (written by me, though unsigned) responds to a proposal to impose a bed tax on hospitals.

Who's behind the idea? The Illinois Hospital Association. Why in earth would they do that? Because they can simply pass along the tax to insurance companies and their biggest customer, the state. In return for spending more money, the state gets more federal matching funds, which the state can turn over to the hospitals, who say they are grossly underpaid by Medicaid. Such is the perverse incentive structure of federal health care financing.

The Institute's director, Greg Blankenship, comments on this scheme over on his blog, A New Can of Worms: "When doctors and patients game the system like this, they usually go to jail -- that is if they are caught."

When government officials do this, it's called finding a short-term solution to a difficult situation.
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Governor Tells Local Officials: Cut Now
The Ironwood Daily Globe reports on the "deficit tour" of Governor Jennifer Granholm. Appearing in Marquette (the largest city in Michigan's Upper Peninsular), Granholm told the crowd, "For those of you in government I have two words -- 'Cut now.'"

The governor and legislature worked hard to plug a deficit hole over the summer. But now, officials expect a $920 million shortfall. That's put spending on government schools on the table for consideration. The governor suggested that "We have an opportunity to create government that is lean and nimble." Well, yes. There are many ways to cut spending, and make government both more efficient and more effective. But instead of trying to do the same with less, perhaps it ought to try to do less with less.
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Self-Government Won't Work Without Self-Discipline
I thought of that old adage, popularized by Paul Harvey, when I read about the 43-year old father who vandalized a house when his son reported not receiving any Halloween candy from the homeowner.

Ok, it's trick or treat, but "tricks" have long passed the point of being acceptable.
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Dumb Growth Advocates Elected to Town Council
Advocates of dumb growth and weak communities were elected to the Birmingham (MI) city council. At least that's the impression you would get from reading this account in the Detroit Free Press.

Advocates of so-called "smart growth" were defeated at this week's municipal election. (This would make opponents of planned congestion and small houses ... Advocates of "dumb growth," correct?) Those turned out of office had, as the Free Press described it, "favored strengthening neighborhoods." (This would make "dumb growth" advocates in favor of "weak neighborhoods"?)
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Test Scores Down, Participation Up In Michigan
Officials in Michigan are trying to interpret the latest results of the MEAP (educational achievement) tests. The percentage of students passing the standards for math slipped to 60 from 67 last year. Sadly, only one out of three falling below the standard is pretty good these days.

Some schools say their rates may be affected by the fact that more students took the tests this year. Previously, there was a conflict between the dates for the MEAP and some tests for Advanced Placement (AP). Since AP students tend to be the highest achievers in schools, one would expect that MEAP scores would go up. It's hard to tell from this Detroit Free Press article if that actually happened anywhere.

Meanwhile, the Detroit News takes a more critical view of things.
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Odd Timing
Earlier this week, we got our first "real" snow; that is, it lasted for 24 hour hours before it melted. And on the same day that the snow fell ... I received in the mail my first issue of Golf Digest.
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Working Poor Need Autos, Not Bicycles
Unless you happen to live in a very small geographic area--Manhattan, say--you must have a car to fully participate in American life and work. So who's standing in the way of the working poor getting access to better jobs? Some advocates of mass transit.

Wendell Cox and Ronald Utt observe that 20 percent of federal transportation dollars are spent on mass transit, which serves only 2 percent of travelers. Further, transit's share of urban travel has plunged to that level from 7 percent in 1960.

As it turns out, roughly 2 of every 3 transit riders are from low-income households. Given the choice between the flexibility of having a car and the inflexibility of depending on transit, most people opt for the car--if they can afford it.

Some scholars advocate giving the poor money for automobiles. (The Buckeye Institute found that it would be cheaper to lease new cars for transit riders than it would be to build a rail system.) Federal rules were changed a few years ago to make it easier for the poor to have a car.

The Surface Transportation Policy Project doesn't like this, though, and wants to make sure that federal policy discourages the working poor from achieving one of the badges of economic self-sufficiency, automobile ownership. It favors funding bicycles and transit.

Bicycles? Fine for recreation. But as a public policy, it's So 19th century.
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This Should Upset the Librarians
Sometimes, good ideas become bad ideas when they are used inappropriately and divorced from other good ideas. A good case in point is the confidentiality of library records.

Whether or not a state agency has the right to inspect a person's library record is an important question. It is, for example, one of the contentious issues under the Patriot Act. But what should not be an issue is whether parents have the right to inspect the library records of their minor children.

Librarians, who serve as champions of freedom of information, overstep their bounds and good sense when they apply this principle to minors. It's not an absolute principle, and must be tempered with ... well, reality. There's a reason (many, really) why some people are called "parents", and some are called "children," and anyone who can't tell the difference between the two needs a little bit of education.

The Wisconsin General Assembly is now set to establish a law giving parents access to the library records of their minor children. This takes the government out of the role of wedge between parent and child.

The measure came about after one couple received an overdue notice from a library, for books checked out by one of their children. The parents were not sure what book(s) the overdue notice was for, and asked a library staff for more information.

Even though the parents would be financially responsible for replacing any lost books (I'm going out on a limb on this point), the library said that the information was privileged, and could not be revealed except to the minor child.

The privacy-at-all-costs advocates omit one fact: minor children are, well, minors. And if they want to read books without their parent's knowing about it, there is always in-library reading.
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Drivers Licenses for Illegals?
Illinois is considering a proposal to allow illegal aliens to obtain drivers licenses. The PolicyGuy is not a champion of closed borders, but one quote from this Daily Herald article is bizarre. An advocate of the measure said "We think it is fair to give these people driver's licenses in order to get to work and not be breaking the law by doing it."

By their very act of being in this country without going through the official procedures that millions of other people have gone through these "undocumented" folk are, well, illegally here. They've already broken the law.

Immigration policy needs some fixing, but a dual track--you're not supposed to be here, but, well, have a drivers license--is unsustainable.
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Where Art Thou, FDA?
The Knight-Ridder newspapers continue a series on off-label use of prescription drugs. Today's installment goes after the FDA for weak enforcement.

It has gotten one thing right. "The bottom line for consumers: Beware." People have died even when they use medicines in FDA-approved ways, and people have lived better by doing things not approved by the FDA.

The old rules--still on the books--say that pharmaceutical companies can advertise only in ways approved by the FDA. If they say that such-and-such a drug may be suitable for condition X, they must first get FDA approval for doing so. But does the FDA have constitutional authority over medical publications in which doctors write about how a new drug has worked for an off-label use? Not exactly. "Proposals to restrict drugmakers' efforts to get around the ban on promoting off-label drug uses ran into a blizzard of legal challenges by the Washington Legal Foundation, a free-market advocacy group. On free-speech grounds, the courts turned away many of the FDA's arguments."

One final comment: the reports mention stories of people who have suffered, and even died, after undergoing off-label therapy. I don't recall any stories of people who have benefited from off-label use.

The deaths and illnesses mentioned are certainly tragic. They are not, though, in themselves a blank check for the increased regulation--on the freedom of the press, on the doctor-patient relationship, and who knows what else--required to eliminate off-label use.
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More Money Than Sense
Voters in Ann Arbor, Michigan, have decided that more government is a luxury good. Yesterday they approved a tax hike to purchase "open space." Then again, no one should be surprised; in a university town, all sorts of things are possible.

Freedom of choice in neighborhoods (sometimes expressed in what is derisively known as "sprawl") has gotten a bum rap of late. This vote will likely encourage similar measures elsewhere, even though a Mackinac Center study on the main farmland preservation program in Michigan found it has failed.
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Would be Funny if it Wasn't True
According to The Onion, Americans Demand Increased Governmental Protection From Selves. Writes this satirical newspaper, "Alarmed by the unhealthy choices they make every day, more and more Americans are calling on the government to enact legislation that will protect them from their own behavior."

The newspaper "quotes" several individuals who call for "greater guardianship," including "Rebecca Burnie," who says "I'm $23,000 in debt, but the credit-card companies keep letting me spend. It's obscene that the government allows those companies to allow me to do this to myself. Why do I pay my taxes?"

Also appearing in The Onion article are several bogus organization that have real life analogues, including "the American Citizen Protection Group," and a Christian group called "Please God Stop Me."

As I said, it would be more humorous if it wasn't so close to the truth.
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Health Insurance Among Small Employers
According to a survey of small business owners conducted by the National Federation of Independent Businesses, roughly half of all small companies (48 percent) offer health insurance to their employees. The smallest of small companies--those 9 or fewer employees--are least likely to offer insurance plans (41 percent); larger companies (those with 20 or more employees) were more likely to offer insurance, checking in at 79 percent.

Most small companies that did offer insurance limited their offerings; 83 percent had a single plan. Premiums averaged $402 for single coverage and $732 for family coverage. (Premium amounts include employer and employee contributions.)

(I cannot find the survey on the NFIB website; the results are summarized in today's WSJ, "Less Than Half of Small Firms Offer Health Plans.")
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Conceal Carry Claims Oversold?
The Milwaukee Journal-Sentinel says that both advocates and opponents of shall-issue laws overstate their case.

If that's the case, why not err on the side of granting individual liberty, and pass the Wisconsin bill?
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Chicago May Apply "Sledgehammer" to Residents, Others
Alderman Edward M. Burke wants the city to impound the cars of people who try to sell their autos on the street.

Alderman Burton F. Natarus, meanwhile, says that the city ought to give an exemption to people who sell the cars outside their own residences. That seems like a reasonable approach--though that may mean that a person may have to remove the sign each time he visits a friend in another street, lest the car be towed.

One force behind the move: local car dealers, who don't like the competition.
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The Governor Who Stole Christmas
Governor Jennifer Granholm (D-Michigan) has been a surprisingly good manager of the state's budget. She has, with the Republican legislature, worked out a plan to balance the budget without widescale tax increases. And she's running a touchy-feely campaign to shore up the morale of state workers, who may see their pay, but not hours, cut.

Now I wonder if she's able to be labeled "The governor who stole Christmas." Several Detroit-area cities are cutting back on Christmas lighting displays, citing reductions in money from Lansing.

Give credit to the leaders of city government in Livonia, Berkley, St. Clair Shores, and Harrison Township for making unhappy, though necessary choices. Jack Kirksey, mayor of Livonia, says that putting the lights up cost the city $75,000 a year, and that before the cost of electricity. The Detroit News says that "If Kirksey had an extra $75,000 in the Livonia budget, he'd probably use it to hire another firefighter or police officer -- not to keep Livonia's 70,000 holiday lights twinkling this year."

The News is surely overwrought when it says that such displays "come dangerously close to the hearts of their communities." Rather, the work, worship, and gatherings of family and friends of people represent "the hearts of their communities." Lights are nice (I know, I used to greatly enjoy the lighting displays in the New England-style small town I used to live in). But are they a core function of government? Are they preferable to a new police officer, or buying new equipment for the fire department? I don't think so.

Totally absent from the News account: the suggestion that private individuals and communities would, out of community spirit, take over the role of supplying and installing the Christmas lights. (Christmas? We're barely out of October! Good grief, Charlie Brown!)
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Prison Lawsuit Over ... For Now
In 1988, a group of prisoners filed suit against the Michigan Department of Corrections. This suit was resolved ... this week.

At issue over the years, whether prisoners should have color televisions or were black and whites sufficient. (I wonder if the origins of the song I Want My MTV lie in this case?)

Now, the fact that prisoners can sue the state is probably a good thing. A person does not lose all his constitutional rights in prison. Lord Acton said "absolute power corrupts absolutely," and there are fewer places where one person has more power over another than in a prison.

Yet, this case, which has run for 15 years and has cost state taxpayers millions, shows that the legal system is out of control when it comes to prison lawsuits. As the Free Press account notes, "a lawyer for the prisoners acknowledged that the original claims have mostly been dismissed." Makes me wonder how strong the case was in the first place.
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Off-Labeling Story Blasts Pharmaceuticals
As I expected, the Knight-Ridder series on the off-label use of prescription drugs has turned out to be another tool to bludgeon pharmaceutical companies with. The subheadline of the installment in today's Detroit Free Press: "Pitches lucrative for companies, unsafe for patients." In other words: government good, companies bad, doctors foolish, patients stupid.

There's a reason why we call it the practice of medicine, though. What works for one person, or even hundreds of people in a clinical trial may not be what is best suited for another. Somewhere in here, there ought to be a place for the patient and the attending physician.

The story sings the songs that the price controllers have sung over the last two years: physicians are duped by large, greedy companies; your health is at risk from a doctor who sold his professional soul for a Prozac mousepad from the sales rep. That's the first verse. The second verse is that advertising to consumers is wasteful. This all reminds me of the old chestnut that free markets are inherently wasteful, while centrally planned economies are more efficient. No money down the drain on marketing, you see.

Off-label use can be dangerous. It can, however, be just the ticket for some situations. They solution to this "problem" is not more government regulation, but more knowledgeable and aggressive consumers. Thanks to the Web, which exponentially expands the availability of medical resources, it's starting to happen. So we're in a race, and I am not sure who will win: the empowered consumer, who will insist on making his own decisions, or the even more empowered government agency, which will dictate "best practices" for all.
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The Rise of the Alternative Media
A while ago, "alternative" when applied to media source would mean statist or at least progressive. While this still applies to some newspapers (e.g., the Village Voice), there's been a whole 'nother set of alternative media that is aggressively anti-liberal (in the American sense) or conservative.

Brian C. Anderson writes of these alternative sources of information in a long discourse published in today's OpinionJournal. He describes three forms of new media: cable TV networks and programs (think: Fox News); Internet blogs (InstaPundit, AndrewSullivan); and book publishers (Regnery, Spence).

Anderson's article comes from City Journal, a fine "highbrow" policy-oriented magazine, so essay on OpinionJournal is rather long, though quite readable.

It does a powerful review of how "South Park" does a better job of sending up political correctness than just about anyone. Since it heavily quotes from SP dialogue, this part of the article is crude. But it's also, surprisingly (to me, at least) quite funny.
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Illinois Budget Numbers
The Quad Cities Times reports on the Illinois state budget. The state responded to a budget shortfall "with a state budget built around untested financial maneuvers, one-time sources of revenue and controversial tax and fee increases."

Among the results so far: a proposal to tax the sale of private airplanes has brought in just barely half of expected revenue. A new tax on trucking has brought in only $13 million. Even the hoped-for sale of a state office buildings has not brought in the money yet, since the deals has not been completed. People always respond to tax incentives--which often means that increased tax rates don't always lead to the amount of increased tax revenues that the tax-raisers hope for.

Sounds like the politicians need to dig a little deeper into the toolkit to come up with ways of addressing a perilous budget situation.
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Feds Rate Home Health Care
The Centers for Medicaid and Medicare Services has started compiling consumer reports on nursing homes and home health care. By making "report cards" available to the public, the agency may do some good by doing so it facilitates consumer choice.
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Government Economic Development Officials: Don't Be Cute
Dawson Bell, writing in the Detroit Free Press, ponders the effectiveness of branding a state or region's economy. Call it industrial policy on the cheap. There is, for example, the Technology Tri-Corridor. And then there's simply "The Core." Where do you think "America's Technology Corridor" is? Here's a hint: it's nowhere near San Jose, home of "Silicon Valley," the one nickname that has stuck. "Automation Alley," meanwhile, looks most favorably upon businesses that provide lots of jobs--in other words, "Automation Alley" is best suited for firms that are not automated.

Marketing is too often an attempt to substitute style for substance, a form of feel-good imagery put in place when reality is less-then-desirable. This is true both in the private sector and in the public sector. And in the case of public-private attempts at boosting economic development, clever marketing tags are a poor substitute for what will help: low tax rates, a low-cost and transparent regulatory process, and functional school systems.
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Newspapers Don't Get It
I'm not a media critic by vocation, but a couple of words here. Both the Chicago Tribune and the suburban Daily Herald are sloppy in their website design. Click through, from the main page, to either DuPage County (Herald) or West suburbs (Tribune), and you will, in fact, find stories from DuPage County. (DuPage is the county immediately west of Cook, home of Chicago.)

But you will more often than not also find stories from the north or south suburbs of Chicago as well--counties that already (allegedly) have their own links/sections. So why are north suburban stories in the portion of the website devoted to the western suburbs? The web is all about allowing customization, but these two papers (and, I am sure, others) don't always do a good job of using that ability.

Just a cranky comment for the morning.
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Wisconsin Conceal-Carry Update
The Milwaukee Journal-Sentinel says that 69 percent of people surveyed oppose a proposal "to allow people who can legally own handguns to carry concealed weapons in most public places." Proponents criticize the language of the survey.

The question still remains: will Badger state backers of heat packers be able override an expected gubernatorial veto?
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Laws May Be Designed to Help, But Help Yourself First
Norma Jean Goben, 60, was struck and killed by a garbage truck as she attempted to cross the street in a non-signalized pedestrian crosswalk. Pioneer-Press columnist Ruben Rosario notes that such crosswalks--painted lines in the middle of a block, for example--"gives pedestrians, particularly older citizens, a false — and sometimes deadly — sense of security."

Nationally, Rosario says, one pedestrian is killed every 2 hours. In a sad case ounintendedec consequences, "A study last year by the University of Washington found that marked crosswalks in general doubled the risk that pedestrians 65 and older will be struck by an oncoming vehicle."
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Off-Label Use of Prescription Drugs Growing
The St. Paul Pioneer-Press is running a series on the off-label use of prescription drugs. Off-label use refers to the use of drugs for a purpose other than that which the FDA has granted approval.

According to the Knight-Ridder newspaper chain (which owns the Pioneer-Press, the Detroit Free Press, and Miami Herald, among others), 115 million off-label prescriptions were written last year. Among the uses: epilepsy drugs for depression, and asthma drugs to delay premature labor.

While the chain admits that "For patients with rare, intractable or fatal illnesses, off-label prescribing is sometimes appropriate," and "there may be gold-standard studies backing an off-label use," the tone approaches fear-mongering, and a call for greater FDA regulation of drug use. It quotes one FDA internal memo expressing disapproval of one premature-labor prevention therapy: "This case could be viewed as a conspiracy to circumvent the FDA approval process."

The second story in the series goes, not surprisingly, after pharmaceutical companies for employing sales representatives who offer product samples to doctors. Sometimes, the samples are used for an off-label purpose.

This all has the feel like a call for government-dictated "best practices" for the use of every medication. Given the genetic and other differences among human beings, as well as the slowness with which the bureaucracy responds to the need for change, I am not sanguine about standardizing medical care through government agencies.
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