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Below are the 20 most recent journal entries recorded in CMR: Chief Middle-management Resident's LiveJournal:

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Friday, December 10th, 2010
6:50 pm
Convergence and Divergence of Health and Health Care

As I participated in the Hope Street Group project to Re-Invent Primary Care, I came to think about how medicine is at a unique opportunity to both converge and diverge at the same time. This creates some tension as different stakeholders favor going in opposing directions. However, I think there is a framework that will enable us to strive for a healthier society. To do so, we should recognize that "health care" is really two things: 1) maintaining health and 2) treating illness.

Maintaining health should be primarily the responsibility of patients and communities. Physicians are, let's be honest here, not really trained to think about maintaining and promoting health and healthy behaviors. These behaviors should be taught in school, supported by the design of communities, and re-enforced by cultural ideals. The health care system (clinics, hospitals, etc) is not the ideal place to instill such education about health. It would be best to decentralize the way we promote health and healthy behaviors. Instead, these should be "outsourced" to families and communities in order to create a culture of health. As a society, we should emphasize that maintaining health is the responsibility of patients.

How? Tough question, for sure. But social and personal media can help -- just think if your cell phone kept track of how far you walked every day, or if your grocery discount card also provided feedback on your diet (in comparison to ideals and other people). This is a realm of huge potential for innovation, particularly if patients/consumers know it is their responsibility to find the tools that work for them.

This is the divergence -- maintaining health as the responsibility of the individual and community. There will be roles for policy changes related to food subsidies, zoning codes for fast food, etc, but the bulk of the power still lies with the individual (which can be encouraged through social interactions).

The opposing tension is the "sick care" system: how we treat individuals when they do become ill. Appendicitis will still happen, as will infections and heart attacks. When they do happen, patients should be treated in integrated, comprehensive care systems that know their past medical history, have a full range of treatment options available (acute primary care appointments all the way up to the ICU and cardiac surgery). When people develop acute illnesses, our system should be consolidated and coordinated to care for them.

This means the era of the solo practice - the "cowboy physician" - is coming to an end. Physicians are more likely to be leading health care teams that care for patients, seeing the patients when needed due to acute illnesses or complex cases, but coordinating care with nurse practicianers when able and appropriate.

We need an integrated, vertical health care system that can treat everything from a minor ailment to highly complex illnesses. This will require consolidation of the health care system, but not every patient and every appointment will need to be seen at a major academic institution. There is still a role for the local provider, but that provider should be connected to (no, integrated with) secondary and tertiary care centers that can pick up the care of patients that exceeds the capacity of the local provider.

So, that's how I see the future of medicine: empowering individuals with the tools and instilling them with the sense of responsibility to maintain their health, while integrating and consolidating the treatment of acute illnesses into multi-specialty health care organizations when they do occur.

Thursday, July 15th, 2010
12:09 am
My comments to the FDA advisory committee re: rosiglitazone
Thank you to the committee for taking the time to listen to our testimony today. My name is Dr. Christopher McCoy. I am the chair of the Policy Committee of the National Physicians Alliance, a national multi-specialty organization of physicians committed to restoring the integrity of our profession. The National Physicians Alliance does not accept funding from pharmaceutical or device manufacturers; I have no personal financial disclosures. I am Board-certified in internal medicine, and practice as a hospitalist at the Mayo Clinic in Rochester, Minnesota. I speak today on behalf of myself, my patients and the National Physicians Alliance. I do not represent the views of the Mayo Clinic.

I would like to make three points today:
• First and foremost, the FDA is charged with ensuring that prescription medications are safe and effective; patients and physicians must have trust in the treatments that are prescribed.
• Secondly, healthy skepticism and a thorough analysis of the all data is fundamental to advancing the science of medicine.
• Lastly, evidence has repeatedly shown that financial relationships with the pharmaceutical industry correlate with endorsement of the industries' products; furthermore, it is likely that the pharmaceutical industry amplifies the voices and views that favor its perspective.

As a physician, I make recommendations to my patients about the best treatments available. When questions are raised about the safety of medications, the public and providers look to the FDA for guidance. As a practicing physician, I do not have the time nor the expertise required to fully critique all of the complex studies that have raised concerns about the safety of rosiglitazone. Moreover, providers and patients do not have - as the FDA does - access to the original data to re-analyze and confirm the stated findings. We understand that prescription drugs have associated harms and must be used judiciously, but to fulfill my role as a physician, I need to know the extent of the risks of the medications I prescribe. To do that, we trust that FDA is fulfilling its duty to ensure that our pharmaceuticals are both safe and effective.

The episode with rosiglitazone is unfortunately not uncommon: a new medication is approved for use, it is widely promoted by the manufacturer, and then new safety concerns slowly become apparent as more data are collected. A healthy scientific process requires an active discussion about new data and conducting further studies to confirm trends. But the FDA should also determine when we reach a point when additional studies are merely delaying the inevitable and a definitive answer can be based in the existing evidence.

On my final point, a multitude of peer-reviewed articles has shown that individuals with financial ties to industry are more likely to provide perspectives that support the industry. In a review of published articles about rosiglitazone since the original Nissen article, my colleagues and I found that 66% of the authors with financial ties to the manufacturer expressed favorable opinions of the medication, while only 8% of those without financial ties were of the same opinion. This is not to imply that physicians and scientists can be "bought" by industry, but it raises the concern that the industry amplifies the voices and views of those who provide the perspective that industry wishes to promote. However, the scientific process is not a weighing of all perspectives and a pursuit of a compromise. Science search for a definitive answer to a question. Today that question is: Does rosiglitazone clearly and unambiguously meet the standards of safe and effective?

In summary, we have all pledged, “First, do no harm”. That first principle of medicine is the core of the discussing today. As a physician, I rely on the FDA to closely and thoroughly review the data regarding the safety of prescription medications. As physicians and the FDA are both beneficiaries of the public trust, we must ensure that all of our actions and decisions place the public’s health first and foremost, above all other conflicting interests. Failure consistently to do so will erode the trust that our patients have in our medical recommendations. On behalf of my patients, and my profession, I urge you to make your decision grounded in science, the deliberative process of seeking the truth, not a process of compromises and appeasing the loudest voices in the debate.

Thank you.
Sunday, April 18th, 2010
5:50 pm
Welcoming Open Arms?
The Conceal Carry movement has had significant success in the past two decades, and the Supreme Court has finally weighed in whether the 2nd amendment applies to individuals (it does).

Now we're apparently moving into the next phase of this movement: what's the fun of carrying a weapon if you have to conceal it?

This is an issue that I believe is best handled on the local level: the connotation of carrying a firearm in Kansas is far, far different than carrying a firearm in, say, Chicago. Let those decisions be made at a local level. To this point, we're also seeing a movement to invalidate local ordinances that allow specific places to ban guns (hospitals, businesses, etc) based on the desire of the owner. (It's fascinating to see how a group of people who feel their rights are being imposed upon are responding by ... imposing upon the rights of others.)

I have several concerns about unintended consequences of this movement. First of all, I actually won't be surprise to see research that shows crime (particularly armed robbery) declines in areas with conceal carry laws (though there isn't any solid data yet). While I don't believe that criminals are subject to rational behavior analysis (if they were, they wouldn't commit street crime to begin with), but there probably is some truth to the thought that if a criminal believed that there was a strong possibility that his intended victim was armed and would actually harm him in the encounter, the criminal mind might pursue crime in a less risky manner (such as property crime rather than armed robbery). (Note: doesn't open carry actually work against this? Conceal carry created "herd immunity" -- criminals don't know who out there is armed ... but open carry makes it obvious who to target and who to avoid.)

One of my biggest concerns about these laws is what I'll call the "Good Samaritan Friendly Fire" problem. Say an individual hears cries for help down a alley. He pulls out his weapon to investigate and intervene on the situation. Now, say a second person also hears the same cries for help, and at the same time sees the first individual carrying a weapon, heading down the alley. Police are trained to avoid shooting each other, and yet it still unfortunately happens. Citizens don't have that training, and are probably more prone to making that mistake.

But while that's a concern, it isn't a personal concern -- Good Samaritan Friendly Fire is a risk that a gun-toting citizen should understand that they are taking, but I'm not one. However, there is a way that every citizen could be put at risk by increasing the number of law-abiding people carrying guns. While many "rational" thieves will conclude that the benefits of robbery are outweighed by the risk that the target will be armed, some will come to the conclusion that the way to reduce that risk is to shoot first, and rob second. What would have been a simple hold-up carried out by the mere threat of a weapon will become an assault rather than taking the risk of being shot. That is one "rational" response to the incentives that are being created. And one that has a worse outcome for the victims.
Thursday, January 21st, 2010
9:22 pm
The Supreme Court got it right.

So, it's been a bit of an eventful week in politics, and I wanted to weigh in on one of the more profound announcements that will potentially affect politics for years to come. I speak, of course, of the confirmation that Quinn Hunter's father is John Edwards.

Just kidding.... Well, actually Edwards *is* the father, but I'm joking that I would actually offer commentary about that National Enquirer scoop.

The big news today was the Supreme Court ruling on the Hillary Movie. Well, the ruling was about campaign finance laws, but it stemmed from the production and distribution of an anti-Hillary documentary.

I think the Supreme Court got it right.

I agree with the detractors who worry that this is furthering the "personification" of corporations, but I think it would eventually prove impossible to separate political speech by individuals and that of corporations. After all, a corporation could easily pay people to speak on its behalf. Okay, so we'd try to ban the exchange of money for speech (insane!), but that would only restrict unions and politcal action groups without barring political speech by the rich. Bill Gates doesn't have to solicit money from anyone to express his opinion widely, if he so chooses. I guess you could try to limit how rich people spend their money ... but that'd be a strikingly un-American way to promote an un-American idea of limiting speech.

It's a very slippery slope from blocking commercial speech to blocking the speech of individuals with a commercial interest in an election (like, say, tax-payers).

But this issue has more slippery slopes than Vail. As it was discussed in this case, what *is* the difference between releasing a movie before an election and releasing a book? Is it coherent to give written media broad protection, but not other forms of media? What are blogs, then? We often forget why broadcast media were once treated differently than other media: the radio frequency spectrum is "limited" and requires government regulation (in the form of protection of frequency ownership) to allow it to have value. (Without protection, we'd end up with cacophony where broadcasters would interfere with each other on every frequency, making all worthless in value.)

Perhaps what irks me most about the campaign finance issue is the fact that those that want to limit it seem to believe that people are unable to think, analyze and come to their own opinions. They are merely sheep that do what the talking box tells them to do. In the end, our democracy is founded on the decision that happens behind the voting booth curtain. No amount of money can "buy" an election with absolute certainty. Just ask Steve Forbes. (There is actually empiric evidence behind this.)

I agree that there is a worry that politicians would become (or appear) encumbered by donations by the wealthy, but that *can* be regulated. I'd like to repeat my simple campaign finance rules:

  1. Candidates for political office can accept donations only from individuals who can vote for them (registered voters in the appropriate precinct/county/state/nation).

  2. Candidates must disclose the source of all donations (above $20 or $50 or something trivial).

  3. Donations would include money and the cash-value of in-kind donations (like airtime, airplanes, etc).

There. That's all. The first rule would still restrict donations by corporations and unions (they aren't people, and so can't register to vote). Yes, monied interests could pay someone in a district to donate to a candidate, but that would have to be reported both by the candidate in the disclose. (And, curiously, to the IRS as income for that individual.)

The disclosure rule would let voters know who supports a candidate - which may not be a good thing. And the third rule exists to prevent candidates from coordinating with corporations/unions/etc. Corporations, unions, foreign governments, etc would all be allowed to buy ad time, publish books, film documentaries that push their political view -- they just couldn't coordinate with campaigns to do that.

So, rather than trying to divine if it is a corporation (not protected) or an individual (protected) speaking ... rather than trying to determine if the media is a protected form (books) or regulated (television) or something else (Internet) ... rather than flooding the courts each election with hair-splitting cases ... let's just open the flood gates.

And let the people sort out the truth, and render it behind the curtain in the voting booth.

Friday, January 15th, 2010
10:40 pm
Calling a Foul on My Own Team

As we speak, a few select members of the Democratic leadership are hammering out the final language for the health care reform. In very much the back-room dealing-making manner that they said they wouldn't resort to.

One of the signs of partisanship is the double-standard -- it's okay when my side does it, but not when the other side does. Sure, everyone attempts to explain away this by saying that this situation is different than that other situation, but just watch The Daily Show on any given night, and you'll see how flimsy those arguments are. But that doesn't stop them from being made. And if anyone does actually raise an issue with their own side's behavior, they risk being ostracized by the whole group, thereby punishing those who seek to consistently apply principles in a just way. (Aren't these the "factions" that George Washington warned us about?)

Well, that being said, I'm going to call a foul on my own team. While I (generally) agree with what we're going to get out of the health care reform, as we enter this final endgame, the methods are disappointing. Back in my LAD days, I used to show the entire "I'm Just A Bill" cartoon -- it's great entertainment, and surprisingly accurate for a 70's cartoon. But it does leave out one key step in the legislative process: the conference committee to reconcile differences between versions of legislation passed by each house. However, as we are currently learning, that conference committee isn't actually required -- using procedural steps and backroom agreements, they can get the same bill to each chamber without the official conference committee.

Why skip the conference? Well, from what I can gather, it's not because it could derail the process -- it's generally agreed that whatever came out of conference committee would get through Congress in one final vote. However, it would require several more of those hairsplittingly close procedural votes in the Senate, plus more time. So, in short, the Democrats are skipping the conference to save time, not to change the end result.

But the process matters. Or, it should matter. That's why we have laws, rules and regulations -- to establish the *way* we get things done. One of the significant strengths in our country is that while we may disagree with the content of a law proposed by the "other" side, we agree with the process for that proposal to become law (or die a quiet death in committee). It's that underpinning and consensus that lets us have debates and discussions. But it should be respected, because the desire to etch away at it for the need of political expediency is always present. And if your side contributes to that erosion, there's less there to hold the "opposition" back when it's their opportunity to make changes.

This does raise an interesting political and sociological discussion that I haven't entirely settled for myself: why are back-room discussions bad? In general, debates and decisions that are made by "representatives" should be public. Back in the day when only white men with land could vote, ballots were not secret because it was felt that since they were voting on behalf of their women and their property (both physical and human), that it was appropriate to know how they voted. As we wised up and figured out that both the woman, the landless, and the previous slaves might actually have an opinion of their own that was not represented by the pale penis people, the ballot became secret because it was now an act of self-interest to cast a ballot (what do I think is best for me and my country?).

Congressional votes are always public because this is a representative democracy -- we need to know how our representatives are voting to know if we want to keep them in office. But there is also a role for private discussions, particularly in the early stages of legislation as deals are made. Imagine how productive the process would be if everyone witnessed how their favorite project or ideal was offered up as a sacrificial bargain during negotiation? Those bargains not taken need not be know (but those that are made final should and must be publicly discussed and debated).

So, there is a role for private, backroom bargaining to hammer out the details. But the reality is that there will not be a full, public debate with back and forth negotiations and compromise in a public forum -- are we bypassing a necessary part of representative democracy? (For the most part, no -- the bill was debated in the open for weeks, but should there still be an opportunity for us to see who offered up what parts for compromise? That's the open question in my mind ...)

In terms of process, I see this as a foul on the Dems ... but not a reason for ejection from the game. There were many more flagrant fouls that were considered (using Reconciliation to pass the health care reform -- now that would have been a serious erosion of the process). But when the Dems are in the minority again (and it will happen, though probably not in 2010), they will have less trust established with their colleagues and less mutual respect for the agreed upon rules. When you are "the other side", it's best to be able to say, "Look, we followed the rules and the process to get our goals achieved ... you should too."

Wednesday, December 16th, 2009
9:00 pm
An awful smell coming from Washington
Liberal America has been overcome by nausea and malaise caused by an awful smell emanating from Washington, DC. I think it's the smell of sausage being made ...

Yes, the health care reform bill stinks. It smells to high heaven right now. It's just plain awful, and everyone near it is holding their nose and breathing through their mouths. Including the health care types, who don't even wince at the blast of a melanic stool or the stench of a gangrenous foot.

It's really bad, that thing they are cooking up in Washington. They've tossed out all of the fresh ingredients like the public option, and thrown in some seriously unhealthy stuff -- like an individual mandate to buy health insurance.

It reeks, indeed, but it's the only meal we're going to get served this year, or even this decade. And we're just going to have to swallow the swill that Joe Lieberman is dishing up if we want to have any hope of making a better health care system.

The Senate bill is undesirable for sure, but the status quo is worse. The status quo allows insurance companies to dump patients the moment they get sick. It allows insurance companies to stop paying out when patients cost them too much (and they get to define what "too much" is). And those are the people who can even get insurance -- those with pre-existing conditions are deemed Untouchables by the insurance industry.

Those are the options we face right now: reform that applies a few more patches around the edges and doesn't do much to fundamentally alter the system, or a status quo that lets 18,000 people die every year because they don't fit into the for-profit business model of insurance.

Pretty grim choices.

On one hand, we have the party that is a herd of cats. And on the other we have the Party of No! But remember, only one side is even offering a choice, even attempting to address the problems. To switch metaphors for a moment, at least the Dems are on their feet and stumbling around (occasionally even in the right direction). The GOP is plain passed out in the gutter. The GOP's hope for coming out ahead on this is that the Dems stumble into the path of an on-coming car. It's hard to describe either image as "leadership", but I'll side with the guy on his feet -- he at least has a chance of getting home.

As a physician, I know that it takes a long time and hard work for patients to take control of their illnesses and move to better health. And through every long change process, there are set backs and moments when it feels like things will never get better.
As doctors, we work with our patients through the hard times, and help them take the small steps that lead to health. We help them through the tough patches, but we don't abandon them when they have set-backs. We are partners with our patients through the whole process.

Our health care system has been seriously ill for a long time. It will take a long time to bring it back to health. We of all people should know that there isn't a magic pill that will cure all ills overnight. Our health care system has a chronic disease, that has to be overcome in small bits, day by day, through a life-long process. There is no magic solution to making our health care system better - only hard work and thoughtful effort.

Right now, we have a key moment to make critical decisions that will make the health care system better. Not every decision will be for the best, but we need to stick with our "patient" to help guide it through the long-term reform process: legislation, regulatory process, state-level responses, etc.
There have certainly been set-backs during this reform process, but we need to stay with the process and help guide the reforms, now and in the future. Our patient will not always make the best decisions - we need recognize that. And while we may not agree with those decisions, now is a critical time for us to be engaged and to continue providing our recommendations.

We need the Senate to pass something (anything!), so that we have a starting point for the debate in the conference committee. "Starting over now" will lead to a certain death - we'd be starting in a weaker place than where we were after Obama's election. This is our chance to any reform in this decade: insurance reforms, coverage expansion, malpractice models and payment reform ... all are necessary and better than than the status quo. We need to make this a victory, and use it as momentum for the next steps. Otherwise, we'll have more of the same: rapid cost increases, less insurance coverage, and more medical bankruptcies.

That smell from DC is foul, rank and nauseating. But it's better than the rotten, spoiled gruel we're eating right now.
Tuesday, November 10th, 2009
6:52 pm
Summary of HR 3962 for patients
[The below is a draft summary of the House legislation that I've created. Please feel free to add comments, clarifications, or additional questions]

What does this legislation do?
- It reforms the insurance industry to forbid basing premiums on pre-existing conditions or health status. Premiums may vary based on age, but only to a maximum 2:1 ratio between the highest and lowest premiums. Plans may no longer have lifetime or annual limits on spending, and out of pocket costs are capped. These rules apply to all plans, with time allowed for them to come into compliance. Currently existing plans will not need to meet these requirements.
- Creates a Health Insurance Exchange for individuals not covered by employers, Medicare or Medicaid. Businesses may also participate in the Exchange, starting with small firms in 2013. States may also create their own Exchanges. A Public Option will exist in the Exchange, funded entirely by its premiums (not through tax dollars).

Who is required to obtain health insurance?
- Individuals are required to have health insurance coverage. Failing to do so results in a fine equal to the lesser of 1) 2.5% of their adjusted gross income or 2) the average premium in the Exchange. Veterans and Native Americans are exempted.
- Employers must cover 72.5% of the cost of premiums for employees (65% for families), or pay into the Exchange to subsidize low-income individuals and families. Employers who do not provide qualified plans will pay 8% of payroll to subsidize employees seeking coverage in the Exchange.

How can I afford to purchase insurance through the Exchange?
- Affordability credits are provided to individuals and families with incomes less than 400% of the Federal Poverty Level ($88,200 for a family of 4 in 2009). Annual out of pocket costs for these individuals are also capped. Credits are not available to individuals who qualify for Medicare or Medicaid.
- Medicaid is expanded to 150% FPL ($33,075 for a family of 4).

Will I have to pay more in taxes?
- Taxpayers earning more than $1,000,000 (joint) or $500,000 (single) will pay 5.4% rate. There is also a 2.5% excise tax on medical devices. Contributions to health savings accounts are limited to $2,500. There are several other minor funding provisions.
- Employers must cover 72.5% of the cost of premiums for employees (65% for families), or pay into the Exchange to subsidize low-income individuals and families. Employers who do not provide qualified plans will pay 8% of payroll to subsidize employees seeking coverage in the Exchange.
- Small businesses (payroll less than $500,000) are exempt from 8% payroll contribution. Businesses with payrolls between $500,000 and $750,000 pay less than 8% on a graduated scale.

Will my Medicare coverage be affected?
- Medicare Part C (Medicare Advantage) plans will be required to limit cost-sharing (what you pay out of pocket for care) to be equal or less than traditional Medicare.

What about prescription drug coverage (Medicare Part D)?
- The Donut Hole in Medicare Part D is eliminated over several years.

Will a “death panel” pull the plug on Grandma?
- No.
- Qualified insurers are required to provide information about end-of-life planning to individuals. However, there is no obligation for a patient to establish advance directives or comfort care orders. The information cannot “promote suicide, assisted suicide, euthanasia, or mercy killing.”
- Comparative Effectiveness Research (CER) cannot be used to “mandate coverage, reimbursement, or other policies for any public or private payer.”
Friday, October 9th, 2009
9:20 pm
An ethical argument for the public option

As we enter the final stretch of the legislative process for health care reform, we are beginning to get an idea of what the final bill will look like based on the five existing bills: definitely regulation of the insurance industry (no more "pre-existing conditions"), most probably an individual mandate to obtain insurance (enforced by a fine or a tax), and maybe (?) a government-run public option to compete with the private insurers.

Is there any other place in our lives where the government mandates that we purchase a good which is only available from private vendors? Car insurance is similar, but there is no mandate to purchase car insurance unless you wish to be licensed to drive -- and many people are not licensed because they don't drive. Businesses often have requirements to carry certain kinds of insurance, but businesses aren't endowed with individual rights.

We do have laws in this country that compel mandatory attendance in school (with exceptions for home-schooling, etc). However in this case, the government also provides the means to meet that mandate: the public school system. (We are so lucky that Horace Mann lived in a different era ... in today's world, we'd have bitter partisan fights about creating a public school system and a "right" to a basic education, and we'd probably end up with a multitude of profit-seeking private schools who used their political influence to stop the creation of public schools.)

Is it ethical to institute a mandate for everyone, but not provide the means for filling that mandate? I'd argue no ... if we believe as a society that everyone should have health insurance (which is what the legislation does, via a democratic process), then it is also our obligation as a society to ensure that health insurance is obtainable. And the only way to *guarantee* the availability of insurance is to have a public-sponsored program.

Private companies are not permanent, nor are they necessarily stable. It's not a far stretch of the imagination to see a world where due to, say, a fiscal meltdown, all private health insurance companies suddenly go insolvent and are unable to offer new policies. Suddenly, we have a law that requires coverage, but the marketplace is unable to offer a product to satisfy that law. The failure is with the insurance companies mismanagement, but the penalty is enforced on the consumer. Through no choice of their own, Americans are penalized by the law.

I'd argue that it would be unethical to write a law that allows citizens to be put in such a bind. That's why I'd argue that a public-sponsored insurance option is a necessary part of any health care reform that also includes an individual mandate.

I realize that a focus on the individual mandate opens up libertarian arguments against it. However, I believe we have a right as a society to determine that some things are social goods, and that the state can use its power to tax and/or fine in order to enforce that social good. Again, education is similar. And so are the police and fire departments -- people are required to pay taxes (under penalty of imprisonment) to support those endeavors because there is a public good generated by having those services available to everyone. And it is much more efficient to have everyone paying into the system to support those departments than to have, say, a "fee for service" police department. ("Welcome to Cops 4 Less: Filing a robbery claim will cost $500, charging someone with assault will cost $350 and don't even ask about investigating white-collar crime -- that'll cost you an arm and a leg.")

Finally, turning to the perpetual argument against the public option: it'll drive private companies out of business. First, I doubt it -- private firms will find markets where they can deliver value to customers (perceived or real), and people will pay for that additional service above what the public option offers (see: MediGap policies). Secondly, even if it did, that would be only because the public option was more efficient than private firms (they couldn't offer additional value, so they went out of business), so we'd be doing that same task of providing insurance to the population at a lower overall cost to society. What isn't to like about being more efficient in 16% of our economy? Oh, that's right, there's less room for profit-seeking enterprises to capture profit without providing additional value.

Which brings me to my concluding point: health insurance reform with an individual mandate but without a public option is nothing more than the "Health Insurer Bail-Out Act of 2009" -- we'd be giving tax dollars straight to the private firms, who have a market guaranteed by law. Shouldn't we demand that they at least compete for our tax dollars?

Sunday, August 16th, 2009
9:17 pm
Conservatives and Lies

The heat of August has settled in, and the Congress has fled the swamp of Washington, DC. After the townhall forums this month, I suppose a few wished they had never left.

We knew the debate would get ugly and heated, but what I think has truly caught me off guard is the degree at which the discussion is occurring about topics completely disconnected from reality. There are no "death panels" in the legislation (or even effectiveness review boards, which could become "death panels"). There is no plan to socialize the health care system (let's recall the definition of socialize: place it under government control, like GM or banks that are taken over by the FDIC). The public health insurance option, which isn't even expected to be in the Senate Finance legislation, wouldn't have the support of the government and would have to function like a private insurer in the private market (minus the profit-seeking). And even that is about to be abandoned. (Apparently, winning an election and a majority of Congress, while running on the domestic issue of health care reform, isn't enough of a mandate to actually pass the ideas that were talked about during the campaign.)

I understand the political process, and how winning in the public relations battle can be more important than the actual legislation (Harper's has an article about how the PR battle has replaced the actual wording of the Durban Accords on race in many minds). But our public servants (elected officials like Senators, former Alaska governors, etc) are not correcting out and out lies being circulated about the legislation by the conservative commentariat. That is highly disappointing, and I'm having a hard time coming up with similar examples of liberal politicians promoting demonstrably false statements for political gain. Liberals lie about sex scandals, but so do conservatives.

I would actually expect liberals to have multiple "truths" -- they are the ones of "relative truth" after all, where no culture, society or group has a monopoly on the Truth. But I am disappointed in the conservatives: they are the ones of "absolute truth" -- and what is written in legislative language is pretty much absolute, provable and undeniable. Where are their principles? (You know, those things you stand by even when it isn't immediately to your own self interest to do so?)

Despite my personal political leanings, I tend to respect conservatives for the role they play in ensuring that liberals don't go off the deep end with their "brilliant" ideas. You know, a sounding board, a cooling chamber, a parental voice of reason when the kids want to have candy for dinner. I think this was expressed well by a founding father of the modern conservative movement, William F. Buckley, when he founded the National Review: "It stands athwart history, yelling Stop, at a time when no one is inclined to do so, or to have much patience with those who so urge it." (Full disclosure: I have subscribed to NR for a dozen years - I'm often amazed that it hasn't undergone spontaneous combustion when it has been placed in my mailbox next to Harpers, Atlantic Month, New Republic, the Nation, etc.) Buckley made the Republican party respectable by ousting the influence of the John Birch Society and bringing it back to reality.

But recently, there was an insight into the Buckley family that I did not expect at all. Christopher Buckley, William's son, recently wrote about his life in the Buckley household. Now, it stands to reason that he did not have a wonderful childhood (he did, after all, endorse Barack Obama for President), but his description of his mother stunned me:

"Over the years, I heard Mum utter whoppers that would make Pinocchio look button-nosed .... I remember the time I first caught Mum in some preposterous untruth, as she called it... I looked at Mum and realized — twang! — that she was telling an untruth. A big untruth. And I remember thinking in that instant how thrilling and grown-up it must be to say something so completely untrue — as opposed to the little amateur fibs I was already practiced at, horrid little apprentice sinner that I was, like the ones about how you’d already said your prayers or washed under the fingernails. Yes, I was impressed. This was my introduction to a lifetime of mendacity. I, too, must learn to say these gorgeous untruths. When Mum was in full prevarication, Pup would assume an expression somewhere between a Jack Benny stare and the stoic grimace of a 13th-century saint being burned at the stake. He knew very well that King George VI and Queen Elizabeth did not routinely decamp at Shannon. The funny thing was that he rarely challenged her when she was in the midst of one of her glorious confections. For that matter, no one did. They wouldn’t have dared. Mum had a regal way about her that did not brook contradiction.

So, the founder of modern conservativism, who launched a magazine - and a movement - to stop history from running over the facts, lived with a serial speaker of "untruths" and had given up trying to stop it.

I think I'm beginning to understand conservatives, after all...

But why does it work for conservatives to completely make things up? On one hand, we go back to the fact that their opponents are the believers in multiple truths: there is always some piece of truth in a statement, right? Even if that "truth" is only the fact that the person saying it thinks what they are saying is true, despite all evidence to the contrary. It is important to acknowledge that truth, or else we might hurt someone's feelings and self-esteem.

Secondly, we are witnessing the failings of the profession that sees itself as the seekers of truth in our lives: journalists. As a commentator in the Washington Post wrote today:

Conservatives have become adept at playing the media for suckers, getting inside the heads of editors and reporters, haunting them with the thought that maybe they are out-of-touch cosmopolitans and that their duty as tribunes of the people's voices means they should treat Obama's creation of "death panels" as just another justiciable political claim. ...It used to be different. You never heard the late Walter Cronkite taking time on the evening news to "debunk" claims that a proposed mental health clinic in Alaska is actually a dumping ground for right-wing critics of the president's program, or giving the people who made those claims time to explain themselves on the air. The media didn't adjudicate the ever-present underbrush of American paranoia as a set of "conservative claims" to weigh, horse-race-style, against liberal claims. Back then, a more confident media unequivocally labeled the civic outrage represented by such discourse as "extremist" -- out of bounds.

(Side note: that mental health clinic in Alaska was one of the things that WFB brought up as an issue with the Birch Society ... see, conservatives used to actually care about the truth.)

One of the reasons I pay such close attention to the travails of the profession of journalism is that they are another profession that have their role in society undermined when profits are the sole pursuit (in their case, via the pursuit of sensational stories to drive up viewers rather than a discussion of facts and issues of the day). Actually, the very definition of a "profession" implies that as a class, the group provides a service to society that cannot be fully marketized; same goes for lawyers, clergy, police, etc. Democracy needs a profession to seek the truth of what is happening to real people, not to spout talking points generated by those who are currently in power. You know, the whole "Power to the powerless and afflict the comfortable."

I am worried that journalism as a profession will not survive our adoration of "the marketplace". And I'm worried that my profession will be next.

Sunday, July 19th, 2009
10:21 pm
Reviewing the House Bill

I skimmed through a 41-page summary (PDF) of the House version of the Affordable Health Choices Act (PDF, 1018 pages) looking for the sections most relevant to physicians. There are lots of details that will be of interest to physicians in various areas of medicine, but I tried to capture the key portions.

Below is that provider-specific summary of that summary. I've tried to ensure accuracy, but if there's something that isn't right, please let me know. I encourage you to read the original sources if you have any questions about the details.

The House Tri-Committee bill expands health insurance coverage primarily through two mechanisms: the creation of a Health Exchange and expansion of Medicaid.

Plans that are sold through the Exchange will be required to meet minimum standards, and can offer more benefits to obtain one of several higher benefit levels. An advisory committee chaired by the Surgeon General would be responsible for making recommendations to HHS about the coverage required to meet the various levels of plans in the Exchange.

Companies will still be able to offer packages outside of the Exchange that do not meet the Exchange standards (but would have to meet the appropriate state regulations, as is currently the law).

The Exchange will have a step-wise availability to the population. It will initially be open to those currently in the individual market, as well as employees of firms with less than 10 employees. In subsequent years, the Exchange will become available to more employees at larger firms until everyone has the option in year 5. Medicaid-eligible families would be enrolled only in Medicaid rather than the Exchange for the first five years, then would be able to enroll through the Exchange. There will be credits available to families up to 400% Federal Poverty Level for plans purchased through the Exchange. These credits will not be available to families currently offered insurance through an employer unless that plan costs more than 10% of their income.

The Public Health Insurance Option would start in 2013, to be available through the Exchange. It would be under the same regulations as the private insurance. Premiums will be geographically-adjusted and must cover the cost of the program (ie, no tax dollar support). Payment rates for the first three years (2013-15) will be based on Medicare rates plus 5%. After three years, the HHS can change the rates as necessary to ensure access, affordability and efficient delivery of care. The payment system can further be changed to develop new ways to reimburse for care to enhance health outcomes, reduce health disparities, manage chronic illnesses and encourage care-integration.

The Public Health Insurance Option can negotiate for drug prices. The Medicare Part D Donut is phased out by 2023. Part D beneficiaries can change plans mid-year if a formulary change adversely affects them.

Providers currently participating in Medicare would be automatically enrolled in the Public Health Insurance Option unless they opt out. “Balance billing” would be limited. The Sustainable Growth Rate is repealed. Medicare will increase payment for primary care services and psychiatry. Primary care reimbursement will be allowed to increase at a faster rate than other providers. It also provides incentives to physicians practicing in areas that provide cost-efficient care (lowest quintile of per-capita costs nationally).

Payment to hospitals will be linked to re-admission rates for three conditions (to be named later) starting in 2011. Integrates post-acute care providers into the payment system in the following years.

Medicare will have an alternative payment system through Accountable Care Organizations, which are physician grouped around a common delivery system (hospital or integrated practice). Spending will be benchmarked; quality care delivered at reduced costs will be rewarded.

Demonstration projects for language services, which will be studied by IOM.

Eliminates cost-sharing for preventive services in Medicare and Medicaid. Requires smoking cessation to be covered as prevention by State Medicaid programs.

Cost effectiveness research center in AHRQ to be guided by public/private stakeholder commission. The commission cannot mandate coverage for public or private plans (advisory role only).

Physician Payment Sunshine Provisions requires disclosure of any payment from a device or pharmaceutical company to a provider of value above $5.
Thursday, June 11th, 2009
10:32 pm
Let's get this health reform started!
I am touched and honored that my letter to the AMA resonated with so many other health care providers, and even more with patients. It was humbling to read through the comments on the HuffingtonPost and see how many people want desperately to restore the integrity of the profession, and to see physicians practice on behalf of their patients.

I must admit that I was also amused by the number of Star Trek references (I actually get very few of those in my daily practice). The best was "Dammit, Jim! I'm a doctor, not a profit-center!" I was also honored to be recommended for the Nobel Peace Prize, but I think that's a bit premature -- we need to get health care reformed passed (with a public health insurance option) before I'll entertain thoughts of a Nobel. :-)

In just one day, we saw an incredible impact: the AMA retracted its opposition to the public health insurance option. This just shows how we are on the right side of history. We know that we must do what is in the best interest of our patients if we are ever to have a health care system that works.

There was one theme in the comments to my letter that occurred time and time again - something that I know is not true: patients and the public believe that I am a unique physician in my desire for a patient-centered health care system; one without profits, salary or income as my first concern.

Quite to the contrary, I know there are thousands of doctors who believe that we can be the professionals that we dreamed of being when we applied to medical school. If you are a physician who shares this vision of health care, please sign the petition to support the public health insurance option, join the National Physicians Alliance, and talk about these issues with your colleagues.
If you are not a physician, you can send the above links to your friends in health care, as well as your own health care provider. You can also support our campaign to advocate on behalf of patients first.

I know I am not alone in my belief that physicians have a duty to ensure that the health care system works for our patients. But we need to work together to ensure that our policy leaders hear our voices, because we know the opposition will be strong, will be organized, and will attempt to scare our patients into believing the current dysfunction system is the best that America can do.

That is not true. We can have affordable, high quality health care in the United States, and we can do it while still offering the choice to our patients of keeping their current insurance plan if they like it, selecting another private plan, or choosing a quality public health insurance plan.

Health care reform will happen this year. We will make the health care system work for our patients.
Wednesday, June 10th, 2009
10:17 pm
Dear AMA: I quit!
Dear American Medical Association,

I recently had the opportunity to read your response to the Senate Finance Committee proposal for health care reform, and it is clear to me that I cannot remain a member in your organization. Please remove my name from your membership rolls, effective immediately.

In reading the response, I was frustrated and disheartened by the fact that you couldn't get through the second paragraph before bringing up the issue of physician reimbursement. This merely highlights how the AMA represents a physician-centered and self-interested perspective rather than honoring the altruistic nature of my profession. As a physician, I advocate first for what is best for my patients and believe that as a physician, as long as I continue to maintain the trust and integrity of the profession, I will earn the respect of my community. The appropriate financial compensation for my endeavors will follow in kind.

I encourage the AMA leadership to read Atul Gawande's recent article describing how physician culture drives up the cost of health care without benefiting patient outcomes. At the heart of this problem are physicians who have a vision of themselves as money-generating profit centers rather than professionals serving the public good. The AMA represents, and encourages, this mindset with its single-focus on physician reimbursement over all other health care reform issues.

However, the most disappointing aspect of the AMA's response to the proposed health care reforms was the opposition to the public health insurance option. I simply cannot support an organization that opposes the public health insurance plan for my patients. Instead of advocating for patients, the AMA is supporting the private insurance industry, which has been a driving force in creating the dysfunction health care system we have today.

But this should not have surprised me: when health care reform has been necessary, the AMA has always stood on the wrong side of history. The AMA opposed the creation of Medicare in the 1930s, when it was first proposed as part of Social Security. The AMA opposed Medicare again in the 1960s, going as far as to hire an actor named Ronald Reagan to read a script to the AMA Auxiliary declaring Medicare as the first step toward socialism, and concluding with the statement that if Medicare were to become law, "One day, we will awake to find that we have socialism.... One of these days, you and I will to spend our sunset years telling our children, and our children's children, what it was once like in America when men were free."

That was 50 years ago ... and none of that has come to pass. And yet this year, the AMA argues that a public health insurance plan will destroy the private insurance market. I challenge the AMA leadership to cite a single example of an industry where involvement by the government has lead to the elimination of private enterprise. This has not been the case with the creation of public police forces in the second half of the 1800's (private security companies still exist), we have a robust system of public and private colleges existing the same market, and bookstores still sell books despite the presence of public libraries. A mix of public and private enterprises in the market is a truly American solution to ensuring equal access, as well as competition to drive quality improvement. In fact, the creation of the public health insurance option will *increase* competition, as demonstrated by the AMA's own studies showing that 94% of health insurance markets only have 1 or 2 providers in the market.

It would appear that the AMA's position against the public health insurance market is driven by out-dated political ideology that blindly supports private industry rather than a careful examination of the facts of the current situation.

The AMA seems to be fixated on the fact that Medicare and Medicaid payments are lower than other payers. Let's go back to the history again: because the AMA opposed the creation of Medicare, physicians were not represented at the table when the system was designed. As a great policy wonk once said, "If you're not at the table, you're on the menu." And thanks to the dismal leadership and short-sightedness of the AMA in the 1960s, physicians were not a full partner in the creation of Medicare. And we're still feeling the reprocussions of that today. And yet now in 2009, the AMA is going to repeat that mistake by opposing the public plan.

The health care system is broken, and physician leadership is needed now more than ever to help direct the reforms that are desperately needed. However, the AMA has not shown itself to be the organization to provide that leadership in restoring the profession of medicine. New physician leadership is needed to fully achieve a reformed health care system that works for our patients and for our country.


Chris McCoy, MD
Saturday, May 30th, 2009
7:07 pm
Residency, by the numbers
444: Number of inpatient admissions worked up
109: Nights on call
1: Call nights in which I got absolutely no sleep
11: Number of admissions to the MICU during that no-sleep night
0: Call nights in which I admitted no patients
0: Patients admitted over a call night on oncology covered by a colleague when I was away for a conference
3: number of times I biked home in the rain
1: number of times caught by a rain storm on the way to work
5: Codes run
0: Peripheral IVs placed
0: Urinary catheters placed
5: Central lines placed
1: Pap smears performed
2: Patients treated with adenosine for SVT
97: Most number of hours worked in a 7-day period (on Gen Med as a senior)
5:15: earliest time in the morning I arrived for a shift (in the MICU as an intern)
8: most hours of sleep on a call night (on 10-3)
6,413: Hours spent in the hospital on inpatient services; add another 1,600 hours for the ten months of electives and outpatient clinic for about 8,000 hours total
Wednesday, April 22nd, 2009
10:57 pm
Can we find compromise on the public health insurance option? Should we?

(Cross-posted at the National Physicians Alliance Blog.)

The major battle lines in the upcoming debate about health care reform will likely be drawn around the idea of creating a choice of a public health insurance plan to compete in the market with regulated insurance companies. Republicans have made it clear they will not support such a plan, and many Democrats have announced they will oppose reform that lacks this option.

Compromise is as American as motherhood, apple pie and the creation of the US Senate. Undoubtably, our political leaders will attempt to find compromise on this issue as well. While it is less important for the House (where the majority party has near total control), it will be necessary to obtain the 60 votes that may be needed in the Senate. However, the two positions appear mutually exclusive at the moment.

But I think there will be proposals that will attempt to find a middle ground. I anticipate they will be focused on the area of competition, since that is a linch-pin of modern GOP talking points. In particular, they are many places in the country with only one or two private health insurance providers, so the creation of a public health insurance plan would engender competition in those markets. (These areas also tend to be rural, which may attract the votes of Senators from important states such as Iowa and Maine.)

One approach that has been suggested for similar debates in the past is to create a public plan only for people who live in areas that lack competition among private plans. Thus, the public health insurance option would create competition and choice for those who currently don't have it.

Is this a compromise we could live with? Or should every American have the option of enrolling in a public-sponsored insurance plan, regardless of how many private options they also have?

Now, consider the alternative proposal that will be suggested to stimulate competition: allow Americans to purchase health insurance across state lines. Currently, health insurance is regulated at the state level. Some states have passed laws requiring health insurance to be quite comprehensive; other states have only minimal requirements. However, if people could choose insurance from any carrier in any state, it would create more options for everyone to choose from.

I would call this type of proposal the "UnderInsure America Act". It would lead to many more people purchasing inexpensive and, too late for them to realize, inadequate coverage.

Now, how does that first compromise look in comparison? Maybe it is something worth considering ... it would create public plans for some people, allow us to work out the details, have a model to expand to other markets as insurance companies exit, etc.

On the other hand, the public insurance plans would likely exist only in rural areas, which have a much different population than urban centers. It may be harder for those plans to build the numbers necessary to demonstrate efficiencies over private insurers.

Is this a compromise we could consider?

Monday, December 1st, 2008
8:35 pm
I'll be keeping my day job

So, Obama has nominated Hillary for Secretary of State. Umm, I guess my political musings haven't been particularly prescient. Hillary for SoS? I didn't think so. And now it seems Sarah Palin is the face of the GOP, as opposed to a one-hit wonder who would drop off the ticket within two weeks.

Yeah, I'll keep my day job. Hopefully, I'm slightly better at it.

Current Mood: Humbled

Friday, November 14th, 2008
9:18 pm
Transition: From Hope to ?

Indiana? And Nebraska's second district? Wow ... I thought I was going on a limb when I called North Carolina for Obama.

But now the warm, fuzzy, post-election feeling is starting to fade. And reality sets in. This country is in a deep, deep hole. And we're still sinking deeper by the day. President Obama has his work cut out for him.

(As an historical aside, President Reagan also started his first time in a deep recession, but as I recall, things had turned better by the time the '84 election around. Will Alaska be the only remaining red state on the 2012 map?)

The hot gossip of the moment is whether Hillary will be part of Obama's Cabinet. Don't count on it. There is no place in the Cabinet that would meet her goals and agenda. And Hillary subordinate to Obama? I can't imagine it.

I suspect their clandestine meeting in Chicago was to allow Obama to talk with Hillary about who she would suggest for Cabinet positions. As Bill did many years ago, Obama will fill his Administration with the best-qualified, not just the best-friends. But even if Hillary were the most qualified person for Secretary of State (and I don't think she is), I don't think she'd want the position.

No, Hillary's seat in the Senate is a nice place to be. As a member of the Senate HELP Committee, Obama's health care plan has to go through her. Plus, she's on the Armed Forces Committee and the Environment and Public Works Committee. She has a lot of power just where she is now. And unless she's the Decider, I can't see her working in the Executive Branch.

There's another issue that is beginning to come up from the left-wing of the Democratic Party: what to do about Bush and torture. This is the single issue that most disturbs me about the Bush Administration and his legacy. He has immensely damaged the image of America as a nation of laws and justice. We must forcefully condemn those actions as antithetical to everything America stands for.

However, how to do that? Put Americans on trial? When they were instructed that their actions were legal ... by the Justice Department itself? That doesn't seem right, and in fact, violates the ex post facto clause of the Constitution. I think the best response is to clearly state that the rules have changed, and we will never allow Americans to torture again. This change in policy could in theory be reversed by a future administration (since it appears the current administration is impervious to laws passed by Congress), but I hope that no administration would ever go into that dark place again.

We need to move on and move forward. We should relegate the Bush administration to the dustbin of history, where it belongs.

Current Mood: Hopeful

Sunday, November 2nd, 2008
8:30 pm
Final Election Thoughts

I'll be on call tomorrow, on the eve of the election, so I won't be going to a Bruce Springstein concert this time. (Apparently, though it didn't work for Kerry in Ohio in 2004, he's doing it again for Obama.) Instead, I'll be doing emergent pre-operative evaluations on the elderly who fall and break their hips on Election Eve. There are worse things to be doing in my distracted state of mind (MICU?).

But before I disappear into the hospital for 30 hours, I wanted to toss out a few disconnected pre-election thoughts.

  • Election Day is way better than Christmas: Not only is it for everyone (except felons), but it only comes once every 4 years. And unlike Christmas, when you are likely to get nice gifts from friends and family, on Election Day there is always a possibility that you'll really get a lump of coal. And not just any chunk ... one that will stick around for 4 (or 8!) years. It's like fruitcake! Only your fruitcake doesn't show up on the front page of the national papers on a regular basis reminding you how you didn't get that cool thing you really wanted instead.

  • Sarah Palin - the gift that keeps giving? Sarah in 2012? Please, pretty please, don't throw us in that briar patch! Let's see, she would be a second term Alaska governor running against ... an incumbent Barack Obama. (Or, more disturbingly, Joe Biden carrying forth with the legacy of an Obama Presidency.) By then, Barack will have solidified his national security credentials, and Sarah will have ... invaded Russia? Do you remember what happened with Dan Quayle after his ticket lost the election in 1992. Neither do I ....

  • Hillary done in by a non-issue: It's amazing to think that Hillary's biggest flaw in the eyes of the Democratic primary electorate was her vote to approve the use of force in Iraq in 2002. That irritated the left-wing of the party, and gave Obama an issue to use to peel away idealistic voters. And now? Iraq is a complete non-issue. Barack's signature issue that defined him from Hillary ... is a nonplayer. How would Hillary do against McCain in the context of the economic turndown that has dominated the election since September? Quite well, I suspect. So yes, she could have been President. If I were her, that thought would keep me up at night.

    I wonder if she'll support a movement to shift the primary season so it is closer to the general election, as to lessen the chance of the issues changing so dramatically from the primaries to November?

  • Atheists: don't bother running in North Carolina. Though the country was founded by a group of Christians, they had good sense to explicitly state in the Constitution that there should be no religious test for public office. Sure, it's tacked on near the end in Article VI, but it's there. Perhaps Senator Dole should be reminded of the wisdom of the Founders.

  • Fortuitous Five? While door-knocking this afternoon, I found a five dollar bill on the sidewalk. No one was around, no clear owner. So I donated it to the cause.

  • The spectrum of Obama's supporters: amazing. Today, I talked with naturalized citizens from Africa, Mexico, and Eastern Europe. But the best moment was when an older Vietnamese man told me (through his teenage daughter, who was translating) that he would be voting for Obama. His face lit up when I responded with the only Vietnamese that I know: cam on.

  • My wildest prediction: Obama takes North Carolina. He'll also take VA, PA, OH, FL, CO, and NV. We'll know the election is over when they call NC for him. Or Colorado. Or Florida. Or Ohio.

    But he won't take Missouri.

  • McCain's (only) path to victory: he manages to win Pennsylvania. And Ohio. And Florida. And Nevada. I suspect, however, that McCain's ritual early bedtime won't be disrupted by the need to wait for late results to come in before making the phone call to Obama.

Current Mood: Hopeful
Thursday, October 30th, 2008
8:28 pm
Let's hear it for early voting

Here's a crazy notion: how about a democracy where everyone who wants to vote, gets to vote. (Once.)

It seems like an obvious way to run a representative democracy, but 2008 is looking like one of the first years where that is actually happening. But not in every state. Just the 30-some with early voting.

Early voting appears to be the solution to the historical mistake of voting on Tuesdays. Lots of people, you know, "real Americans" have jobs (sometimes two or three) on weekdays (and weekends). They often can't make it to a polling place between 7am and 7pm on the first Tuesday after the first Monday of November. In 2000, I asked one of the cafeteria workers at my dorm if she had voted. She hadn't because she had been swiping our meal cards from 6:45 am until 7 pm. Sure, she had breaks, but probably not enough time for her to go back to her precinct and vote. Apparently, her vote wasn't important enough to count. (Actually, since it was Chicago, there's a chance that she did "vote", but that's another story I'll touch upon below.)

Previously, people like her were told: too bad -- you should have planned ahead and jumped through three hoops to get an absentee ballot.

But now states are providing early voting. What a concept: Vote when it is convenient for you! There are necessary limitations (a week, or a month, and not after Election Day), but this seems to implement the ideals of our democracy: The People Decide.

Not just some of the people, or those with jobs that allow time to vote (or those now without jobs). Everyone. (Except ... foreign nationals, people under 18 and those incarcerated. But those are appropriate limitations.)

Remember photographs of polling places in South Africa during its first open election? I get goosebumps looking at similar pictures from here in the US. And this is during the *early voting*! Will there be anyone left to vote on Tuesday? I hope so, I hope so.

The concern for voter fraud is, well, a fraud. And here's why: yes, there have been fraudulent registrations turned in by voter drives. And while that creates a hassle for the county to verify or invalidate dead fish, live puppies, or cartoon characters, the vote itself is not disturbed. Unless said dead fish shows up to vote.

What about people voting multiple times? Yes, it could (and probably does happen ... rarely). Yet, to have a significant effect on the outcome of the election, it would have to be a coordinated effort with lots of people. And by that very nature of having to be large to be effective, it would be easy to detect -- those kinds of efforts tend to leave a paper trail, disgruntled participants, people with loose lips, etc. It would be exceedingly difficult to secretly tip an election by a coordinated effort of multiple voting.

No, the better way to sway an election is to purge the voter rolls of people with names similar to felons. To supply inadequate quantities of ballots to certain voting locations. To use machines and ballots that are confusing to the average voter. Turn off the "overvote" detection in some precincts but not others. Do you get my drift?

Everyone who wants to vote, should vote. Period.

Current Mood: Patriotic

Saturday, October 25th, 2008
5:51 pm
Counting Calories and Carbon

Between May 1st and November 1st, I estimate that I will have biked to work about 120 times (out of a possible 130 opportunities). At about 10 miles round-trip, that's 1200 miles that I haven't driven. My car gets about 25 miles per gallon in the city, so that's 48 gallons of gas I haven't burned. Gas averaged about $3.60 this summer, so that's about $170 in gas savings. On the environmental side, a gallon of gas produces 19 pounds of CO2, so I've reduced my emissions by 930 pounds of carbon dioxide.

However ... I don't hold my breath while biking to work. How much CO2 does biking produce? A quick Google search shows that most estimates say that a person exhales about 2.2 pounds of carbon dioxide daily. That CO2 comes from the food we eat, so if we assume 2200 calorie diet, then for every 1000 calories burned, about a pound of CO2 is produced.

Biking consumes about 500 calories per hour. It takes me 45 minutes to bike to and from work each day (20 minutes in and 25 minutes home -- it's downhill going in and I'm usually tired from rounds when going home). So 120 trips lasting 45 minutes amounts to 90 hours of biking. That's 45,000 additional calories consumed to propel myself to work. (For reference, a single gallon of gas has about 31,000 calories.) At 1 pound of CO2 per 1000 calories, it looks like I'm exhaling about 45 pounds of CO2 on my way to work.

My primary source of those additional calories is the slice of toast that I add to my breakfast during the summer. A slice of bread has about 100 calories, and there are 24 slices in a loaf, so I eat about 19 loaves of bread to power myself. At $2 per loaf, that's $40 that I spend in groceries for those additional calories.

So, to summary the savings and expenditures for biking to work:

  • Savings

    • Carbon Dioxide: 930 pounds

    • Dollars: $170

  • Expenditures

    • Carbon Dioxide: 45 pounds

    • Dollars: $40

  • Net savings by biking to work during the summer:

    • Carbon dioxide: 885 pounds

    • Dollars: $130

  • The opportunity to watch the sunrise (and often the sunset) each day as I enjoy the fresh air, the morning quiet and the occasional sighting of deer, foxes and other animals:
    • Priceless.

Current Mood: contemplative
Thursday, October 2nd, 2008
9:48 pm
That Reagan Quote

Sarah Palin ended the debate by including a quote from Reagan: "Someday, we will be telling our children, and our children's children, what it was once like in America when men were free."

I know that quote. In fact, it was a highlight of my Failure of the American Health Care System that I gave as AMSA Legislative Affairs Director.

Want the full context? Listen to it. Reagan was speaking out against Medicare in the 1960s, paid by the AMA. It gets good starting at about the 7th minute. The quote comes at about 10:50.

Current Mood: Flabberghasted

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