Mark Pine

“I knew about the waterboarding, not specifically in any one particular case, but as a general policy that we had approved,” he said.

Apparently, the former veep is using the royal “we.”

Cheney seems to have no worry and feel no compunction about his role as a commander who “approved” torture. He believes that the goal of preventing attacks on the United States justifies the means of torture. He makes no apologies for himself or the nation.

The report released last week by the Justice Department said that interrogators threatened to kill a detainee’s children and sexually assault family members. The CIA operatives also staged mock executions and intimidated prisoners with implements.

So what’s so awful about threats, if they’re not carried out? That’s probably how Cheney and others overseeing the interrogators reasoned. Threats really hurt no one.

No one but our nation.

That’s what angers me about Cheney’s horrible hubris. He was the decider, one of them apparently, who decided it was OK for the United States to seem as evil as any other nation that tortures prisoners. He decided on his own authority, apparently, that two centuries of America standing as the beacon of liberty should be extinguished.

He was determined to show the world, it seems, that the United States could be as brutal and lawless as any nation.

Let’s think about what is at stake. Three thousands deaths on 9-11 was horrifying. The collapse of the twin towers was devastating. But more people will die this Fall of the flu than died on that day. Nations in Europe and all over the world have sustained terror attacks, but they survive and move forward. And America is much stronger than most other nations.

Cheney vilified his own country by approving this national misconduct. He flushed our reputation down the toilet. But it is my country, too. Our country. And I believe the former vice president should not have made such decisions.

He should be investigated for his role in ordering torture, and I hope he is indicted and tried.

In a broadcast email yesterday (“Seniors and Health Insurance Reform,” HHSPRESS@LIST.NIH.GOV), HHS Secretary Kathleen Sebelius charged that “A typical older couple in traditional Medicare will pay almost $90 next year on average to subsidize private insurance companies who are not providing their health benefits.”

The message cited a newly released report on Medicare that asserts that overpayments to private insurance companies providing Medicare Advantage plans are a large factor rising health care costs for seniors and in the looming exhaustion of the Medicare Hospital Insurance Trust Fund in 2017.

A report to Congress by the Medicare Payment Advisory Commission in March explained why this is so.

About one senior in five is enrolled in a Medicare Advantage plan, which offers additional benefits over standard Medicare. But payments by Medicare to these plans exceed what Medicare would usually pay for equivalent benefits. For all such plans, the average Medicare overpayment amounted to 14% but went as high as 20%. Moreover, some plans were particularly inefficient with a $3 payment from Medicare buying an additional $1 of increased benefits for covered seniors enrolled in those plans.

All seniors on Medicare pay for these excessive payments through Medicare premiums, whether or not they are enrolled in a Medicare Advantage plan.

The secretary said health care reform would reduce or eliminate the overpayments. She also asserted that other elements of health care reform would help seniors afford coverage and “keep Medicare strong.” Among these were an agreement from the pharmaceutical industry to reduce some costs for drugs to seniors.

The secretary promised also that an impending cut next year in Medicare reimbursements to doctors would not go through if health care reform is enacted. That would prevent some doctors from refusing to treat seniors or discontinuing treatment with seniors who already are their patients.

Most Americans fear that the federal government will get involved in their personal health care decisions, waiting times for medical services will increase, and a public insurance option will increase health care costs and premiums.

But most Americans don’t believe the government will decide whether they get treated, when and how elderly Americans will die or that millions of Americans will lose insurance due to health care reform.

These opinions result from a survey by Indiana University’s Center for Health Policy and Professional Research of 600 adult Americans taken August 13-19.

The survey focused on health care “myths”—beliefs about health care reform, not knowledge of actual bills in Congress. Thus, respondents’ answers reflected their guesses about the future of health care and how reform might affect them.

A majority of those surveyed believed 8 of 19 assertions:

• The federal government will be involved in personal health care decisions;
• health care will be rationed;
• taxpayers will fund abortions;
• waiting times for care will increase.

A public insurance option would
• (i) increase costs,
• (ii) increase premiums,
• (iii) be too expensive for the government to pay for.
• Tort reform would decrease health care costs.

In my view, none of these possible outcomes is absurd. They all reflect realistic fears, whether justified or not by facts. The survey showed that the majority of affirmative (agreement) responses came overwhelmingly from Republicans, with 60-90% believing the assertion. Democrats overwhelmingly disagreed with them, less than 1/3 agreeing in most cases. About 50-60% of independents agreed with the assertions.

In contrast, the majority of respondents doubted more the dubious statesments:

• The federal government will decide whether they get treatment;
• government officials will be in charge of personal medical records;
• the government will decide how and when the elderly will die;
• millions will lose coverage due to reform;
• small businesses will be hurt;
• private insurance will be eliminated;
• employer-sponsored insurance will be eliminated;
• illegal immigrants will be covered;
• the elderly will get euthanized;
• reforms will be covered by cuts to Medicare.

Nevertheless, a majority of Republicans believed almost all these statements, too. The disbelievers came overwhelmingly from Democrats and a majority of independents.

Since it’s not possible to know whether any of the assertions put forward in the survey will prove correct or not, the results indicate the need for reassurance. President Obama and the Democrats must make clear that nothing in the reform package suggests that any of these outcomes will come to pass.

The recent statements by the President and advertisements by liberal groups may have actually contributed to the acrimony of the debate. They have targeted the insurance industry and defended against false accusations.

But what the public may need to hear the most is that things will be OK. Reform will make things better. No one will get hurt or disadvantaged. A comforting prime-time TV talk by the president might do good, as would pro-reform ads emphasizing the benefits of reform.

The Kennedy brothers are now all gone, and the era they initiated and drove forward is coming to an end.

With the deaths of Eunice and Teddy this month, the time of the Kennedys has ended, and with it my era — the boomer generation, the age group the Kennedys inspired — begins to recede. It was their spirit—the liberalism that created the Voting Rights Act, the optimism and trust in technology that took on the voyage to the moon, the hope to try and build a better America in a better world—that my generation felt in the Kennedys and carried forward.

Like Edward, Robert, and John who aroused us, we have been grand and base, and noble and flawed. We accomplished great things and failed miserably. We have many reasons for satisfaction but just as many for disappointment.

Edward Kennedy took ill just as his life-long goal of passing health care reform moved forward, and wasn’t able to guide it. He died before seeing it come to pass. We might think God took him before he could reach his promised land, but that would be mistake. Edward Kennedy was not like Moses in that way, because an even greater goal was realized while he lived. The promised America he did live to see is the America that elected President Barack Obama.

Christopher Koch is confused about consciousness.

In the July issue of Scientific American Mind, Koch asks “Do you think that your newest acquisition, a Roomba robotic vacuum cleaner that traces out its unpredictable paths on your living room floor, is conscious?” Answering his own question, Koch writes that “nobody except a dyed-in-the-wool nerd” would think a Roomba sentient.”

Koch is trying to explain the integrated information-theory of consciousness (IIT) propounded by Guilio Tononi, a psychiatrist at the University of Wisconsin. Tononi uses a statistic Ø from information theory to characterize consciousness. Koch says,

At least in principle, the incredibly complex molecular interactions within a single cell have nonzero Ø. In the limit, a single hydrogen ion, a proton made up of three quarks, will have a tiny amount of synergy, of Ø. In this sense, IIT is a scientific version of panpsychism, the ancient and widespread belief that all matter, all things, animate or not, are conscious to some extent.

By that standard, though, the Roomba is conscious. So which is it?

The answer is that Tononi’s theory doesn’t describe consciousness as a unitary thing—either present or not. Consciousness isn’t a step function. IIT ascribes to consciousness varying degrees. Koch writes of the theory, “the amount of integrated information that an entity possesses corresponds to its level of consciousness…. The more integrated the system is … the more conscious it is.”

But despite his own words, Koch persists in seeing consciousness as something either present or absent. For example, he writes of patients undergoing surgery that their consciousness is “transiently turned off and on again with the help of various anesthetic agents.” And in another place, he says that consciousness depends on the existence and function of the cerebral cortex and the thalamus but not of the cerebellum.

Although Koch appears to accept the notion of levels of consciousness, he reverts repeatedly to an all-or-nothing concept of it.

In my view, consciousness is a fundamental property of the universe, present in everything. I believe I am with Tononi in this. We both understand consciousness as something that exists in degrees, depending on the complexity of the system. Tononi uses the quantitative statistic Ø (the degree of integration in information theory) to precisely characterize the level of consciousness of a system.

Tononi is correct I think, but I view it qualitatively and more simply. The level of consciousness depends on the amount of communication within a system or between systems. Indeed, in my view, communication is consciousness, and the fundamental carrier of communication, the photon (the vector of light), carries the universal property of consciousness.

Koch mentions split brain patients:

Consider split-brain patients, whose corpus callosum—the 200 million wires linking the two cortical hemispheres—has been cut to alleviate severe epileptic seizures. The surgery literally splits the person’s consciousness in two, with one conscious mind associated with the left hemisphere and seeing the right half of the visual field and the other mind arising from the right hemisphere and seeing the left half of the visual field.

The conclusion I draw from this is that when communication is cut, consciousness doesn’t cease, but it becomes more limited. Fundamental confusion results from seeing consciousness as all-or-nothing, present or absent. Consciousness isn’t like that, it has levels or degrees.

Most of us reading this possess intact callosa. Our consciousness is not split into left and right, but is whole and integrated. The lesson is that communication expands and unifies consciousness. The degree or level of consciousness increases with the amount of communication.

Today communication is global, instantaneous, ubiquitous and abundant. Communication happens constantly on the internet and other telecommunication media. As a consequence, in my view, consciousness is being taken to the next level. I think humanity is in the process of developing world consciousness.

In 2006, my daughter, a young adult woman, asked me about a recommendation by her gynecologist that she receive the newly licensed Gardasil vaccine against some types of HPV infection. On the basis of news reports, we both believed that preventing the infection by receiving the vaccine would substantially reduce the risk of cervical cancer. Apparently in raising the subject with her patient, my daughter’s gynecologist believed that also.

But according to articles this week in the JAMA, the journal of the AMA, all three of us may have been misled by the publicity. It turns out that evidence is lacking that Gardasil significantly reduces the cancer risk, although it is still possible that it may do so. But also Gardasil has been associated with serious adverse reactions, and it’s not clear whether the benefit of the vaccine would outweigh the risk of vaccine-related illness.

Knowing what I know now, I would not have recommended that my daughter receive the vaccine.

One of the JAMA articles is an editorial that analyzes the scientific information on the vaccine, including some of the data in the other two articles. Charlotte Haug, the physician writing the perspective, makes these very relevant points:

First, there are more than 100 different types of HPV and at least 15 of them are oncogenic [cause cancer]. The current vaccines target only 2 oncogenic strains: HPV-16 and HPV-18. Second, the relationship between infection at a young age and development of cancer 20 to 40 years later is not known. HPV is the most prevalent sexually transmitted infection, with an estimated 79% infection rate over a lifetime. The virus does not appear to be very harmful because almost all HPV infections are cleared by the immune system. In a few women, infection persists and some women may develop precancerous cervical lesions and eventually cervical cancer. It is currently impossible to predict in which women this will occur and why. Likewise, it is impossible to predict exactly what effect vaccination of young girls and women will have on the incidence of cervical cancer 20 to 40 years from now. The true effect of the vaccine can be determined only through clinical trials and long-term follow-up.

In a nutshell, the evidence presently available doesn’t support the claim that Gardasil will significantly reduce the risk of cervical cancer.

At the same time, a second article in the journal, written by physicians at the CDC and FDA, analyzed reports of Gardasil-associated adverse events. It found that serious events included allergic reactions, fainting, nerve disease and paralysis, thromboembolism (clots), and death. Although the association of these events with Gardasil may have been coincidental, fainting (8 events per 100,000 patients) and thromboembolic events (2 events per million patients) appeared to be reported more frequently than would be expected. More than 23 million doses of Gardasil were dispensed in the U.S. through the end of last year.

So although the benefit of Gardasil in preventing cancer hasn’t been established, it’s likely that there is some degree of risk for serious adverse events.

The third article describes the marketing strategy of the pharmaceutical company, Merck, which sells the vaccine. Although the company’s clinical trials of Gardasil demonstrated only that the vaccine prevents HPV infection with four strains of the virus, Gardasil was “promoted primarily to ‘guard’ not against HPV viruses or sexually transmitted diseases but against cervical cancer.”

One marketing tactic involved contributions to professional medical associations, like the American College of Obstetrics and Gynecology, the professional association that my daughter’s gynecologist may belong to. The funds from Merck were used to sponsor educational programs for doctors, to encourage treatment with the vaccine.

Merck has a history of marketing of at least one previous problematic treatment. In my view, the company was involved the largest adverse event catastrophe in American history. Merck manufactured and marketed Vioxx. Critics of Merck’s behavior in relation to Vioxx made reasonable estimates that tens of thousands—perhaps even a hundred thousand or more—excess heart attacks may have occurred among patients who took Vioxx before the company withdrew the drug from the market.

I am not asserting that the Merck’s behavior with Gardasil is nearly so serious. But I am asserting that once again the company’s marketing of one of its products raises significant questions and doubts.

“I don’t trust what he’s saying,” said a senior woman of President Obama. “I’m plain scared of what the future holds for us.” She was responding on video recording to questions from a NY Times reporter to residents of the Sunrise Lakes Retirement Community in Broward Co., Florida. Like most of the residents, she had voted for the president. But she now doubts her choice.

The president’s health care message hasn’t gotten through to many Americans, including some seniors heavily dependent on medical treatment for chronic illness. The article accompanying the video suggested some of their fears might be realistic. The simple truth is that with health care costs continually rising and with plans to expand coverage to tens of millions of uninsured, it’s natural and sensible for seniors to worry whether Medicare—the nation’s most costly health care program—will get shaved.

The huge and growing uncertainty about the outcome of health reform care has enveloped the nation like a fog. It has cost the president dearly. The Cook Political Report summarized several polls showing his approval rating just over 50% and predicted major losses for the Democrats next Fall if trends continue.

The ship of state seems to flounder, with Obama hesitant to take the helm. For weeks, commentators have opined that his health care plans are vague, and to move the legislation forward, he needs to come out forcefully with focused messages and clear preferences. Meanwhile, Republicans and conservatives have seized control of the debate with simplistic and succinct distortions, like the allegations of “death panels.”

I agree that the future of health care looks problematic. For me, next year is Medicare. I’m not as worried as the Sunrise Lakes residents—I have the same insurance offered to the president, the federal employees program, which can coordinate well with Medicare. Still, the emerging legislation seems likely to expand coverage to the uninsured and prohibit denial of coverage for pre-existing conditions. But there doesn’t seem to be any way it would succeed in controlling costs. It won’t change they way medical care is reimbursed, and it will continue paying for expenses that don’t improve health, like unnecessary treatments, and the marketing and advertising expenses and profit of private insurance companies.

Two kinds of preventable medical illness could be reduced, improving the health of Americans and saving the health care system billions of dollars.

The sickest patients with chronic illness, who cost the most to treat, could have their expenses substantially reduced by participating in a program of proactive, comprehensive care. As reported in ScienceDaily, researchers at Johns Hopkins enrolled the patients in a controlled study in a “Guided Care” program, with nurse-physician-health aide teams that performed comprehensive health assessments at home, planned the patients’ care, monitored and coached the patients monthly, and encouraged active participation in the care by the patient and the family. In comparison to control-group patients receiving usual care, the Guided Care patients cost 11% less to their insurers.

In terms of dollars, the results could mean that such a program caring for 11 million eligible Medicare patients would cut costs by $15 billion, or more than $1000 per patient per year. For each Guided Care registered nurse, the annual savings amounted to $75,000, which resulted from largely from reduced hospitalization rates.

Other studies by the CDC and Hearst Newspapers found another sources of avoidable health care costs: medical errors. Reported online by Hearst, a CDC study found that 98,000 patients per year die of preventable medical mistakes. And another 99,000 die from preventable hospital infections.

The number of treatment-related errors has grown in the last decade, since the publication of a report by the National Academy of Sciences’ Institute of Medicine, which determined that 50,000-100,000 patients die each year from medical errors and recommended a national effort to reduce the errors by 50% in 5 years.

The investigation by Hearst found that federal and state governments and medical providers have taken few effective measures to reduce mistakes. Their survey of 1,434 hospitals in five states showed that only 20% were participating in a national safety campaign.

The 1999 IOM report estimated that medical errors increased direct health care costs by more than $17 billion.

What links both these sources of needless medical expenses is that our current system of fee-for-service medicine doesn’t pay for programs or procedures to reduce them. If anything, it’s to the contrary, since most forms of reimbursement today pay more per patient, when the patient requires more treatment. Thus medical providers have no financial incentive to treat their patients proactively and monitor and guide their care. Similarly, there’s no incentive to reduce medical errors, as the widespread failure of hospitals to participate in the national safety program would suggest.

If anything it’s the reverse; hospitals and other providers increase reimbursements when preventable hospitalizations and treatments aren’t prevented.

America could and should create a new health care structure that pays providers for each patient treated, rather than for each treatment rendered. A government-run public insurance program would have the size and authority to negotiate with providers to put in place new forms of reimbursement based on paying for patients. Then the financial incentives would grow to motivate efforts to reduce preventable illnesses and medical errors, since that would reduce costs and maximize earnings.

Providers would then have good reason to institute proactive programs to treat chronically ill patients and to participate in safety programs to reduce medical errors.

This morning the NY Times editorializes that it’s not clear how a public plan could “reform the hospitals and other providers of medical care to hold down the cost of care (and premiums).” But, it continues, “If the White House and Democratic leaders decide to go it alone, and they may well have to, they should restore a robust public plan. It is the best way to give Americans real choice.”

I agree with both comments. The Democratic leaders, including in the administration, have finally recognized that Republican/conservative opponents of health care reform are aiming to portray Obama as Napoleon and make the present legislative battle his Waterloo. The president’s efforts at bipartisan compromise have only emboldened them, and backpedaling on the public option has just allowed them to move forward and apply the same tactics to idea of nonprofit insurance co-ops.

Still, it’s isn’t apparent how either the public plan or the co-ops would reform medical care and reduce costs. Medicare is a national public plan for people over 65, but the costs of health care for that group are still high and growing fast. And we have many nonprofit health care providers, including some co-ops, and that hasn’t reduced costs or rate increases.

In my view, we can control health care costs and their increases only by changing the way we pay for medical care. As long as we reimburse for each service—the fee-for-service system—providers will have every reason to do more treatment and use the most expensive treatments available.

If fee-for-service remains in place, we won’t be able to control costs, because providers will continue to insist that more tests, more drugs, more procedures, more expensive treatments are needed to provide the best care—and who would say otherwise? Any federal effort to limit or prohibit treatments would be branded and resisted as rationing.

The fee-for-service payment system should be replaced by fee-per-patient. Reimbursements should paid for each patient, based on the patient’s disease(s), and geared to outcome—the better the result, the higher the payment. Under such a system providers would have no incentive to do more treatment than necessary and they would have every reason to choose the most effective therapies.

Would a public health care entity be able to reform the health care system in this way—paying for patients instead of for treatments? I don’t know. But there’s no other element in the current proposals that could. Most existing insurance companies and health care providers would continue to operate as they do now, except for no longer denying coverage for pre-existing conditions.

Only a public insurance organization could or would have the size, authority, and financial incentive to change the way that providers get paid.

As soon as he signs the bill, it will be the president’s plan, no matter which legislative committees write it. But as things are going, it won’t control the rising costs of heath care, because there will be no public health insurance option.

In the NY Times today, Anne Underway interviews heath policy expert Timothy Jost. He makes clear that the insurance cooperatives Finance Committee senators want to create as an alternative to a government run plan will be too weak to compete with mammoth insurance companies—if the co-ops manage to survive at all.

Jost explained, “The thought that you’ll have a few businessmen get together and set up a co-op that will compete with Aetna or Cigna is just dreaming. It’s not going to happen.”

But he said the United States government could compete. “Maybe it would be a lousy competitor and fail, or maybe it would be a great competitor and force private insurers to compete and come up with a product that was more affordable than what they’re selling now. I don’t see a problem with trying it.”

Like most commentators who favor including a public plan in health care reform, Jost thinks it could drive down costs by increasing competition. I see things differently.

Competition won’t reduce costs. In health care, the effect of competition is unpredictable. For example, several hospitals in a town might compete to offer the same expensive service. That could drive costs up. Or many providers might compete to offer the same high tech but often unnecessary procedure. That might bring down the cost of the procedure, but it could increase its utilization and increase the overall costs of care.

Perhaps the president hopes that his proposal for an enhanced Medicare panel would succeed in curtailing soaring health expenses. The panel, as he envisions it, would “provide recommendations about what treatments work best and what gives you the best value for your health care dollar.” But the idea is already running into resistance on the Hill. And associations of providers and anti-government conservatives would surely try to undermine it as a form of rationing. Moreover, it’s not clear how such a panel could control costs for the majority of Americans with private insurance.

To control costs, America needs to move away from the fee-for-service reimbursement system. What would stop rising costs would be to stop paying providers for each treatment they perform. As things are now, with most payments on a fee-for-service basis, providers compete to do the most treatments—which means to get the most reimbursements—which means costs go up.

Instead providers should be paid on fee-per-patient basis, with fees geared to good outcomes. That way providers would make the most money by doing what’s necessary and effective—which means costs come down.

In my view that’s the best reason for a government run plan. Only the government would have the clout—the size and the authority—to shift reimbursements from fee-for-service to fee-per-patient.