I think that Mr. Krauthammer has it wrong. The main reason that it is failing is not because of cost. The main reason that it is failing is that many in the public are both angry and frightened that the government is going to take something from us that is important and return something that is decidedly going to leave us worse off. We are afraid that we are going to get inferior healthcare and rationing. It is impossible to ignore the fear of rationing that permeates this entire discussion. In line with that, it is clear that government bureaucrats will decide who can get treatment and who will be denied, and there is no way to appeal any of these decisions.

For this reason, the proposed Obamacare 2.0 will fail as well. We will want to know the fine print in the bill, and the hidden rationing that is included. Obamacare 2.0 looks an awfully lot like Romneycare 1.0. This is failing in Massachusetts; it will fair everywhere else.

The more I research cost models, the more I wonder how any of these models can be accepted as valid. In most cases, risk is unknown, so the probability of risk is often made up. I keep seeing estimates of the number of deaths from the swine flu. Today, it was as many as 90,000. These deaths are used to justify the immediate distribution of the swine flu vaccine (when it becomes available). There is even talk about setting up vaccine lines in elementary schools.

The question is, just how does anyone know who many flu cases there are? While many go to their physician when they have the flu, and the case can get recorded at the Centers for Disease Control, many people just ride it out and never get counted. Because the flu behaves like so many different upper respiratory infections, the flu can often be diagnosed, and again it can get over- or under- counted because there is usually no verification that it is (or is not) the flu.

In the hospital, the codes used for billing do not include a code for the flu. Therefore, it gets assigned a billing code for pneumonia or some other infection rather than the flu. So how can these estimates be accurate?

I just received a note from my Congressman, John Yarmuth. He gave me the same lie that Barack Obama keeps telling about the health care takeover by the federal government. The lie? "If you like your healthcare, you can keep it." According to HR3200, there is an incentive for employers to drop healthcare coverage and have all employees go on the public option. There is an 8% tax per employee, which is often lower than the cost of the healthcare. Of course, once everyone is on the public plan, that 8% will very quickly become 16%. For those of us lucky enough not to be dumped into the public plan, there is only a 5-year window for us to keep the plan. Then, we must switch to a government "qualified" plan. In other words, there is absolutely no way for any of us to keep what we have.

Why are such lies necessary to gain support for the plan? Given the nature of the townhall meetings, the lies are not working.

It makes many of us afraid of our government, afraid of what the government will take away from us and what we will get in the place of what we have.

Although the term, "rationing" is not used in HR3200, rationing is an important part of the plan. The various boards and commissions and regulatory agencies will see to that. They will often use outmoded concepts. For example, in Oregon, only cancer drugs that are 95% effective for 5-year survival (ie, almost none of them) are covered; those who are not covered will have to die.

We are fighting for our very lives. This takeover by the government allows that very government to decide who gets to live and who gets to die just by what treatments are allowed and denied. Do we want faceless bureaucrats to make these important decisions?

Bernie Madoff went to jail for his ponzi scheme. Who should go to jail for social security and Medicare, which are also ponzi schemes. They both depend upon the taxes of employees to fund the retiree benefits. Will the government public plan become another ponzi scheme that starts taxing people to death?

Ponzi schemes eventually collapse. Medicare is no different.

Apparently there are a number of people in Britain who take offense at our continued bashing of the British healthcare system. In fact, an article in today's Washington Post claims that the British system is much better. And yet.... many people in Britain have to take out their own teeth with pliers because there are so few dentists. Also, because of comparative effectiveness analysis, patients with macular degeneration cannot get treated until they are blind in one eye. Cancer survival is much, much better in the US because we do not use comparative effectiveness analysis to deny patients cancer drugs (except in Oregon, which does use comparative effectiveness analysis).

The biggest difference between the two systems is that in the US, healthcare is an individual benefit; in Britain, it is a collective benefit. That means that some do without in order for others to benefit. The decisions in the US are made based upon the needs of an individual patient. In Britain, the individual can be sacrified for what some define as a greater good.

There are, for example, 24 MRI machines per million people in the US; there are 12 in Canada and 8 in Great Britain per million. Obviously, it will take far longer to schedule an MRI in Great Britain than in the US. Moreover, because it does take so long to schedule the MRI, many who would receive an MRI in the US will not receive it for a similar condition in Britain. It is simply not possible to use 8 machines in the same way that 24 can be used.

Without comparative effectiveness analysis, a treatable disease would never been untreated because the money is needed for some other patient, in the way it is with macular degeneration. If there is a shortage of dentists, there would be some way to serve the need. That is the reason for nurse-practitioner offices in Wal-mart, Kroger, etc. The supply is increasing to satisfy the demand.

It looks like the public plan is dead. Barack Obama and his underlings are backpedaling. However, there are still problems with the bill-a co-op plan could very easily become the public plan. Comparative effectiveness analysis remains in the bill along with rationing. The House bill still includes the boards and commissions to define all insurance plans. We need to work to get rid of these aspects of the bill as well. We also need to be careful that the public plan is not reinserted in the conference committee.

The National Health Service in Britain has been using comparative effectiveness analysis for quite some time.  NICE stands for the National Institute for Health and Clinical Excellence.  This organization has defined an upper limit on treatment costs, and if the cost exceeds this pre-set limit, then the treatment is denied.  It does not matter if the drug is effective or not. That means that there are many beneficial drugs that are simply not available to patients.As this panel can decide who gets treatment and who does not, and if the proposed treatment is life-saving or life-prolonging, it can most certainly be called a "death panel".

How does this work? A comparative effective analysis starts with the perceived patient’s utility given the disease burden. The QALY, or quality of life-adjusted years is an estimate of the number of years of life gained given the proposed intervention. Each year of perfect health is assigned a value of 1.0. A patient in a wheelchair is given a correspondingly lower value as is a patient who is elderly; this value is not clearly defined and is rarely based upon patient input.

Consider an example. Suppose a cancer drug for patients with liver cancer allows a patient to live an average of 18 months compared to not using the drug.  However, as with most cancer drugs, there are potent side effects. Suppose that the analyst decides that the quality of life is only 40% of perfect health (giving a weight of 0.4). Then the drug gives 1.5*0.4=0.6 QALYs to the patient. Suppose that at the initial introduction of this drug that it costs $1000/month, or about $18,000 for the anticipated additional life of the patient. Then the cost per QALY is equal to 18,000/0.6=$30,000 per year of life saved. According to the NICE organization, this drug then is too costly regardless of the fact that there is no comparable drug that is effective in prolonging the patient’s life. However, suppose the analyst uses a measure of 60% of perfect health. Then the drug gives 1.5*0.6=0.9 QALYs to the patient at a cost of $20,000, which brings the amount closer to the pre-set value defined by NICE. Therefore, this definition of a scale of perfect health is of enormous importance. In fact, NICE has denied such a cancer drug because of its cost.

If a person is otherwise young and healthy and a drug costs $10,000 per year, then the
QALY is $10,000. However, if a patient is older and has a chronic condition, then that patient’s utility may be defined as exactly half that of a young and healthy person. In that case, the QALY is $20,000 for the same drug. If the patient is old and has two or more chronic conditions, then the patient’s utility could be defined as 25% that of a young and healthy person. In that case, the QALY IS $40,000 per year of life saved.  By defining $15,000 as the upper limit for treatment, it is easy to see how the definition of a person’s utility can be used to deny care to the elderly.