More Dumb Things Politicians and Political Appointees Say About Health Policy

As we previously discussed, the fierce debate about whether to revise, or "repeal and replace Obamacare", more formally, the Affordable Care Act, continues in the US.  The legislators in the US House of Representatives, and then the US Senate who have written "repeal and replace" bills have done so without any obvious input from health care professionals, health care policy experts, or patients, much less legislators from the opposition party, and so far have impeded any consideration of these bills by legislative committees.  Nonetheless, many of the politicians involved in the debates, and other politicians who have addressed relevant issues, seem to feel free to comment on health care policy issues with reckless abandon.

We have recently found some more remarkable examples, discussed in chronologic order. 


Senator Ron Johnson (R - Wisconsin): Someone with a Pre-Existing Condition is Like "Somebody Who Crashes Their Car"

As reported by RawStory on June 25, 2017,

The Wisconsin Republican pointed to Obamacare rules that forbid insurance companies from charging more for people with preexisting conditions.

'We know why those premiums doubled,' he opined. 'We’ve done something with our health care system that you would never think about doing, for example, with auto insurance, where you would require auto insurance companies to sell a policy to somebody after they crash their car.'

The last phrase suggests Senator Johnson might be talking about people who deliberately crash their cars, or at best people who were at fault in a car crash.  Setting aside the consideration that sometimes fault in a car crash is hard to assign, he seems to be implying that all people with pre-existing conditions are at fault for for their conditions.  Yet, accidents thay may cause permananent injury are accidental.  Diseases are caused by many factors, or by factors unknown to modern science.  It is very hard to think of a disease whose occurrence is purely caused by choices made by the patient who is afflicted with it.  So it appears that Senator Johnson's argument rests on a logical fallacy: false analogy, in this case between car accidents and pre-existing conditions.

Middletown, OH, Councilman Dan Picard: Town Emergency Medical Technicians Should Deny Naloxone Treatment to Narcotic Addicts Who Have Overdosed Two or More Times Previously

As reported by the Huffington  Post on June 26, 2017,

'I want to send a message to the world that you don’t want to come to Middletown to overdose because someone might not come with Narcan and save your life,' Picard told Ohio’s Journal-News. 'We need to put a fear about overdosing in Middletown.'

Also,

But Picard seems to believe that EMS crews are working a bit too hard to stem the tide of overdoses, and is upset that taxpayers are footing the bill to revive people, many of whom are transients and not residents of Middletown, he says.

Picard also proposed that instead of immediately arresting or jailing overdose victims, they should receive a court summons and be required to work off the cost of treatment by completing community service. But there’s a catch.

'If the dispatcher determines that the person who’s overdosed is someone who’s been part of the program for two previous overdoses and has not completed the community service and has not cooperated in the program, then we wouldn’t dispatch,' said Picard.

Narcotic overdoses left untreated are often fatal. The article also quoted

Martins Ferry Police Chief John McFarland said some people have begun taking these casualties as a foregone conclusion.

'You hear from the public, ‘Why don’t you let them die?’' McFarland told the Dispatch. 'We’re not God; we don’t decide who lives or dies. … We have the ability to save them, so we do.'

That is the point. Emergency medical services have a duty to attempt to treat people with acute conditions that can be immediately fatal, otherwise they would be "playing God."  At best, Mr Picard seems unaware of the mission of emergency health services. 

Note that a Washington Post story on Mr Picard's new policy idea, published June 28, 2017, which quoted this argument the Councilman made in favor of his proposal,

a decision to not save repeat overdosers would be one of many that communities make about how much care they'll provide to dying people.

'If you have a toothache and you call Middletown, we’re not coming,' he said. 'For your heart attack, we’re not going to do the stint or your bypass. Decisions have been made about what services we’re going to provide. We need to make a decision about overdoses.'

Of course, this is another, and whopping example of a false analogy. Revascularization procedures for myocardial infarctions (coronary artery stents or coronary artery bypass grafting) cannot be done by emergency medical technicians and must be done in a hospital given current technology. So decisions about when to deploy these treatments are not made by EMTs, or City Councilmen for that matter.

By the way, the Huffington Post article noted that Mr Picard was not the first one to come up with the policy of withholding Naloxone to save money.  Maine Governor Paul LePage (R) apparently floated something similar in 2016. As reportedy by the Huffington Post in April, 2016:

LePage explained Wednesday that he blocked a bill to increase access to a life-saving overdose medication because the people it could save are just going to die later anyway.

'Naloxone does not truly save lives; it merely extends them until the next overdose,' LePage wrote.

It was not the first time LePage had shared such a belief, but attaching it to his veto elevated it to a statement of official policy.

The state legislature later over-rode his veto. Note that Governor LePage apparently based his article on a faulty perception of the prognosis of patients who overdose.

'Creating a situation where an addict has a heroin needle in one hand and a shot of naloxone in the other produces a sense of normalcy and security around heroin use that serves only to perpetuate the cycle of addiction,' he wrote.

While a staggering number of people have died as the result of the heroin and opioid epidemic, many have also recovered, and many more are waging battles with addiction they will eventually win. LePage’s assertion that everyone who overdoses once and lives will surely overdose again, rather than seek treatment and recover, is divorced from reality.

Counselor to the President Kellyanne Conway: Instead of Getting Medicaid, Able-Bodied People Should Find Jobs "Then They'll Have Employer-Sponsored Benefits Like You and Me"

As reported by Fortune on June 26, 2017,

In an interview on ABC's This Week on Sunday, Conway, counselor to President Trump, said that Obamacare expanded Medicaid to those who did not truly need it, because they were able to work. She was defending the Senate's proposed health care bill, which would make big cuts to Medicaid, by lowering the income limit for those who qualify, among other measures.

'Obamacare took Medicaid, which was designed to help the poor, the needy, the sick, disabled, also children and pregnant women, it took it and went way above the poverty line and opened it up to many able-bodied Americans,' she said. Those 'should probably find other — at least see if there are other options for them.'

She continued:

'If they are able-bodied and they want to work, then they'll have employer-sponsored benefits like you and I do.'

This was just a straight-forward, but important factual error.  Per Fortune,

Many Americans who are covered by Medicaid are already working, often in lower-paying jobs that may not have health insurance benefits, according to a report by the Kaiser Family Foundation, cited by CNBC.

Representative Paul Ryan (R-Wisconsin): If Insurance Prices Go Up, "It's Not Like People are Getting Pushed Off the Plan, It's That People Will Choose Not to Buy Something That They Don't Like or Want"

As reported by RawStory on June 27, 2017,

During an interview that aired on Tuesday, Fox News host Brian Kilmeade asked Ryan to respond to a recent Congressional Budget Office (CBO) report that said there would be 22 million more people without health insurance by 2026 if the Senate’s version of the health care bill is signed into law.

'What they are basically saying at the Congressional Budget Office, if you’re not going to force people to buy Obamacare, if you’re not going to force people to buy something they don’t want, then they won’t buy it,' the Speaker opined. 'So, it’s not that people are getting pushed off a plan, it’s that people will choose not to buy something that they don’t like or want.'

'And that’s the difference here,' he added. 'By repealing the individual and employer mandate, which mandates people buy this health insurance that they can’t afford, that they don’t like — if you don’t mandate that they’re going to do this then that many people won’t do it.'

Please note that the mandate to which he refers is a relatively small tax under "Obamacare" paid by people who do not have health insurance. Further note that under the proposed Senate bill, many poorer people would lose substantial subsidies of their health insurance. So Mr Ryan seems to be using linguistic sleight of hand.  He accepts the term "mandate" as literally true, allowing him to claim that the negative financial incentive which the "mandate" imposes while the negative financial incentive caused by losses of subsidies and increases in insurance prices is not.  A rose is not a rose when it's called something else? This is the logical fallacy of ambiguity, using double meanings or ambiguity of meaning in language to disguise the truth. 

Summary

Whether to maintain our current - admittedly Rube Goldberg-esque - system of financing health care, or to radically change it is a serious question.  The answer will affect the wellbeing, health, and even lifespan of many people.  The question should not be taken lightly.

So what to make of so many politicans and political appointees making pronouncements on whether to keep, or "repeal and replace Obamacare" that are based on major factual errors and logical fallacies?  The last time I took this on, I speculated whether health care policy has sunk into a swamp of postmodernism generated by years of exposure to the post-modernist stance of many in academia.  That may have been fanciful.

On the other hand, another speculation is that this is the result of "managerialism."  We have discussed the doctrine promoted in business schools that people trained in management should lead every type of human organization and endeavor.  Management by people from the disciplines most relevant to the mission and nature of particular organizations should be eschewed.  So managers, not physicians or other health care professionals, should lead health care organizations.  Following that theme, managers, or those like them, rather than health care professionals and health policy experts should lead health policy. 

However, managers who run health care organizations, or make policy, have an unfortunate tendency to be ill-informed (as well as unsympathetic if not hostile to health care professionals' value and the health care mission, and subject to perverse incentives that often put short-term revenue ahead of the health of patients and the population.)  And in the latest health care reform debate, some of the politicians and political appointees who are the de facto managers of health policy have disdained the advice of health care professionals and health policy experts.  

The causes of this trend are certainly open to debate.  However, I believe we should all be really worried about continued health care policy making by people who are driven by factual errors and non-evidence rather than evidence, and logical fallacies rather than sound reasoning.  We need health policy leadership that is well-informed, understands the health care mission, avoids self-interest and conflicts of interest, and is accountable, ethical and honest.   (Of course, we have often said we need leadership of health care organizations with these characteristics.)  Right now, we are not coming close.  Woe is us.

Evidence-Based Policy Making? - Dumb Things Politicians Say About Health Care Policy

There have been multiple legislative attempts at major health care reform in the US.  Typically, such attempts feature considerable public debate, including speechs, congressional committee hearings, sometimes progressing to debates by the House and Senate.  (For example, see this Frontline chronology of the proceedings up to the passage of the Affordable Care Act, aka "Obamacare," in 2009.)  Usually the discussion includes some real experts on health care policy, and some real health care professionals, and at least appears to reference some data about medicine, health care, and health economics. Whether previous debates were truly evidence-based is not clear, but it appeared to me that they at least acknowledged the importance of evidence, and maybe even at times a rigorous approach to it.

However, the proceedings up to the passage of the American Health Care Act seemed somewhat different.  There were no public committee hearings or debates.  Per a Los Angeles Times article in April, 2017 (via the Chicago Tribune):

President Trump and House Republicans, in their rush to resuscitate a bill rolling back the Affordable Care Act, are increasingly isolating themselves from outside input and rejecting entreaties to work collaboratively, according to multiple healthcare officials who have tried to engage GOP leaders.

In particular,

And senior House Republicans and White House officials have almost completely shut out doctors, hospitals, patient advocates and others who work in the healthcare system, industry officials say, despite pleas from many healthcare leaders to seek an alternative path that doesn’t threaten protections for tens of millions of Americans.

'To think you are going to revamp the entire American healthcare system without involving any of the people who actually deliver healthcare is insanity,' said Sister Carol Keehan, president of the Catholic Health Assn., whose members include many of the nation’s largest medical systems.

While the experts have been shut out, some of its supporters of the AHCA in the US House of Representatives have been free with their explanations of their actions.  Some have been rather alternative, so to speak.   Some recent examples, in chronologic order,

Rep Roger Marshall (R-Kansas): the Poor "Just Don't Want Health Care"

As reported by the Washington Post, March 9, 2017

'Just like Jesus said, ‘The poor will always be with us,’ ' Marshall said in response to a question about Medicaid, which expanded under Obamacare to more than 30 states. 'There is a group of people that just don’t want health care and aren’t going to take care of themselves.'

He added that 'morally, spiritually, socially,' the poor, including the homeless, 'just don’t want health care.'

'The Medicaid population, which is [on] a free credit card as a group, do probably the least preventive medicine and taking care of themselves and eating healthy and exercising. And I’m not judging; I’m just saying socially that’s where they are,' he told STAT, a website focused on health-care coverage.

The problem is that Marshal, who is a physician, did not provide evidence that there is some essential characteristic of the poor that causes them to make bad health decisions, or discus whether perhaps the poor face constraints on their health care decision making that the rich do not.  The implication appears to be that Marshal is treating an promoting an ideological or religious opinion as if it were derived from epidemiology.

House Speaker Paul Ryan (R-Wisconsin) The Problem with "Obamacare" is "the People Who Are Healthy Pay for the People Who Are Sick."

As reported by MSNBC, March 9, 2017

Take today, for example, when the GOP House Speaker did a little presentation on Capitol Hill for reporters in defense of his controversial American Health Care Act, which some have begun calling 'Trumpcare.' At one point during the slideshow – complete with Ryan’s sleeves rolled up – the Wisconsin Republican tried to explain what he sees as the Affordable Care Act’s fatal flaw:

'The fatal conceit of Obamacare is that we’re just gonna make everybody buy our health insurance at the federal-government level, young and healthy people are going to go into the market and pay for the older, sicker people. So, the young healthy person is going to be made to buy health care, and they’re going to pay for the person, you know, gets breast cancer in her 40s or who gets heart disease in his 50s. […]'

'The whole idea of Obamacare is … the people who are healthy pay for the people who are sick. It’s not working, and that’s why it’s in a death spiral.'

As MSNBC reported, the problem is with that is

that Ryan doesn’t seem to understand what “insurance” means.

Look at that quote again: The whole idea of Obamacare is … the people who are healthy pay for the people who are sick.' Well, yes. The whole idea of health insurance is to establish a system in which the people who are healthy pay for the people who are sick.

This really isn’t that complicated. In fact, it’s incredibly common for the vast majority of Americans: we pay premiums, the money goes into a pool, funds from that pool pay for care. It’s Insurance 101.

If Ryan disapproves of this model – which is weird, given that his own reform bill is built on consumers getting coverage through traditional insurance – there are effectively three alternatives. If the healthy aren't going to pay the sick, who will? The sick can try to pay for themselves, the government can pick up the tab, or the sick simply won't get care.

Rep John Shimkus (R-Illinois) Why Should Men Have to Purchase Prenatal Care? 

As reported by the Washington Post, March 9, 2017, regarding a hearing in the House of Representatives Energy and Commerce Committee

'What mandate in the Obamacare bill does he take issue with?' Doyle asked Shimkus, using the formal parlance of congressional committees.

'What about men having to purchase prenatal care?' Shimkus said.

At that point, one could hear the room start to stir.

'I’m just . . . is that not correct?' Shimkus said. 'And should they?'

Rep Shimkus, apparently like Rep Ryan, does not seem to understand the concept of health insurance.  The Post article put it this way,

Here’s how insurance expert and columnist Nancy Metcalf answered a similar question from a Consumer Reports reader that year:

Health insurance, like all insurance, works by pooling risks. The healthy subsidize the sick, who could be somebody else this year and you next year. Those risks include any kind of health care a person might need from birth to death — prenatal care through hospice. No individual is likely to need all of it, but we will all need some of it eventually.

So, as a middle-aged childless man you resent having to pay for maternity care or kids’ dental care. Shouldn’t turnabout be fair play? Shouldn’t pregnant women and kids be able to say, 'Fine, but in that case why should we have to pay for your Viagra, or prostate cancer tests, or the heart attack and high blood pressure you are many times more likely to suffer from than we are?' Once you start down that road, it’s hard to know where to stop. If you slice and dice risks, eventually you don’t have a risk pool at all, and the whole idea of insurance falls apart….

Rep Mo Brooks, (R-Alabama): "People who Lead Good Lives" Do Not Get Sick

As reported by Vox on May 2, 2017, Rep Brooks said in an interview on CNN to explain why people with pre-existing conditions should personally pay for their health insurance

allow insurance companies to require people who have higher health care costs to contribute more to the insurance pool that helps offset all these costs, thereby reducing the cost to those people who lead good lives. They’re healthy; they’ve done the things to keep their bodies healthy. And right now, those are the people who have done things the right way that are seeing their costs skyrocketing.

He seems to be arguing first that people who virtuous ("good") are healthier than others.  He certainly provided no evidence for this assertion, which, like the assertion by Rep Marshall above, appears to be ideological or religious judgment disguised as epidemiology.


Rep Paul Labrador (R - Idaho) "Nobody Dies Because They Don't Have Access to Healthcare"


As reported by CBS News on May 6, 2017

Labrador made the comments the day after the U.S. House passed a GOP-led health care bill repealing and replacing chunks of Obamacare. Labrador, a member of the conservative House Freedom Caucus, was responding to an audience member who expressed concern about how the bill would affect Medicaid recipients.

'You are mandating people on Medicaid accept dying. You are making a mandate that will kill people,' the audience member said, before being drowned out by Labrador's response.

'No one wants anybody to die,' Labrador said. 'You know, that line is so indefensible. Nobody dies because they don't have access to health care.'

It is not completely clear whether Rep Labrador meant access to health care, or access to health care insurance. A person with appendicitis, acute bacterial pneumonia, a myocardial infarction, etc, etc who fails to seek acute care because of lack of a means to pay for it could well die. As an absolute, this statement is obviously untrue.  

Mick Mulvaney, Director of the Office of Management and Budget: "The Person Who Sits at Home, Eats Poorly and Gets Diabetes" Does Not Deserve Health Insurance

As reported by the Huffington Post on  May 12, 2017

he drew a distinction between people like Kimmel’s son, born with a congenital heart disease, and people who end up with conditions like diabetes. 'That doesn’t mean we should take care of the person who sits at home, eats poorly and gets diabetes,' Mulvaney said, according to a Washington Examiner account consistent with real-time social media reports. 'Is that the same thing as Jimmy Kimmel’s kid? I don’t think that it is.'

This is not exactly the clearest statement but it seems to imply that only people who make unhealthy life-style choices get diabetes, which certainly as an absolute is not true; and furthermore that people who develop diseases due to poor life-style choices do not deserve care.  The juxtaposition suggests that driving this is an ideological or religious judgment about who is deserving.

Video diversion: would Mr Mulvaney think this person deserves "health care?"





 Summary

In 2003 I published an article entitled "A Cautionary Tale: the Dysfunction of American Health Care," which summarized the views of health care professionals about the causes of health care dysfunction.  One of the major findings was the importance of " attacks on the scientific basis of medicine."  In turn, I hypothesized that some of these attacks stemmed from the rise of post-modernism, then a fashionable intellectual affectation on university campuses, mainly of the avant garde left-wing.  I wrote then:

Postmodernism is 'an attempt to question the fundamental philosophical and political premises of the West.   It argues that many of the concepts we take for granted—including truth, morality, and objectivity—are culturally ‘constructed’'  To postmodernists, truth is just what the powerful say is true.

Now it seems that post-modernist "thought" has escaped the confines of left-wing humanities departments, and infiltrated political discourse, and for some unfathomable reason, seems to particularly affect some of those who profess to be conservative. After all, in January, KellyAnne Conway, a senior White House adviser, defended the administration's arguments as "alternative facts." (Look here.)

Facts, however, are stubborn things.  Evidence is evidence, no matter what politician it might offend.  Basing legislation on the sorts of alternative thinking displayed in the cases above could lead to real life, or life and death consequences for the sick, injured and vulnerable.  True health care reform requires clear thinking and the input of people who actually know something about health care.