Wednesday, June 14, 2017

No Chicken Little, It's Just a Budget Cut -- And Mental Health Care Doesn't Have to Suffer

The recently released Trump Administration’s 2018 proposed budget includes a roughly 18% cut in funding to the National Institutes of Health (NIH), with a proportional decrease in the funds allocated to mental health. Cuts were also proposed to the Substance Abuse and Mental Health Services Administration (SAMHSA), as well as to Medicaid and the Centers for Disease Control and Prevention (CDC), all of which provide some level of services for Americans with mental and behavioral health issues. Not unsurprisingly, this has resulted in panicked outrage from those with a vested interest in maintaining ‒ or growing ‒ funding for mental health research and services.

Within the NIH’s proposed budget of $26.92 billion, it is difficult to tabulate the actual total funds appropriated for mental health due to the convoluted structure of the organization. But to be clear, the “draconian cuts” in funding that the American Psychiatric Association (APA) referenced in its May 2017 press release criticizing the budget are a decrease in the National Institute of Mental Health (NIMH) budget from $1.545 billion in 2017, to a proposed $1.245 billion in 2018 – a decrease of $300 million, or roughly 5.9 hours of accrued interest on our national debt clock.

While admittedly the United States has a significant population with mental illness (estimates are 1 in 8 Americans), and a worrisome problem with drug and alcohol addiction, there is limited credible evidence that years of generous funding of the NIH, or of mental health programs, has had any significant positive impact on the problem. Despite the APA’s assertion that “proposed budget cuts will roll back much of the recent advances the nation has made in terms of healthcare,” exorbitant sums of taxpayer dollars spent on mental health research over the past several decades have done little to stem the rise of mental illness. In fact, essentially all of NIH’s funding, and most of the CDC’s, is spent on research. It is entirely unclear what portion, if any, of these cuts would actually impact patient care. The APA’s argument proposes a direct correlation between research and treatment that simply has not been proven to exist.

Furthermore, unlike other areas of medicine and healthcare, the field of mental health is unfortunately lacking in well-established, universal standards and guidelines when it comes to treatment, a particular challenge to the mental health care field. In fact, the NIMH’s own website cites lack of valid metrics for measuring the quality and efficacy of mental health care. In what other industry can you command the dollars that mental health does without producing results and evidence of treatment efficacy? Perhaps a better strategy is to reallocate dollars to improve training and reimbursement for primary care physicians to address mental health issues and increase access to mental health services for patients within their practices, rather than to continue funding research and programs that have not proven useful.

A significant problem here – and one that is not specific to mental health – is how taxpayer dollars are allocated during the budget process in the first place. The NIH’s Justification of Estimates for Appropriations Committees” requesting $26.92 billion references the NIH-Wide Strategic Plan for fiscal years 2016-2020 and its “commitment to responsible stewardship of public funds by conducting research to help battle public health crises including efforts to fight the opioid epidemic.” Unfortunately, that seems a tad vague when it comes to commandeering tens of billions of taxpayer dollars. From a healthcare policy perspective, the practice of block-granting agencies and organizations is inherently flawed because it rests on the assumption that a particular agency is running efficiently and that monies are spent appropriately. In addition to enabling waste, fraud, and abuse, the process is rigid and slow to adapt to new public health needs or threats. The fact remains that research only battles public health crises if it meaningfully directs treatment.

Balancing a budget is always difficult, and being held accountable to the public trust is a weighty responsibility. Agencies can easily find 18% research and administrative pork to eliminate. Without separating the scientific endeavor of research from effective treatment and improved clinical outcomes, the fevered claim of a moral imperative to fund “vital programs and initiatives” is nothing more than political rhetoric aimed at vilifying the engineer while hoping to stoke the gravy train.

Friday, January 10, 2014

Everything I Know About Liberalism I Learned In Kindergarten

 As a result of their wildly failed policies and politicians, leftists have recently abandoned the moniker "Liberal" and its pejorative connotation for the highly sanitized label, "Progressive".  Mutton can call itself lamb, but it doesn't change the facts; they were Liberals before, and they're still Liberals today.

As an ideology, Liberalism is predicated on a set of communal values and the idea that the “collective” is far more important than the individual.  There is an underlying belief system, the gist of which is that “caring” and “sharing” and “looking after ones neighbors” are all that is required to create a utopian society.

The fundamental problem with Liberalism is that it doesn't work. 

At its root, Liberalism is based in childlike emotionalism. It eschews scary adult concepts like Profit & Loss and personal accountability.

Arguments in support of Liberalism are grounded almost entirely on “feelings”. Relying on emotion provides a convenient diversion from the lack of facts otherwise critical to justifying a given position. Emotion also obscures the failure to reach logical and rational conclusions that would be drawn from these facts if they existed.

To Liberals, it doesn’t matter if the budget doesn’t balance because in their minds, their hearts were in the right places. No worries that an entitlement program failed to produce the intended results – After all, “It’s the thought that counts!”  They believe in what they feel, independent of reason, rationality or logic. 

The basic premise of the liberal ideology evokes memories of classic kindergarten mantras:

“It's nice to share.”
“Everyone deserves a medal.”
“Take turns.”

Kindergartners pass out birthday cupcakes to the entire class as a gesture of their celebrity for the day; they gleefully accept well wishes in return, and assume that they will likewise partake in the birthday largess of their peers. The distribution of Valentines to each and every classmate is an exercise in childhood innocence, acceptance and the promotion of “collectivism”.

Presumably, kindergarten lessons are intended to imbue young children with a sense of caring for others as well as the basics of citizenship. They do not, however, translate well to address complex, real-world issues:

War is “mean” and people will get hurt, so it’s “bad”!

John’s feelings will be hurt if he doesn’t get promoted, so his boss should promote him!

That person is poor and it would be nice to give him money, so the government should do it!

Let’s show those people how nice we are, and maybe they won’t want to kill us!

While appealing on some childish, emotional level, the concepts fall flat when applied in the adult world.

Another “downside” to using kindergarten principles to run the country is that they clearly fail to meet economic muster. While liberal governments are quick to promise “goodies for all”, the reality of economics becomes problematic as an ever-smaller subset of the population is actually producing and providing the “treats”.  As the number of producers dwindles, the resources simply cannot meet what has been promised.  The numbers just don’t add up.

Fortunately, Liberals never let pesky constructs like arithmetic, get in the way of an impassioned argument!

Furthermore, Liberalism fails not only on an economic level, but on a moral one as well; it changes the fundamental nature of the human act of “giving”.  

Sharing cupcakes on ones birthday is a far cry from a government mandate to provide a specific flavor and quantity of cupcakes, at specified intervals, to unknown individuals of the government’s choosing.

Once coerced or mandated to “give” to another, the “giver” feels no sense of pride, satisfaction, or goodwill towards the “taker”. Furthermore, the receiver feels no sense of gratitude or moral obligation to the giver. Instead, the government, rife with liberal politicians, pats its collective self on the back for having orchestrated this “good act”.

America’s highly graduated tax structure and growing entitlement programs are nothing more than forced redistribution of wealth aimed at making their proponents feel good about themselves. The moral transaction inherent in true “giving” has been entirely corrupted in the process.

To help them make a compelling emotional argument, Liberals wrap their ill-conceived social programs with highly charged words intended to resonate on a deep emotional level.

With a name like the “Patient Protection and Affordable Care Act, what's not to like? “Protection”, “Affordable” and “Care” are far more embraceable than something as mundane -- and truthful -- as the “Health Insurance Overhaul Act”.

The “Children’s Defense Fund”, “Protect Children not Guns” and the “Strong Start for America’s Children” act: Warm and fuzzy names for bills are a stanchion of Liberalism and part and parcel of their emotion laden rhetoric.

To Liberals, the fact that their programs and policies don’t work doesn’t matter: Their good intentions are treated as more important than the results of their actions.  You get an “A” for effort!

How else can one possibly explain why Kathleen Sebelius hasn’t been fired for complete and total incompetence in the rollout of ObamaCare? Apparently,  “she tried really hard” is enough to ensure job security for a Liberal!

Perhaps the only thing worse than a failed program sold largely on emotional grounds, is a failed program that leaves us far worse off than we were when we started.

Rather than focusing on feelings, conservatives are much more likely than Liberals to consider the long-term consequences of a given policy. While increasing taxes on the rich will, for example, provide more immediate revenue to the government, it also will result in significantly less capital available for investment in commerce.  Liberals fail to grasp the logic that investment capital is critical for true economic growth. All that matters to them is the feel-good idea of playing Robin Hood – Pragmatism, outcomes and sustainability be damned!

Worse yet, failure to embrace the emotional plea of Liberalism is generally met with vitriolic backlash.

Even if their positions are contradicted by facts or logic, Liberals demonize those who disagree with them as corrupt, ignorant, racist or worst.

Liberals know they won’t likely win a debate on logical grounds, so they quickly devolve to the emotional mat. Once the debate has been refocused to emotional issues, Liberals solidify their position on the moral high ground, claiming the cruel and uncaring position of their opponents. What cold, unfeeling person doesn’t want to feed starving children or provide medical care for 26 year olds still living in their parent’s basements?

Then, when all else fails, Liberals resort to the most emotional of all arguments, “the children”.  There is almost no argument a Liberal can make that doesn't somehow circle back to some bevy of anonymous children. You could be debating the pros and cons of nuclear disarmament in post-cold war Russia, and some sappy liberal news anchor will chime in "But what about the children? Let's think about the children!"

There’s nothing a Liberal loves as much as dependency, and there’s nothing so dependent as a child. Liberals find children particularly politically useful because it gives them justifiable reason to act on their little voiceless behalves.  Liberal politicians love to define -- and then “solve” -- the problems of poor, defenseless children.  This generally involves designing new and costly programs that will require funding in perpetuity in order to prevent some previously unwitnessed evil.  You remember, like the leagues of American children found starving in the streets before Liberals pushed school lunch –and now school breakfast –programs into place?

Never mind that soon we won’t be left with money for juice and graham crackers, let alone two publically-funded school meals every day.

No doubt, the impetus behind many liberal programs is heartfelt, but their “solutions” nearly always require more government expense and oversight than can possibly be justified.

In the end, Liberalism comes down to fatuous, feel-good emotionalism; it sounds appealing, but remains oblivious to the objective operational realities of the vision it promotes.

Conservatism, on the other hand, requires doing things the right way, even when it’s painful and not pretty.  It means rewriting policies when they don’t work and disassembling well-entrenched programs that fail to produce the desired results. It means acting like responsible, accountable adults.  It means suffering the playground insults of emotionally charged Liberals who would portray us thoughtless and uncaring.

And it means we have a lot of work to do before naptime.

Monday, October 7, 2013

The ObamaCare Insurance Exchanges: Not Quite Ready for Prime Time

Drum roll please – And with all the drama and thrill of a Fourth of July firework dud, the ObamaCare insurance exchanges officially opened on October 1.

Despite three and a half years of preparation, launches of the much-awaited “healthcare insurance marketplaces” were almost universally fraught with problems.  Multiple states reported near-immediate crashes of their online sites. Visitors to others witnessed a stunning array of error messages, prolonged delays and an inability to complete the forms necessary to register, let alone choose a healthcare plan.

Concerns about privacy, non-encrypted personal data, and poorly trained and minimally screened system “navigators” added to rampant consumer frustration.

All the hype leading up to the October 1st launch -- followed by a floundering debut -- has resulted in a predictable and rapid loss of interest from the public.  Like attendees at a fireworks grand finale that fails to ignite, consumers quickly become distracted.  They pack up their blankets and folding chairs, and head back to the car.

Recall that the exchanges were designed to function as a sort of “marketplace” for consumers, and to be the gateway to health insurance for people who don't have access to coverage through their employers.  The exchanges are critical because the requirement for everyone to have healthcare insurance – the so-called “individual mandate” – is the sine qua non of the reform legislation.

Many states opted not to embark on the onerous task of creating the online exchanges themselves, deferring instead to the federal government to tackle that challenge.

Unfortunately, the government’s own site performed no better than those in the various states that attempted to build and manage their own. One of the most troubling “glitches” was that many consumers who managed to navigate the initial on-line registration were ultimately “timed out” because they took too long comparing and contrasting plans – One of the core advertised functions of the exchanges.

As a result of vast technology problems, the Obama administration shut down its site for an overhaul and repairs within days of the launch. A visit to the site reveals that the enrollment functions will be “temporarily unavailable”.

Perhaps they would have been more inclined to delay raising the curtain on the new exchanges had Obama not granted waivers to all of Congress, their staffers, the unions and a host of his supporters.

Despite what many would describe as an abject failure, the Obama administration released a statement describing the October 1st debut in remarkably favorable terms.

In testament to the administration’s brazenness in spinning a yarn, the release was titled, "Health Insurance Marketplace Open for Business - Week One Success."

According to the statement, "Americans are excited to look at their options for health coverage, with record demand in the first days of the marketplaces".  Consumers have until December 15th to enroll for coverage that they are required by law to have in place by January1, 2014.

Apparently, there’s nothing like the threat of an IRS investigation and a hefty fine to incite “excitement” in a shopping experience.

Unfortunately, the problem with the troubled launch of the exchanges extends far beyond the technicalities of getting people enrolled in healthcare insurance.  

Like it or not, John Q. Public doesn’t have the same “this-is-the-defining-legislation-of-my-tenure” enthusiasm about the Affordable Care Act as President Obama and his omnipotent band of do-gooders in Congress.  In fact, well more than 50% of Americans remain largely critical of the bill and would like to see it delayed, if not fully repealed. 

Furthermore, Americans – particularly the young and healthy whose enrollment is critical to the viability of ObamaCare – don’t have a tolerance for failed technology.  Generations X, Y and Z are fickle; what sounded like a great idea when they voted quickly loses its appeal when signing up requires effort and a time commitment. They have short attention spans and are easily distracted.  Getting them to return to the website after the problems have reportedly been fixed may prove more difficult than predicted, IRS threats not withstanding.

To complicate matters further, many consumers are now realizing that the government’s inability to create and run the on-line exchanges portends an ample threat to its ability to manage something as complex as healthcare.  It’s unlikely that consumers will trust an airline to fly a plane if that airline can’t mange to successfully sell a ticket for the flight.

The Affordable Care Act, lovingly known as ObamaCare, is wrong on just about every level. Ultimately, the bill reflects the arrogance of Liberals who perceive themselves as superior, feel compelled to tell Americans what they need, and then proceed to redefine that “need” as a “right”.  The entire premise is misguided at best, and frankly, with all due respect to Chief Justice Roberts, unconstitutional. 

The vast majority of Americans who already have health insurance are being hit hard with enormous rate increases, skyrocketing deductibles, and huge new taxes and fees as a result of the bill.
The roughly 40% of ObamaCare that is supposed to be funded by cuts in Medicare spending will have a profound impact on doctors and their patients. Access to care will be limited, quality will decrease, and personal choice and privacy will become figments of our past.

Eventually, with enough time and additional taxpayer money, the Obama administration will cobble the insurance exchanges into some semblance of function. Unfortunately, their lack luster debut is nothing more than a harbinger of things to come.

In the words of Congressman Eric Cantor (R-VA), "A dysfunctional website is the least of that law's problems."

Wednesday, May 22, 2013

Confessions of a Serial Profiler – Avoiding "Security Theater"

I admit it: I believe in profiling.  In fact, I have personally profiled people every single day of my professional life.

It turns out, profiling is a critical component of the practice of medicine.  Without it, a physician would be hard-pressed to make a quick and accurate diagnosis.

Profiling is what allows a physician to categorize a patient based on age, gender, race, and body habitus, as well as dozens of other characteristics.  It is what allows us to scan multiple gigabytes of memory within milliseconds, and to begin both considering and eliminating potential diagnoses.   We immediately assign various “labels” (yes, labels!  Just think of it!):  old/young, male/female, white/black, thin/fat, relaxed/distressed, and so on.  These characteristics, taken together, and considered along with the patient’s complaints and presentation, make a specific set of potential diagnoses most likely.  This is known as the “differential diagnosis”, and sets the course for further examination, testing and treatment.

Profiling is what keeps doctors from ordering pregnancy tests on elderly women and suspecting sickle cell disease in Caucasians.  It removes the concern about Tay-Sachs disease in people who aren’t of eastern European decent, and places gall bladder disease low of the list of concerns in thin, young white males.

This practice is not unique to medicine.  We profile every day, in every walk of life, every time we rely on past experiences to make an informed decision.

“Profiling”” is what results from understanding the statistical likelihood of an occurrence, incorporating salient history, and synthesizing the information to guide our further actions. Frankly, it’s what separates intelligent mammals from lower forms of life.

Why then, when it comes to the most serious threat to our national security – domestic terrorism – would we not want to profile?  Why in the world would we want to avoid calling statistical likelihood and past experience to bear?

Let us not confuse “profiling” with “prejudice”. Profiling is the use of personal characteristics or behavior patterns to make generalizations about an individual that are based on facts.  Prejudice, on the other hand, is a pre-conceived unfavorable opinion or hostile feeling formed beforehand, or without knowledge or reason.

But it’s not as if we don’t know who the likely perpetrators of terrorist acts are.  Repeat after me: “9-11, the Boston bombings, Ft. Hood shootings, and Benghazi massacre were heinous acts of terrorism, perpetrated by radical Muslim extremists.”

Yet in the days immediately following the identification of the two Chechen brothers responsible for the Boston Marathon bombings, President Obama warned us to “avoid jumping to conclusions”.

Eric Holder admonished us to refrain from the assessment that this was, in fact, an act of Islamic terrorism, reaffirming America’s firm commitment to tolerance of all religions

The administration displayed the same reticence to identify acts of terrorism employed by Islamic extremists in the case of the Ft. Hood shootings and the Times Square bomber. Although not on domestic soil, the murderous attack on our consulate in Benghazi is a further case in point.

The militant Islamist movement is alive and well in the United States. Without the fortitude to call it by its proper name and to employ profiling to identify those who would act on its behalf, we contribute significantly to our peril.

At the highest level of our government, there is a pervasive unwillingness to call jihadist efforts what they are.  This is exacerbated by a refusal to actively profile those individuals most likely to engage in terrorism fueled by radical Islamic ideology. As a result, we do not have security in this country; we have “Security Theater”.

To make matters worse, we are subjected to daily infringements on our personal liberties for benefit of this illusion of security.

Hundreds of thousands of times a day in airports across the nation, random American are compelled to discard unopened bottles of water and tubes of toothpaste that exceed the arbitrary 3 oz. size limit.

The system is ridiculously inefficient, results in thousands of lost hours for business travelers, and provides a level of stress and annoyance for pleasure travelers that have undoubtedly translated into a decrease in elective air travel.

While the TSA is busy patting down middle-aged blond women and freckled, redheaded toddlers, they are simultaneously ignoring clear and present security threats.  This isn’t just a stupid game; it’s a dangerous one.

Full body scanners and enhanced pat-downs aren’t making us safer. These are reactive measures devoid of common sense and mired in political correctness.

The Department of Homeland Security is applying “equal opportunity” constructs to the task of identifying potential terrorists.  This would be tantamount to a doctor doing a biopsy on all skin lesions and moles so as not to appear “prejudiced” or discriminatory against the ones that are actually cancerous!

Despite all of the intrusions into the lives of average Americans, Homeland Security has failed to secure the homeland. We have spent Billions of dollars and have ended up with front row seats at “Security Theater”.

Physicians do a patient no good by refusing to identify and call a disease by its proper name.  Diabetes, obesity and cancer become harder to treat if they are given some colloquial moniker in an attempt to make them sound somehow less ominous.

That said, not all breast tumors are malignant.  Physicians rely on a physical exam and diagnostic tests such as mammograms and ultra-sounds to determine which lesions require additional evaluation. There are well-known characteristics based on appearance, size, shape and location that increase the index of suspicion.  That’s why not all breast lumps are subjected to surgical excision. 

Similarly, there are tumors that are not malignant now, but have telltale characteristics that reflect a high risk of becoming cancerous over time.  Those lesions require careful scrutiny and ongoing surveillance.

Tamerlan Tsarnaev, the now dead mastermind of the recent Boston bombings was on the FBI watch-list for years.  He was deemed to be such a security concern that he was actually denied US citizenship.
The government of Saudi Arabia warned U.S. high-level officials at the Department of Homeland Security specifically about Tsarnaev’s Islamist militancy.

Likewise, the Ft Hood shooter, Nadal Hassan, demonstrated clear evidence of risk to become a radical Muslim zealot capable of enacting violence in the name of jihad. 

When physicians fail to profile, identify and act on lesions that are well known to be risks for cancer, it’s called “malpractice”.  What shall we call it when our government does the same?