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.
Kelly Victory MD
Insights Into The Future of Health Care In America
Wednesday, June 14, 2017
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
healthcare.gov 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?
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