An Aging Population is pushing the NHS to the Breaking Point as it will push Obamacare to the Breaking Point

Posted by PITHOCRATES - May 25th, 2013

Week in Review

Britain’s Health Secretary said the problem with overworked accident and emergency rooms (A/Es) is that general practitioners (GPs) are not taking care of their patients.  Because a patient can’t make an appointment with their GP, or when they do it is 2-3 weeks later, they just go to the A/E instead.  Because they don’t want to wait.  Or can’t wait because of the pain.  Or because they have a sick child.  This is why accident and emergency rooms are overflowing.  Because the GPs aren’t doing their job.  Or so says the Health Secretary.  Something the GPs take issue with (see NHS A&E departments ‘left unsafe by political meddling’ by Nick Triggle posted 5/23/2013 on BBC News Health).

British Medical Association GP chairman Dr Laurence Buckman has given a speech pointing out the problems that lead to overstretched hospital A&E departments…

He said: “We’ve turned GP practices into places where it’s a daily challenge for receptionists to cope with huge call volumes and GPs to get through to all the people they need to see…”

Dr Buckman added: “He [Mr Hunt] does not want to bother with the facts when he can have a bash at those of us who on his own admission are overworked and strained beyond endurance.

The problem is not with the GPs.  Or with the National Health Service (NHS).  The problem is national health care.  Which may have worked well when people were having a lot of babies.  Making the population grow younger.  With more people entering the workforce than leaving it.  And those who left it had the decency to die soon.  But that was before the Sixties.  When they set up the NHS.  In the Sixties people stopped having so many babies.  Instead of the population growing younger it began to grow older.  And new advances in medical care have allowed retirees to live a long life in retirement.  So the rate of people consuming health care services is growing greater than the rate of those paying for it.  Which has overflowed A/Es.  And is straining GPs beyond endurance.

And so it will be under Obamacare.

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Long Wait Times for Doctor Appointments in UK sends People to the Emergency Rooms Instead

Posted by PITHOCRATES - May 25th, 2013

Week in Review

If you go to some American emergency rooms you could wait to see a doctor for hours.  Unless you’re close to death.  If so then you get to go to the front of the line.  While the less lucky who aren’t as close to death have to wait.  Two, three sometimes even four hours in some cases.  Because that’s how backed up an American emergency room can be.  Why?  Because we don’t have national health care.  And not everyone can afford health insurance.  Something Obamacare was going to fix.  By providing health care to everyone.  So the uninsured no longer back up our emergency rooms.  Just like in other countries with national health care.  Such as Britain (see Can no one force GPs to do their job properly? by Sandra Parsons posted 5/22/2013 on the Daily Mail).

Last week, a friend, a senior doctor in a busy A&E, found herself dealing with a young woman suffering from a urinary tract infection.

While this was undoubtedly painful and potentially dangerous, it was neither an accident nor an emergency.

So why, my harassed doctor friend asked her, hadn’t she gone to see her GP instead?

The patient replied she’d dialled the number over and over again without getting through and, in the end, she went to the surgery to ask for an appointment. The earliest slot, she was told, was ten days’ time. It was at that point she’d gone to A&E instead.

She tried to make an appointment with her doctor but she couldn’t get someone to answer the phone to make an appointment for her.  So she went there in person.  And they basically said, “Okay, I see you’re in terrible pain.  We should take a look at you as soon as possible.  I’ll pencil you in for a rush appointment.  So go home, get some rest and we’ll see you sometime after two weeks to take care of your unbearable pain.  Just hope it doesn’t go septic before then.  NEXT!”

This is national health care.  As done by Britain’s esteemed National Health Service (NHS).  The same NHS they poured accolades all over in the opening ceremonies of the 2012 Olympic Games.  That one.  The treasure of the United Kingdom.  What the left says we should have here.  And it is their fervent hope that Obamacare will evolve into something very much like the NHS.  Because they say that will make health care better.  And keep people from using the emergency rooms for routine medical care because they don’t have health insurance.  Only it’s not working in Britain.  Where people are still going to the emergency room (A/E in Britain) for routine medical care.

An aberration? Far from it: this woman is one of tens of thousands who are turning up at the doors of A&E because they can’t get an appointment with their doctors. The costs involved are huge…

So emergency doctors — highly trained professionals who know how to save your life when you’re having a heart attack or have been in a horrific road accident — find themselves treating minor cuts and chest infections…

Tomorrow, Health Secretary Jeremy Hunt is due to make a speech criticising GPs for failures that include not knowing their patients’ names and hiving off out-of-hours care to outside agencies. He will also highlight the fact that admissions at A&E departments have soared as a result.

Quite rightly, he lays the blame for this on the changes Labour made to GP contracts nine years ago, which allowed GPs to opt out of night calls and rewarded them for complying with targets rather than for treating patients as individuals…

So it’s hardly surprising patients all over the country have decided they’ve had enough and are bypassing their GPs in favour of their local A&E

What he should be telling us is what action he is taking to ensure that all GPs start doing their jobs properly.

That means making night and weekend calls, the way they used to. It means ensuring that we can all make an appointment for tomorrow or the next day — not next week — or turn up and wait if we’re seriously worried. (Yes, I know a few sterling surgeries do operate like this — but too many don’t.)

It also means that when we walk through the surgery door we should not feel we’re an unwelcome interruption in the surgery’s busy day, but that we’ll be listened to and taken seriously.

The most junior A&E doctor seems to be able to achieve this on a fraction of GPs’ generous pay and with far less sleep. Why can’t GPs?

Not knowing their patients’ names?  Working banking hours?  Say what you want about the American health care system before Obamacare at least our doctors knew our names.  And worked in walk-in emergency clinics after hours.  They weren’t quite an emergency room.  But if you had the flu they could do everything for you short of hospitalization.  Including writing a prescription for you that you could pick up at any number of 24-hour pharmacies.  This was the ‘broken system’ that was in crisis that the left said we had to fix with Obamacare.  So we can have something more like the NHS.  Which sounds worse than the broken system we supposedly had.

Note the comment about their generous pay.  This kind of talk must send shivers down the spines of American doctors.  For as the government takes more control of health care and begins to rein in those high health care costs guess how they’re going to do that?  Cutting that generous pay of doctors.  Because no one should be profiting on the sickness of others.  No.  Under Obamacare doctors should answer to a higher calling.  To serve his fellow man.  Not for the money but for the satisfaction of a job well done.  Yeah, that’ll encourage high school graduates everywhere to go into great debt and work a 90 hour week so they, too, can serve their fellow man.

Americans can’t even graduate enough people with math and science degrees.  So American corporation have to rely on foreigners to fill some high-paying high-tech positions.  Are they going to do the same with our medical care because fewer American students will want to go through that Hell just to earn the wages of a UAW assembly line worker?  When it’s a lot easier and less costly to be a UAW assembly line worker?

Could this be the problem they’re having in the NHS?  That they’re not paying their doctors enough to encourage others to enter the profession leading to a shortage of doctors?  Forcing people to the emergency room because they just don’t have enough doctors to see patients in the doctor’s office?  You hear all the time about how we have to pay our federal employees fat salaries and give them generous benefit packages to compete with jobs in the private sector (though few jobs in the private sector enjoy the pay and benefit packages a federal job offers).  But if a doctor makes that kind of money something is wrong with that.  Because no one should profit on the sickness of others.  But a federal worker with a far easier job paid with tax dollars?  They have no problem with these people earning what a doctor earns.  Or at least what a doctor once earned.  Before Obamacare.

Once the government starts paying doctors there will be a push to unionize them.  And then everything will change.  Then the government will want to pay them more.  Cut their working hours.  Hire more doctors.  All of which will require massive new taxes.  While giving an expanding government a powerful new ally.  And a huge source of new political donations.  As they’ll collect a piece of the union dues the newly unionized doctors will pay.  And America will never be the same again.  If you worried about the IRS targeting conservatives just imagine the special treatment conservatives will get in a health care system controlled by liberal Democrats.  Of course, a non-partisan health care system would never base a treatment decision on one’s politics.  Just because the government used the IRS to target conservatives doesn’t mean they will use a national health care system to do the same.

When President Reagan was shot he joked while being wheeled into the operating room, “I hope you guys are Republicans.”  The joke broke the tension and the doctors laughed.  Then one said, “Mr. President, today we are all Republicans.”  They then went about saving the president’s life.  In the future it might be wise to ask instead, “Gee, I sure hope you guys are all Democrats.”  Just to be safe.

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Britain’s National Health Service is more of a 9-5 Business than is the American Health Care System

Posted by PITHOCRATES - May 18th, 2013

Week in Review

People in the IRS used their vast powers to harass people they didn’t like.  People who opposed the Obama administration.  Or the liberal cause.  In general conservatives.  In particular Tea Party conservatives.  People who donated money to the Mitt Romney 2012 election campaign felt the full wrath of the federal government.  Being audited by both the IRS and the Labor Department.  Scary stuff.  Now imagine the IRS being in charge of your health care.  And you’re a political enemy of the liberal cause.  Well, you won’t have to imagine for long.  Because the IRS will soon have that power under Obamacare.  Very soon.

What makes this a frightening prospect is the nature of a more nationalized health care system.  Where limited resources are stretched to cover more patients.  Resulting in shortages.  The need for rationing.  Even the need to deny services to some.  Because the budget just can’t afford it.  Such as being unable to provide health care services after the workweek is done because they don’t have enough doctors available.  So they farm out after-hours work to moonlighting doctors.  Like the NHS is doing in Britain (see Doctors being offered £1,350 per shift for out-of-hours cover by Claire Carter posted 5/14/2013 on The Telegraph).

GPs are being paid £150 an hour for nine-hour shifts to plug holes at times when regular staff are not working.

The firm, Harmoni, is also offering bonuses to doctors for referring a friend in a desperate attempt to staff the service, reports suggest.

The new revelations follow claims that Harmoni is struggling to find doctors to run the service and has resorted to using senior nurses to provide cover. It is claimed that GPs are reluctant to work for the provider because of concerns over care standards.

Despite questions over out-of-hours care, Jeremy Hunt, the Health Secretary, said GPs should not necessarily be on call at evenings and weekends because they work hard and have lives of their own.

Under Labour’s 2004 renegotiation of their contracts, GPs were allowed to hand responsibility for out-of-hours care to private firms such as Harmoni, which has contracts in London, the south east, the midlands and the west country…

It was also claimed terminally ill cancer patients had to wait eight hours for a doctor to visit them to give them pain relief.

The disclosures come amid concern that an extra four million patients are flooding A&E units each year due to insufficient out-of-hours services.

Flooding the A&E units (i.e., emergency rooms)?  People in pain waiting for 8 hours for pain relief?  This is national health care.  Now imagine a government using their powers to distribute these limited health care resources based on one’s political leanings.  Member of the Tea party?  Come back when we open on Monday for your pain relief.  A member of a public sector union and supporter of the liberal cause?  We’ll see you now.

Don’t think this can happen under Obamacare?  Only a year ago people were saying that the IRS wasn’t targeting conservatives in general.  And Tea Party conservatives in particular.  It turns out that the IRS was targeting these enemies of the liberal cause.  So it is likely we’ll be having the same discussion in a few years.  That it turns out the government was using its authority over the health care system to punish their political enemies.  Just like they used the IRS and the Labor Department years earlier to punish their political enemies.  If these past actions are any indication of future actions of an even more powerful federal government.

And the spirit of Thomas Jefferson weeps.  For he would see little difference between what the federal government became and what the British monarchy was.  Oppressive.  And arbitrary.  Where those connected to the ruling elite did well.  While those who dared to speak up against the ruling elite found their names on a list.  And faced persecution.  This is not Thomas Jefferson’s United States.  But what he feared.  If Thomas Jefferson were alive today he would be a Tea Party conservative.  Only he would be more aggressive in trying to reduce the strength and power of the federal government.  As he was more radical than conservative.  And would be unwilling to be as peaceful in his protests as the Tea Party conservatives are.

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The NHS tells Doctors and Hospitals to get by on less while giving more Free Health Care to Foreigners

Posted by PITHOCRATES - October 14th, 2012

Week in Review

The NHS must cut about £5 billion a year to save £15 billion to £20 billion by 2014.  So the pressure is on the health service to pinch every penny.  Ration every service to those who only really need them.  And disapprove services that people don’t absolutely need.  Unless, of course, they’re foreigners who don’t pay any taxes to fund the NHS.  Who can get whatever they want free (see Open door for health tourism: NHS bosses say doctors must treat all foreigners to protect their human rights… but GPs can still turn away BRITONS living too far from surgeries by Sophie Borland posted 10/12/2012 on the Daily Mail).

Health tourists must be given free treatment by GPs because it is their human right, say NHS bosses.

New guidelines tell doctors across England they must register any foreign patient who asks for care otherwise it would be ‘discriminatory’.

These include asylum seekers, overseas students or tourists coming for a short holiday. Once registered, they will be entitled to the same NHS care as all other patients and can receive free blood tests, jabs and – in some cases – free prescription drugs.

In fact, the new rules will give overseas patients more rights than those living in the UK who can be turned away from surgeries if they live a few yards outside its catchment area.

There are also fears the ruling will make it even harder for local patients to get an appointment.

Already half of patients cannot get an appointment with their doctor within 48 hours, according to the Government’s own figures…

One GP, who wished to remain anonymous, said: ‘I am not sure the British taxpayer should be paying for the world’s health treatment for free.’

Mr Skidmore has obtained figures showing that health tourists currently owe the NHS £40million in unpaid medical bills.

Dr Vijayakar Abrol, a GP who practises in Edgbaston, Birmingham, said: ‘The guidance is not worth the paper it is written on. We do not have endless resources. Why should we give these patients – be they from India, Canada, the US or Eastern Europe – free treatment?

‘We cannot go to those countries and get free treatment ourselves.’

Because it’s their human right.  According to the NHS.  Even though technically speaking health care isn’t a right.  For true rights have no cost to others.  Such as the right to free speech.  The right to believe in any faith.  These things people can do without someone else having to pay their way.  Not the same with health care.  As other people are paying for other people.  In other words, this right (health care) compels others to act against their will.  Spending their hard-earned pay not on their families but on the families of others.

How about that?  Half of all people who pay for the NHS can’t get an appointment with their doctor within 48 hours.  But foreigners can get free health care whenever they want.  This was one of the arguments they used to pass Obamacare in the United States.  They said we’re already paying for people who don’t pay for their health insurance as they fill our emergency rooms.  While they deny those emergency room resources to those who do pay for their own health care costs.  So we might as well force everyone to buy health insurance (until we can nationalize health care completely).  But even nationalizing health care won’t remove the problem of people getting health care for free.  Because if it did the NHS wouldn’t be spending £40 million ($64.3 million) on free health care for foreigners.  While at the same time trying to cut NHS spending by £20 billion ($32.2 billion) by 2014.

Something to look forward to under Obamacare.  Giving everything to everyone.  Even if they don’t pay.  Which will, of course, lead to cost cutting, longer waits, rationing and denials of health care treatment.  As they are in the NHS.  Unless you’re a foreigner who doesn’t pay into the system.

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Despite Addendums the NHS Reform Bill still faces Opposition from Health Unions and GPs

Posted by PITHOCRATES - March 18th, 2012

Week in Review

The Royal College of GPs oppose the National Health Service (NHS) reform bill.  The bill that is trying to improve the quality of health care while reducing costs.  By introducing market forces.  And reducing the bureaucratic weight of the NHS.  Which these doctors are opposed to (see BBC News: GPs offer to help with NHS change posted 3/13/2012 on BBC News Health).

The Royal College of GPs has indicated it is willing to work again with the government on implementing changes to the NHS in England, it has emerged.

The body had been omitted from talks since declaring its opposition to the Health and Social Care Bill last month.

Chief among their concerns is the government’s determination to introduce greater competition into NHS provision.

The bill aims to allow more private companies and voluntary organisations to compete with NHS providers, something critics fear could damage the health service and undermine the drive towards integration of care.

Under the plans, family doctors are expected to play a key role in managing the NHS budget…

Dr Gerada told the BBC on Tuesday: “We still want this flawed bill, this complicated, complex bill to be withdrawn.

“But we’re not politicians, we’re doctors, and it’s the 33,000 family doctors across England that are going to have to make the health service work for their patients.

“The letter to the prime minister was one of many that we’ve written to him over the last 18 months saying ‘let’s stop polarising this debate, lets see if there’s some common ground for the sake of our patients, for the sake of the NHS’…”

Other bodies opposed to the bill include the three major health unions, the British Medical Association and the Royal Colleges of Nurses and Midwives…

But Health Minister Simon Burns said: “Patients want doctors to make decisions about their care, not managers, and that is what our reforms will deliver.”

The changes would improve services for patients while saving billions in administrative costs, to be reinvested in healthcare, he said.

Yeah, right.  They’re not politicians.  It’s just coincidental that these doctors align themselves with the three major health unions.  And the union position is nothing but politics.  Because unions protect their dues-paying members.  Patients don’t pay union dues.  So the unions don’t represent their interests.  No, they represent the interests of those treating the patients.  And chief among their concerns is how is this competition that will lower costs affect the pay, benefits and pensions of their members?  Could this be what these doctors are worried about?  Their pay, benefits and pensions?  Or is that just another coincidence?

The NHS is a bureaucratic behemoth.  Where bureaucrats make health care decisions for patients hundreds of miles away.  The NHS reform is trying to put that decision-making into the hands of the doctors who actually treat their patients.  To improve the quality of care.  And lower the cost.  By making health care more about doctors treating patients.  Than maintaining a bureaucratic behemoth that provides a comfortable life for the bureaucrats running it.  While chalking up massive annual deficits.  And creating the bulk of Britain’s national deficit.  Which can’t continue.  They have to reform the NHS.  Before it drowns under its massive costs.  And takes the country with it.

We should follow what’s happening in the NHS closely.  For it’s coming our way.  Unless they repeal Obamacare.  And if they don’t things will be worse in America.  Because America is bigger than the UK.  And the US budget for health care will dwarf that of the UK.  And if the UK can’t do it after doing it for some 60 years it’s the height of arrogance for those in the U.S. to think they can do it better.  Sadly, for what government bureaucrats lack in talent and ability they do make up for in arrogance.  Which means the collapse of the American health care system will be far greater than the problems they’re trying to fix in the ailing NHS.  Because they will ignore all empirical and historical evidence that national health care doesn’t work.  For they will just say that’s because no one as smart as they are has tried it yet.

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Reforms in the National Health Service opposed by the BMA, Royal College of Nurses and the Royal College of Midwives

Posted by PITHOCRATES - January 28th, 2012

Week in Review

There is a struggle in Britain about power and money in the National Health Service (NHS).  Health care costs are rising.  Services are being rationed.  And the current government is trying to fix these problems by decentralizing the NHS.  By transferring budgets and decision making to the general practitioners (GPs) at the local level.  The front-line doctors.  Making the GPs responsible for their budgets.  And their patients’ care.  At the local level where doctors treat patients.  Making the practice of medicine once again an intimate relationship between doctor and patient.  But others see this as a heinous plot to introduce market forces into health care (see NHS ‘in peril’ if health reforms fail, warn GPs by Stephen Adams posted 1/27/2012 on The Telegraph).

In a letter to The Daily Telegraph, the heads of more than 50 new doctors’ groups argue that the British Medical Association’s policy of “blanket opposition” to the Health and Social Care Bill fails to represent GPs’ views.

They warn that previous reforms have not gone far enough and have consequently “paid the price of disengaging the frontline staff most needed to modernise the NHS”…

The letter has been signed by 56 GPs who are helping set up clinical commissioning groups (CCGs) across England. Under the Bill these will effectively replace primary care trusts (PCTs) and be handed their budgets.

Andrew Lansley, the Health Secretary, has consistently argued that the central thrust of the Bill is to give doctors a greater say, and key to this is giving them more responsibility for commissioning health services…

However, many believe the real motive is to open up the NHS for greater private sector involvement.

Last November the BMA moved to a position of total opposition to the Bill, and since the New Year the Royal College of Nurses and the Royal College of Midwives have followed suit. The Royal College of GPs is deeply sceptical, although not yet publicly in total opposition.

The inefficiencies of national health care have resulted in medical rationing.  Which has lowered the quality of health care for the patient.  So why would anyone oppose reforms to improve the quality of health care for the patient?  Because it will introduce market forces into health care.  Which will reduce costs and improve efficiency.  Which could also impact pay, benefits and pensions of health care providers.  The most expensive part of national health care.

This is the danger of national health care.  It destroys the quality of health care.  But it also creates a very vocal and powerful health care bureaucracy.  That takes on a life of its own.  And makes reform nearly impossible.  It’s happening in Britain.  And will happen in the U.S. if Obamacare is not repealed.

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Seeing the Bleak Future of Obamacare in the UK and Canada

Posted by PITHOCRATES - May 6th, 2011

The UK and Canada look to the Private Sector to Rein in Health Care Costs

The UK founded the National Health Service (NHS) in 1948.  That’s over 50 years ago.  And you know what they say?  Practice makes perfect.  So the UK must really have this national health care thing down, right?  Delivering everything President Obama promises to deliver with his Obamacare.  Affordable yet quality health care for everyone.  For the problem the Americans have been having is that they don’t have a national board yet to limit health care costs.  To tell providers how much is enough.  To swat them on the nose with a rolled up newspaper and say, “Bad, health care provider.  Bad.  You have to learn to stop being so greedy.”  Like they must be doing in the UK (see Kill or cure by The Economist posted 5/5/2011 on The Economist).

THE government has put its ambitious health-care reforms on hold, while David Cameron tries to calm a bout of anxiety in his coalition. However, many hospitals are already finding that a combination of rising costs, heavy debts and looming budget cuts is forcing them to seek mergers with stronger institutions or even private-sector takeovers. Even less palatable for the coalition—and patients—there are worries that as the government seeks to save £20 billion ($33 billion) in hospital running costs over the next four years, some closures may be inevitable.

Iain Duncan Smith, a predecessor of Mr Cameron as Conservative leader, last month signed a petition outside 10 Downing Street against closures of the emergency and maternity units of a hospital in his London constituency. Trafford hospital near Manchester—the birthplace of the National Health Service (NHS), where its first patient was treated on its founding in 1948—is considering privatisation, among other options, to resolve its debt crisis. In London, three big hospitals, including the historic St Bartholomew’s, are contemplating joining up into one “superhospital”.

Well, that’s odd.  You see, the UK has a national board to control health care costs.  So they shouldn’t have rising costs.  Heavy debts.  Looming budget cuts.  Mergers.  Or private-sector takeovers.  But here the UK is.  Doing exactly these things.  It makes one wonder why the Americans want to go down this road when the UK has demonstrated that it is the wrong road to go down.  Unless it’s not about providing affordable yet quality health care for everyone.  But the government taking over one-sixth of the nation’s economy.  Whatever the consequences to the quality of health care.

Given how Britons cherish the NHS, privatisations of hospitals might prove as controversial as closures. The government wants a “mixed economy” in the health service, citing Hinchingbrooke hospital in Huntingdonshire as an example of its readiness to bring in private-sector innovation. It will shortly become the first NHS general hospital to be franchised to a private company. Indeed, in Canada’s generally well regarded health service, hospital treatment is often provided by charitable or private operators, with the state paying the fees—so there is no reason why more private-sector involvement in Britain’s NHS would put its principle of free treatment for all at risk.

So things may not be that bad.  The NHS may just become more like the Canadian health care system.  In Canada, the Canada Health Act (CHA) determines how the government reimburses private health care providers for their services.  And it is these private health care providers who hire doctors and nurses.  And funds their retirement.  They are not government employees.  Like in the UK.  Canada is more like the USA.  Only with a single insurance company, i.e., a public option.  So the Britons don’t have to worry about change per se in paying for health care.  It will still ultimately come from tax dollars.  And they will have the same problems they currently have in the UK (see Canada’s health care crisis is an economics problem, not a management problem by Brett J. Skinner, President and Director of Health Policy Studies and Mark Rovere, Associate Director of Health Policy Studies Fraser Institute, posted 4/19/2011 on Troy Media).

Government health spending is growing at unsustainable rates, while patients are facing shortages of medical resources and declining access to necessary medical care.

The Canadian health system has been run as a government monopoly since 1970. It doesn’t really matter which level of government tries to manage the system, our experience shows that political planning doesn’t work. Adding federal management would be as effective at averting disaster as rearranging the deck chairs on a sinking ship.

So, yes, the UK is looking to the Canadian system as a lifeboat for the NHS.  Unfortunately, the lifeboat they chose also happens to be sinking.

This cost crisis is happening despite significant government efforts to centrally restrict spending on health, which has resulted in shortages that create long waits for access to necessary medical goods and services.

The Fraser Institute’s annual survey of Canadian physicians shows that, in 2010, patients waited approximately 18.2 weeks from the time they obtained a referral from a general practitioner to the time they received treatment from a specialist. Although health spending consumes a larger share of provincial revenues each year, Canadians are waiting 96 per cent longer for surgery than they did in 1993 when the average wait was only 9.3 weeks long.

The problem is that both the NHS and the CHA have the same problems.  Adopting a system more like the other doesn’t get rid of those underlying problems.  There is something they both can do, though.  Use less government.  And more market forces.

The real solutions are quite simple: user fees and private insurance options would introduce economic incentives for efficiency that would regulate supply and demand, shift costs off the public system and offer a sustainable source of additional resources.

The US has private insurance options.  For now, at least.  But they wrote Obamacare to put them out of business to get the public option in through the back door.  A two-step process to get the US to a national health care system.  So they can have the same problems as their dear friends in Canada and the UK.

National Health Care makes Unhappy Health Care Providers

The problem with a single-payer system is that there is no competition to keep costs down.  That’s what a free market economy does.  Keeps prices down.  That’s why one store can’t sell a TV set for $2,500 when another sells the exact same set for $750.  Because consumers will not pay more for the same thing.  That’s what competition does.  Makes people honest.  Without competition, though, you have to trust someone.  Or some panel.  To set fair prices.  And fair salaries and benefits.  And when costs are too high the only options available are to ration services.  Or pay health care providers less.  Or make them work longer hours for the same pay (see NHS reforms push third of GPs to head for exit by Laura Passi posted 5/5/2011on PulseToday).

The first part of Pulse’s State of the Profession Survey, published this week, paints an alarming picture of GPs’ working lives, suggesting they are being forced to work longer hours, are spending less time with patients and are struggling to meet expectations as a result. Almost half of the 576 GPs who responded to the poll reported they were suffering from stress.

But it is the fallout from the Government’s far-reaching NHS reforms that appears to have pushed the number of GPs looking to quit to the highest level for more than a decade, with 71% claiming morale had fallen as a direct result of the health bill and only 9% saying it had risen. Just 18% said they believe general practice is currently moving in the right direction.

Here’s a news flash.  Being a nurse is hard.  Being a doctor is hard.  Telling them that they have to work longer and harder for less pay just isn’t going to get people to go into medicine.  Or stay in medicine.

BMA chair Dr Hamish Meldrum told Pulse he feared low morale could lead to an exodus of senior GPs.

He said: ‘Morale isn’t that good when it comes to things like pay, the threats to pensions and the various other things that are going on in the NHS.

Yes, we want you to sacrifice and give all you can so we can live healthier lives.  But we don’t want you to get rich in the process or enjoy life.  Your reward should be knowing that we can live a long and healthy life so we can get rich and enjoy life.

Dr Julia Hodges, a GP in Elephant and Castle, south London, was one of many to blame the fall in morale on the NHS reforms: ‘A lot of people feel quite betrayed because the story was that there would be no major top-down reorganisation, and then suddenly the biggest changes since the inception of the NHS are being discussed. I feel the changes are badly thought out and so destructive. Inevitably there has to be more rationing, more cuts, more waiting lists. I think it’s going to be really unpleasant to try and commission services when the budget is shrinking rapidly.’

Yeah, it has to be this way.  Because when there is no competition, the only way to cut costs is for someone or some panel to determine who they are going to pay less.  Or who they are going to make work harder for the same amount of pay and benefits.

It’s about the Power and the Money

When it comes to the health care debate in the United States, people have to understand it’s not about providing affordable and quality health care for everyone.  It’s all about political power.  And the money.  The utopian solutions pointed to in the UK and Canada are not the utopias some think they are.  Their cost problems are worse than the American cost problems.  But does that dissuade the defenders of Obamacare?  No.  Which should tell you everything you need to know about their true intentions.

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The International Fight against Universal Health Care

Posted by PITHOCRATES - April 16th, 2011

The Most Effective Cost Control Mechanism is Market Forces

They keep saying that they’re not trying to nationalize our health care.  In fact, Obama promised that if you liked your doctor you could keep your doctor with the new Obamacare.  Of course, that decision won’t be entirely yours.  For your doctor may choose to drop you.  And if they keeping cutting Medicare doctor reimbursements, doctors will finally say enough is enough.  I’m outta here.  No more Medicare patients.  Which could force you to find another doctor.  Even though Obama promised that wouldn’t happen.

There’s a lot of talk about controlling costs in Medicare.  And there’s only one way to that with the current system.  You pay doctors less.  Which they are always trying to do.  Is that fair?  Put yourself in their position.  Would you keep seeing patients?  After doing what so few other people do (go to college, medical school, serve an internship and a residency after racking up huge student loan debt that has to be paid back at the same time you have to pay ever rising medical malpractice insurance premiums leaving you with little money to enjoy the first decade or so of your new medical career)?  Because some government bureaucrat says you’ve earned enough money?  All the while no government restrictions are placed on public sector pay and benefits?  To add the ultimate insult to injury, a lot of those same bureaucrats telling doctors that they’ve earned enough money and should be happy with what the government deems is appropriate will no doubt make more than the doctor.  With far less training.  And far less responsibility.  Which just ain’t right.

They like to blame the doctors for the runaway costs.  But they’re not the lone scapegoat.  They also blame the pharmaceutical companies.  The hospitals.  And, of course, the great ‘big bad’ in the health care industry, the insurance companies.  Whose costs keep going up.  Greater than the rate of inflation.  So the runaway costs in the health care system must be their fault.  Because they’re greedy.  It can’t have anything to do with the system we force them into.  Where third party payments shut out all market forces (the person receiving the service isn’t paying the bill), thus eliminating the only effective cost control mechanism.  And introduces government.  Making health care a public good.  Where non-health care government bureaucrats determine fair pricing, supply and demand.  And you know where that will lead to.  To the here and now.

Labour fights against Market Forces for the NHS in the UK

Government bureaucrats don’t like privatization.  Or market forces.  They’d rather manage things.  Because they’re smarter.  Narcissistic.   And they covet that money and power.  They want all those tax dollars funding health care to go through their fingers.  And having people dependent on them for their health care makes that a whole lot easier.  So when conservatives try to introduce effective cost mechanisms, liberals push back.  In the US.  In Canada.  And in the UK (see NHS bill to ‘substantively’ change, says Oliver Letwin posted 4/16/2011 on the BBC).

Labour wants the plans for the NHS in England, which encourage more private sector competition, to be scrapped.

Under the shake-up, GPs are also to be given control of much of the NHS budget.

To cut costs, reduce wait times and improve quality of the NHS, the UK is trying to decentralize the NHS.  Give more decision-making authority to the general practitioners (GPs) in the local communities.  Letting the local health care providers in the communities they serve determine how to best spend the NHS money.  Which, of course, is anathema to Big Government liberals.  Such as Labour in the UK.

Liberals fight against Market Forces for the CHA in Canada

Wherever you find national health care, you’ll find bitter partisan debate over the money paying for that health care.  Except in Cuba.  Or North Korea.  Luckily, for them, there are no opposition parties.  And no one complains about anything.  For they know better.  But Canada has a national funded health care system.  And opposition parties.  Which can get pretty nasty when they’re trailing in the polls (see Liberals drop gloves with attack ad on Harper’s ‘secret’ health agenda by John Ibbitson posted 4/16/2011 in The Globe and Mail).

Conservatives are reacting with fury to a Liberal attack ad that accuses them of harbouring a secret agenda to cut health care funding if they obtain a majority government.

“The Liberal ad uses some of the dirtiest tricks in the book — including twisting words out of context and deliberately altering dates to make old words appear recent,” Tory campaign manager Jenni Byrne wrote to party supporters in reaction to the new attack ad.

In America, the go-to strategy is to threaten Medicare.  In the UK it’s the NHS.  In Canada, it’s the Canada Health Act (CHA).  The reason is, of course, the sheer size of this budget item.  If you’re trying to cut a budget deficit, that’s where you do it.  Cuts elsewhere just won’t be big enough to matter.  And everyone knows it.

If Mr. Harper is given “absolute power,” the ad warns, he plans to cut $11-billion from the federal budget. “Where would Harper’s cuts leave your family’s health?” the narrator asks.

“The stakes are too high. Vote Liberal.”

So you threaten certain death for you and your family should the opposition get elected.  While all the time promising yourself to cut the deficit.  Which, of course, you won’t.  For it will require cuts in health care funding.  And you’re not going to do that.  For there will be another election.  Eventually.  Sure, it makes you a hypocrite.  But a hypocrite with a job.

The Conservatives do plan to cut government spending as part of their own plan to balance the budget, but they promise to do so without reducing transfers to provinces, including health transfers.

It is true that the Liberal government of Jean Chrétien cut funding for health care in the 1990s as part of its efforts to eliminate the federal deficit. Once the budget was balanced, the Paul Martin government signed a ten-year accord to increase funding by six per cent a year. The Conservatives, when they came to power, honoured that commitment, and pledge to continue the arrangement, as does Mr. Ignatieff.

Anyone living near the Canadian-US border only knows too well the consequences of painful health care cuts.  When doctors and nurses get pay cuts, they scoot across the border for higher paying jobs in the US.  Which makes Canadians’ long waits for health care even longer.  This is the ultimate consequence of national health care.  Cost problems you solve by rationing services.  Whether in the UK.  Canada.  Or the USA.

Massachusetts:  Blueprint for Obamacare

We have Obamacare now.  Maybe.  We’ll see.  There’s a popular movement to repeal it.  After it was snuck through Congress.  By the time people learned what was in it (long after Congress voted it into law), the majority of the population didn’t want it.  It’s a big reason why the Republicans won back the House of Representatives in the 2010 mid-term elections.  For the people felt betrayed by their representatives.  So they fired a bunch of them.  Except Nancy Pelosi.  Who the good people of San Francisco reelected with like 80% of the vote even though her national approval numbers as Speaker of the House were closer to 10%.  Which makes it clear that the San Francisco district she represents is an anomaly in the American fabric.  Where the people think against the national grain, so to speak.  But I digress.

Anyway, before Obamacare there was Massachusetts.  And their little experiment in universal health care.  Which now covers every man, woman and child.  Well, almost.  Only 98% are covered.  That other 2% are the state’s Republicans.  I’m kidding, of course.  I don’t know who that 2% is.  Except that they must be the most unlucky sons of bitches ever to live in Massachusetts.  To live in a state where everyone gets free health care and they still get bupkis.  Imagine how that would make you feel.

But even there, in that universal health care utopia, they have a problem.    They gave health care to everyone (except that unlucky 2%, the poor bastards) but they never figured out how to pay for it (see Massachusetts, pioneer of universal health care, now may try new approach to costs by Amy Goldstein posted 4/15/2011 on The Washington Post).

Massachusetts Gov. Deval L. Patrick (D) is trying to “shove,” as he put it, the health-care system here into a new era of cost control. He is proposing a new way of paying for care that would try to propel changes in the way it is delivered. It would give lump payments to teams of doctors responsible for almost all the care of a group of patients, with bonuses for saving money and dispensing high-caliber services that keep people healthy.

Interesting.  Sort of going the route of the GPs in the UK.  Decentralizing the health care system.  After they just centralized it.

Massachusetts in 2006 created a health insurance exchange, a requirement that most residents carry coverage and subsidies to help them pay for it — central elements now in the federal law. As a result, 98 percent of the residents here are now insured, the highest rate in the nation. But the state’s first round of health-care changes devoted far less attention to medical costs.

“We did access first,” said state Senate President Therese Murray (D). “Now we have to figure out how we afford that.”

Oops.  No doubt during the debate for universal care the opponents said something like, “Are you out of your minds?  You have any idea what something like that will cost?”  Which, of course, the proponents replied, “Don’t worry about it.  We have a plan.”  And that plan was apparently to get the law passed first then figure out how to pay for it.

Fee-for-service medicine “is a primary contributor to escalating costs and pervasive problems of uneven quality,” the commission unanimously concluded in 2009.

Despite the consensus, huge questions loom: Who should be part of the new medical teams? How would the idea work for most doctors who practice alone or in small groups? How much clout should the state wield to blunt the ability of powerful local health systems to drive up costs? And, importantly, how heavy a hand should the government use to compel change?

Fee for service is NOT the problem.  It’s never the problem.  If I want to hire a contractor to build a deck in my backyard, I’ll ask some contractors to quote their fee to build a deck.  If the prices are $15,000, $10,000 and $5,000 for identical services, guess who I’m going to hire.  Now, for the sake of argument, let’s say that each of these prices are fair prices for each of these contractors because of their cost structure (e.g., one may have his office on the beach and pays ten times as much in property tax as the others and therefore has to charge more). 

Now in a system where the government steps in to make prices fair, let’s see what happens.  Say a bureaucrat gets three quotes and determines the fair price is $10,000 (the average of the three).  So the contractor who quoted $15,000 now has to build decks at $10,000 and lose money, eventually going out of business.  The contractor that quoted $5,000 will get rich making over a 100% profit on each deck.  And me?  I’ll end up paying twice as much as I had to for the deck.  This is what happens when you don’t let the market set prices.  You get a mess.

In the pressure-cooker of medical costs in the United States, Massachusetts offers a particularly vivid example. The spending per person on health care is 15 percent higher than the national average — even taking into account the comparatively high wages here and outsize role of medical research and training. The move to near-universal coverage, state figures show, accounts for a sliver of recent increases in insurance premiums, which have soared above inflation. The main reason has been a rapid escalation in prices.

“The growth is outstripping every single measure of society’s ability to keep up,” said Glen Shor, executive director of the Commonwealth Health Insurance Connector, which runs the insurance exchange.

So much for the theory of an insurance exchange being the panacea Obama claimed it would be.  For whenever has a bureaucracy been cost efficient?  Never.  It’s impossible.  You can’t manage an economy and do better than market forces.  It’s never happened yet in human history.  So why do some people (i.e., Big Government liberals) still think they can do a better job?  Oh, but we must remove filthy, nasty profits from health care.  This ‘public good’ deserves better.  It deserves the tender love of a caring government bureaucracy.  Not some evil corporation trying to maximize profits.  Of course, look at what happens when these corporations do just that.  Stuff we like and want to buy is plentiful and inexpensive.  But God forbid if we do that to health care.

Some doctors are embracing the new way of working. David C. Pickul is the medical director of the physicians group affiliated with Lowell General Hospital, in an economically bruised community about 30 miles northwest of Boston. The group is in the third year of a five-year “alternative quality” contract with Blue Cross involving a hub of 70 primary care doctors and a looser group of 200 specialists who are responsible for 20,000 HMO patients. The team now has a financial incentive, Pickul said, to track down patients when it is time for their mammograms or for eye exams for those with diabetes. Under Blue Cross’s quality rating, Lowell has soared the past two years.

Blue Cross is not alone. At Partners HealthCare, the famous Boston-based medical system that dominates health care here, Massachusetts General Hospital has been conducting a Medicare experiment in which nurses are assigned to coordinate care for about 2,500 older patients with multiple ailments. The experiment, which began five years ago, so far has reduced hospital re-admissions by one-fifth and cut medical spending by 7 percent.

“Frankly, the market has already . . . responded,” said Gary Gottlieb, Partners’ president and chief executive. “There is enough momentum for us to do this without instrumental regulation” by the state.

The governor and some other officials disagree. The need to lower costs, they say, is urgent enough that the government should step in, and they have been laying groundwork.

Financial incentive?  Isn’t that another word for profit?  And this pursuit of profits has done what?  Improved patient quality?  Reduced hospital readmissions by one-fifth?  And cut medical spending by 7 percent?  Amazing what will happen when you let the market respond.  What a success story.  But they want to do what?  Step in?  To lower costs?  After the market lowered costs already by 7 percent?  You got to be kidding me.  Whatever happened to if it ain’t broke don’t fix it?

And Alice Coombs, president of the Massachusetts Medical Society, is especially concerned about physicians who work alone or in small groups, older physicians who might choose to retire rather than switch or new doctors who might leave for other states.

And how do you solve that problem?  With compulsory medical service.  Which universal health care coverage gives you.  If you worry about doctors opting out of a new cost-contained system, you make it impossible to opt out.  You simply nationalize health care.  Letting the doctors know, yeah, they may be miserable and unhappy with the new system, but you’ll be just as miserable and unhappy where ever you go.  So why move out of state?  For any where you go, we’ll be there.  Understand?  So just keep curing the people and stop your bitching. 

Sure will make all that medical school, internship and residency worth it, won’t it?

The Song Remains the Same

Liberals everywhere want to expand the size of government.  And a national health care is the holy grail of government expansion.  But everywhere it’s tried the same thing happens.  Cost and wait times increase.  Quality decreases.  And services are rationed.  Most people (especially liberals) want to blame the greed of those who work in health care.  So they come up with new ways to manage and control costs.  Which inevitably adds yet more layers of bureaucracy.  Which benefits liberal governments.  At the expense of the taxpayer.  And patients’ health.

But nothing they try works.  Costs keep going up.  For good reason.  Because the problem is not the greed of the health care people.  It’s the health care system.  There are no market forces in it.  Which is the most efficient cost control mechanism.  Of course, admitting this is an admission that Big Government has failed.  And liberals can’t have that.  So they fight.  Demonize.  And scapegoat. And try to scare the bejesus out of everyone by saying conservatives want to cut health care funding so they can kill your family.

Whatever the name, whatever the country, the song remains the same.  Conservatives will try to cut deficits by reforming the biggest budget item.  And liberals will fight them every step of the way.  Ultimately giving us a health care system with greater costs, longer wait times, lower quality and rationed care.  As demonstrated everywhere in countries with a national health care system.

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Government Bureaucrats are bad for your Health in the UK and in the US

Posted by PITHOCRATES - March 2nd, 2011

 To be Great be like Margaret Thatcher and Ronald Reagan

People have said that the British and the Americans are one people separated by a common language.  We’re very similar.  Even if we speak the Queen’s English a bit differently.  It turns out that’s not the only thing we share.  We also bend over backwards to compare ourselves with great conservatives from our past (see Look at what the Conservatives are achieving by Michael Fallon, MP for Sevenoaks and deputy chairman of the Conservative Party, posted 3/2/2011 on the UK’s Telegraph).

Yes, Thatcher abolished the dock labour scheme – 10 years after she was elected. Yes, she tackled trade union power: they finally lost their closed shop in 1988, nine years after she started. Yes, she set up grant-maintained schools, independent of local authorities. But when we left office, they comprised less than 5 per cent of the country’s total.

David Cameron’s Government has moved further and faster. Take the public finances: public borrowing, cyclically adjusted, will be 0.3 per cent of GDP by 2015, well below the 2.6 per cent it was in 1990, and the budget will be back in surplus. Corporation tax was 34 per cent when Thatcher left office; by 2015 it will be 24 per cent. Small business tax, 25 per cent in1990, will have fallen to 20 per cent.

Not only is David Cameron Thatcher-like, he’s even out ‘Thatchered’ her.  This speaks volumes about the greatness of Margaret Thatcher.  In America, it’s the other half of that dynamic duo.  Ronald Reagan.  Come election time, every candidate is trying to show how Ronald Reagan he or she is.  Even the Democrats.  Even Barak Obama as his poll numbers plunge.

For a first-term prime minister leading an entirely novel coalition, the essential tasks might be enough: growing the economy; weaning it off its over-reliance on public spending, financial services and an unsustainable property boom; and pulling our finances back from the brink over which Greece and Ireland plunged.

Yet far more significant is the quiet revolution that is turning government inside out – away from Whitehall and targets and regional authorities and back to councils, GPs, head teachers, police commanders, community groups and charities. Ending the state monopoly in almost all public services, encouraging new providers, ensuring competition and choice – these are the most radical reforms since the Attlee government.

And Obama couldn’t be any more un-Ronald Reagan-like if he tried.  He’s trying to take America in the opposite direction that David Cameron is trying to take the UK.  Cameron is trying to decentralize while Obama is trying to centralize.  Especially health care.

Poor Quality, High Cost and Rationing in the National Health Service

The National Health Service in the UK has high costs and quality concerns.  The costs have been addressed in the past by rationing services.  The quality concerns have been addressed by layers of bureaucracy that have often been the original cause of the quality concern.

The problem with the NHS is size.  It’s a behemoth.  And because of that, it has layers of bureaucracy.  Which results in bureaucrats making decisions for patients instead of doctors.  They’re trying to change all this by grouping together and empowering local general practitioners (GPs) into consortia (see Hospitals shake-up essential, says King’s Fund by Nick Triggle posted 3/2/2011 on the UK’s BBC).

The government has protected the NHS budget by giving it small above-inflation budget rises over the next four years.

But the report said it was still entering a “cold climate” because demands and costs were outstripping the settlement.

It said without change there could be a “downward” spiral of falling income, growing deficit and declining quality.

Will this fix all the woes of the NHS?

Scandals such as Mid Staffordshire, where an official report found hundreds of patients died needlessly because of poor care, could not be ruled out.

Probably not.  But it’s a step in the right direction.  For the patients, at least.

A Department of Health spokesman said GP consortia would strengthen the ability of the NHS to make the right decisions.

“We urgently need to modernise the NHS – that is why our plans include many measures to make services more responsive to patients and to consistently drive up quality.”

The key to good health care has always been the doctor patient relationship.  The more people that get in between the doctor and the patient the poorer the health care gets.  Because the focus shifts from quality to cost efficiency.

This is a step in the right direction, but it’s still a heavy bureaucracy.  There is another way to ensure quality, though.  Competition.  When my dad had his first heart attack the paramedics gave us a choice of two hospitals they could take him to.  One had a bad reputation.  The other didn’t.  We chose the one with the good reputation. 

That other hospital continued to do poorly for years and eventually had financial troubles.  Then a big hospital bought it and brought it up to their standards.  And many years later, both of these hospitals are now providing quality care.  You see, competition makes everything better.  Even health care.

Using High-Fructose Corn Syrup instead of Sugar making us Obese?

The British and Americans have something else in common.  We like our sweets.  While one of us loses their teeth to this indulgence, the other has gotten obese (see The Fight Over High-Fructose Corn Syrup by Sharon Begley posted 2/28/2011 on The Daily Beast).

Now a stream of studies shows that sugar and corn sweeteners differ in important ways, including how they affect the appetite-control centers in the brain. That suggests that [High-Fructose Corn Syrup] HFCS may be partly responsible for the obesity epidemic…

The new study is too small to decide the question—it included only nine people—but it fits with other research on both humans and lab animals.  Scientists led by Jonathan Purnell of Oregon Health & Science University gave fructose, glucose, or salt water to volunteers and then measured brain activity with functional MRI scans. Over several regions of the cortex, activity increased in people given glucose but decreased in those given fructose, the scientists will report in Diabetes, Obesity and Metabolism. Cortical regions that responded differently included the orbital prefrontal, a key player in the reward circuit, and regions that process the pleasurable effects of food. “It’s evidence that fructose and glucose elicit opposite responses in the human brain,” says Purnell…

Rats eating equal calories from the two gained significantly more weight on HFCS than on table sugar, scientists led by Bart Hoebel of Princeton reported in 2010. The HFCS-fed animals also had increases in abdominal fat and triglycerides. And in a 2010 review, scientists at the University of California, Davis, noted that, in people, fructose added to abdominal fat and other measures “associated with increased risk for cardiovascular disease and type 2 diabetes.” HFCS is not the sole culprit in obesity. But the body and brain don’t seem to treat it as an innocent bystander, either.

Great Britain’s early Caribbean colonial possessions sent shiploads of cane sugar back to England for their tea.  And to make their chocolates.  They so liked their sweets.  And, as a consequence of this sugary indulgence, their bad teeth are legendary in the world of dental hygiene.  George Harrison even wrote a song about a fellow Brit with a chocolate addiction.  Eric Clapton.  Who he warned that he’ll have to have all his teeth pulled out after the Savoy Truffle (a song on the BeatlesWhite Album).

So the British are the butt of many a dental hygiene joke.  But they aren’t obese.  Like the Americans are.  Who also have a sweet tooth.  But we don’t eat sugar.  We eat HFCS.  Why?  Not because we prefer it.  But because of our government.  Big Corn lobbies Congress for sugar tariffs.  And Congress delivers.  Which makes imported sugar more expensive than HFCS.  So we eat HFCS not by choice.  But by government fiat.  And it now appears it may be part of the cause for the explosion in obesity and diabetes in America.  How about that? 

Yet another reason to keep government bureaucrats out of our health care system.

Conservatism Works every time it’s Tried

Bureaucrats are good at shuffling paper.  They aren’t good research scientists.  Or doctors.  So it’s best to keep them shuffling paper.  And let the professionals determine what we should eat.  What we probably shouldn’t eat.  And take care of us when we get sick.  I’m sure we’d all live a longer and healthier life if we do.

The dynamic duo of Margaret Thatcher and Ronald Reagan knew this.  Their conservatism worked.  It made the UK and the US great again.  And this is why everyone bends over backwards to show how much they are like these great conservatives from our past.  Even those who couldn’t be more opposed to their philosophy.  Because they know that conservatism works and has worked every time it’s been tried.  And they’re willing to admit that (a little) at election time.  Even if they’re lying through their teeth.  That is, if they haven’t been pulled out yet after the Savoy Truffle.

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