What Would Happen, If … ?

I’ve been spending some time in Paul’s letter to the Colossians. As is my habit, because I am rather dense about matters of the spirit, I read and reread short sections, day after day, trying to quiet the mind, shut out the noise, and open the spirit to insight beyond what this world has to offer.

And the noise is relentless, played at full volume, unmercifully, irrationally, without pause or purpose. Health care reform. Corrupt and condescending politicians. Wars and rumors of wars. Recession and depression. Culture clashes and the death throes of a dying society. Insistent demands in my head for just one more thing, another possession, to satisfy the emptiness of the soul and feed the lie that my wants are one with my needs.

And so I come to this:

This same Good News that came to you is going out all over the world. It is bearing fruit everywhere by changing lives, just as it changed your lives from the day you first heard and understood the truth about God \'s wonderful grace.

And this:

So we have not stopped praying for you since we first heard about you. We ask God to give you complete knowledge of his will and to give you spiritual wisdom and understanding. Then the way you live will always honor and please the Lord, and your lives will produce every kind of good fruit. All the while, you will grow as you learn to know God better and better.

We also pray that you will be strengthened with all his glorious power so you will have all the endurance and patience you need. May you be filled with joy, always thanking the Father. He has enabled you to share in the inheritance that belongs to his people, who live in the light. For he has rescued us from the kingdom of darkness and transferred us into the Kingdom of his dear Son, who purchased our freedom and forgave our sins.

And I start to wonder, what would happen, if I prayed like that? Without stopping? For things such as these?

What would happen if, with every person I encounter each day, be it friend, foe or family, that I prayed for them? Short prayers, simple requests for gifts of wisdom and understanding for them?

What would happen if, with each patient I see, I were to ask for such wisdom and understanding, endurance and patience?

What would happen if, rather than obsessively seeking the opinions of those whose ideas reinforce my own convictions and feed my frustrations, I prayed instead for peace within my heart, and thanksgiving for all I have and have received? What would happen if I prayed instead to be a better citizen of the kingdom of the light rather than trying to wrestle the kingdom of darkness, already defeated, to the ground?

What would happen if, instead of merely passively and passionately following the demands of my many addictions and compulsions, dark desires and destructive impulses, I sought instead through prayer and perseverence the power to overcome them?

What would happen if, I prayed for the Church, to purify herself from the world and find once again her First Love? What would happen if I prayed for my pastor and my congregation, rather than finding fault with this teaching or that behavior? What would happen should I pray that the Church — yes, and that specifically includes me, and mine — would be passionate about sharing the truth of the Good News, that it might “bear fruit by changing lives,” when so many need just such change, and can find it nowhere else?

What would happen if, I prayed to be able to pray like that, since my mind and my spirit are so deadened by the noise and distractions and by the mental parasites that paralyze the soul and sap the spirit?

Just wondering, what would happen, if…

On ‘Death Panels’, Compassion & Choice

I must confess to having had some misgivings about the uproar over Section 1233 of the proposed health care reform bill HR 3200. This section pertains to government payment for counseling on end-of-life options under Obamacare. From Sarah Palin’s ‘death panels” to an endless host of hyperbolic rhetoric about how this counseling is “mandatory” (it’s not) and will inevitably lead to euthanasia, I have felt that much of the discourse is over the top and poorly supported by the text of the bill, and may well prove counterproductive in the long run.

This is not to say that there is no reason for concern: the enormous financial strains which the proposed legislation will place on the health care system, combined with a government panel to decide the “appropriateness” of medical care, certainly introduces significant moral hazards in creating pressures to restrict expensive care at the end of life. Given the growing legality of physician assisted suicide (PAS) — first legalized in Oregon and most recently in Washington, with many other states considering it legislatively or by fiat from judges — it is likely that PAS will become one of the options which must be discussed as part of such end of life counseling, and that there will be pressure to use such “cost-effective” options. Oregon is now offering coverage for PAS while denying expensive palliative chemotherapy. It is not hard to imagine such a trend developing at the federal level as well.

But despite my reservations about the current political firestorm on this issue, there may well be more cause for concern than I have previously believed: via the invaluable Second Hand Smoke, Wesley Smith picks up an interesting trail: the organization Compassion and Choices was deeply involved in helping to craft this section of HR 3200.

So who exactly are these folks? Does the name “Hemlock Society” ring a bell, per chance?

The Hemlock Society was founded by Derek Humphry in 1980, a rabid proponent of assisted suicide and euthanasia, as he himself makes clear:

Born in 1980 in my garage in Santa Monica, California, Hemlock went on to be the largest and oldest right-to-die organization in America fighting for voluntary euthanasia and physician-assisted suicide to be made legal for terminally and hopelessly ill adults.

But the name ultimately proved a little too close to the truth for comfort, and so eventually needed to be changed to something more anodyne: “We [also] need access to the halls of government in the states and in Washington DC – access that the name ‘Hemlock’ is currently denying us. The name Hemlock … is also baggage, baggage that we can no longer afford to have weighing us down or interfering with our being able to partner with such important and powerful organizations as AARP.” And so Hemlock joined other pro-death organizations in 2003 to become reincarnated as “Compassion and Choices.”

And now, clearly, they have the congressional access they sought. Ahh, the power of euphemism — what would a death cultist do without the words “choice” and “compassion”?

Compassion and Choices has become the shepherd and sole spokesmen of Oregon’s assisted suicide law — and were intimately involved in writing the Oregon legislation. They have been involved in over 75% of PAS cases in Oregon, and tightly control the media disclosures surrounding these suicides:

The group promoting assisted suicide, so-called “Compassion and Choices (C&C)”, are like the fox in the proverbial chicken coop; in this case the fox is reporting its version to the farmer regarding what is happening in the coop. Members of C&C authored and proclaim they are the stewards of Oregon’s assisted suicide law. They call it “their law”. They have arranged and participated in 3/4ths of Oregon’s assisted suicide cases. Their medical director reported she’d participated in more than 100 doctor-assisted suicides as of March 2005. A physician board-member reported in 2006 that he’d been involved with over forty such patients. Their executive director reported in September 2007 that he has attended more than 36 assisted suicide deaths. He has been involved in preparing the lethal solution. Yet, he is not a doctor.

Furthermore, there is no outside audit of PAS cases in Oregon; Neither Oregon’s Department of Health Services nor independent outside auditors may review them — and complications of the procedure are reported only by the prescribing physician, an obvious conflict of interest.

They have been involved in like manner in the PAS cases in Washington as well.

Hyperbole aside, there is plenty of reason for concern when government gets in the business of managing end of life decision making; assisted suicide will be a very tempting option when government desperately tries to reign in runaway costs for care of the elderly and dying.

And you can be sure if they implement these controls that groups like Compassion & Care will have a seat at the table.

H.R. 3200

If you have a serious case of insomnia, have far too much time on your hands — or have a vested interest in not seeing government take over your health care — then you will want to spend quality time reading the legislation which will change your life, irrevocably and disastrously, forever: HR 3200, “America’s Affordable Health Choices Act of 2009”. Various summaries and commentaries are floating about the web, and while helpful, they are tainted by too much histrionic commentary, often SHOUTED TO MAKE A POINT! which may or may not be be a valid inference from the legislation.

Here’s the HTML version with links.

So now you can go straight to the source, and judge for yourselves. Even though your elected representatives will try to pass this without reading it, that doesn’t mean you can’t do the responsible thing and get informed.

Here’s a good summary of HR 3200’s key aspects, from AAPS:

New bureaucracies: These include State Health Help Agencies (HHAs), with a federal fallback plan should states refuse to create them; an advisory committee to report annually on modifications of benefits, etc.; some mechanism to “adjust” the Medicare Part B premium based on whether or not each individual “participates in certain healthy behaviors”; other agencies to calculate payments, monitor individual behavior, set standards as for chronic disease management, check compliance with standards, monitor loss ratios and outcomes of chronic-care management, etc.

Individual mandate. All adults must buy a government-approved Healthy Americans Private Insurance Plan (HAPI) [love the abbreviation!] and constantly report on compliance, at every interaction with federal, state, and local government, including at voter registration, motor vehicle departments, or other checkpoints, as well as when filing tax forms. This applies to all legal residents, including non-citizens, although not to illegal aliens.

Penalties. The penalty includes the average monthly premium, plus 15%, for all “uncovered” months. Penalties are not subject to discharge by bankruptcy. This means that the HHA, which receives the penalties, takes precedence over other creditors.

Insurance mandates. Guaranteed issue, community rating, coverage of “wellness” without copayments, annual physicals, a required “health home” (gatekeeper), mental health parity, and reconstructive surgery post mastectomy are all mandatory. Each HAPI plan “shall” make available supplemental coverage for abortion, unless affiliated with a religious institution.

Progressive taxation equivalent. Premium subsidies are phased out incrementally up to 400% of poverty. This means that working harder and earning more is punished by higher mandated health insurance “premiums” (which are the functional equivalent of taxes). People will constantly be reporting on their income status.

School-based clinics. Care must be provided at no cost, or on a reimbursable basis, by school-based clinics, which must provide, “at a minimum,” mental health services, and use electronic medical records by 2012.

Job killer. Every employer “shall pay an employer shared responsibility payment,” which increases for each additional employee in excess of 50. Employers must deduct the individual shared responsibility payment from wages “as and when paid.” This amount is not allowed as a deduction from the employer \'s taxable income.

Savings. To offset the costs, Medicare and 90% of Medicaid disproportionate share (DSH) payments are to be “recaptured.” Tax exclusions for health benefits will be limited (sections 661-666). According to section 801, “private insurance companies will be forced to hold down costs and will slow the rate of growth because they are required to offer standardized Healthy Americans Private Insurance plans.”

These cool cats in Congress are, of course, only interested in your welfare, and always have the interest of their constituents first and foremost in their minds:

So give them a piece of your mind, here.

The hour is late, and the corrupt political class wants to radically transform the health care system — not for your benefit, but for theirs.

Get to work before its too late.

Texas Tort Reform

Over at the Belmont Club, Richard Ramirez has a post citing a proposal by a physician for reform of the health care system. The proposal is thoughtful, with some excellent suggestions (which will never get implemented in today’s environment, sadly).

What caught my eye in the comments was a summary of the changes which tort reform has brought about in Texas by a commenter, Leo Linbeck:

I \'m pretty familiar with tort reform in Texas, as my dad was the founding Chairman of Texans for Lawsuit Reform. TLR started in the mid-1990s after forty years of steadily increasing tilting of the civil justice playing field in favor of plaintiffs. There were two major inflection points in this fight:

The 1995 session (with George W. Bush was Governor)

Limited punitive damages
Reformed joint and several liability
Restricted venue shopping
Restored the Deceptive Trade Practices Act to its original purpose of protecting consumers in ordinary consumer transactions
Enacted a half dozen other reforms to curtail specific lawsuit abuses

The 2003 session (with George W. Bush was Governor)

Enacted comprehensive reforms governing medical liability litigation, including a $750,000 limit on non-economic damages
Initiated product liability reforms
Made the burden of proving punitive damages similar to criminal law, requiring a unanimous jury verdict
Comprehensively reformed the statutes governing joint and several liability and class action lawsuits
Imposed limits on appeal bonds, enabling defendants to appeal their lawsuits and not be forced into settlements (this is what pushed Texaco into bankruptcy in its famous lawsuit against Pennzoil)
Further limited the filing of lawsuits that should have been brought in other states or countries

The changes to medical liability in 2003 were extraordinary, and had a very substantial impact, including:

1. In August 2004, the Texas Hospital Association reported a 70% reduction in the number of lawsuits filed against the state \'s hospitals.
2. Medical liability insurance rates declined. Many doctors saw average rate reductions of over 21%, with some doctors seeing almost 50% decreases. (Recent information provided to The Perryman Group during the course of this study suggests that premiums are declining even further in 2008.)
3. Beginning in 2003, physicians started returning to Texas. The Texas Medical Board reports licensing 10,878 new physicians since 2003, up from 8,391 in the prior four years. Perryman has determined that at least 1,887 of those physicians are specifically the result of lawsuit reform.
4. In May 2006, the American Medical Association removed Texas from its list of states experiencing a liability crisis, marking the first time it has removed any state from the list. A recent survey by the Texas Medical Association also found a dramatic increase in physicians’ willingness to resume certain procedures they had stopped performing, including obstetrics, neurosurgical, radiation and oncological procedures.

Last year, TLR commissioned a study by The Perryman Group to figure out the impact of these reforms (the above are excerpted from that report). Here are the economic impact findings of that study:

$112.5 billion increase in annual spending
$51.2 billion increase in annual output – goods and services produced in Texas
$2.6 billion increase in annual state tax revenue
$468.9 million in annual benefits from safer products
$15.2 billion in annual net benefits of enhanced innovation
499,000 permanent jobs
430,000 additional Texans have health insurance today as a result of the medical liability reforms

The complete Perryman Group report is here.

As these numbers show, tort reform can have a substantial impact on economic growth and wealth creation, and a huge impact on the healthcare system in particular. Any serious national healthcare reform must include comprehensive tort reform to reduce the practice of defensive medicine and other perverse incentives.

Which is why I do not consider the current proposals from the Obama Administration to be serious (other than being seriously flawed).

Our current re-invention of the health care system, for all its complexity, completely ignores the problem of runaway malpractice lawyers and the costs of defensive medicine. While not surprising, given the huge contributions to the Dems from attorneys, this deficit alone virtually guarantees a disastrous outcome should it be implemented.

The Preventive Medicine Con

Well, the first details of the long awaited health care plan are now coming out, and the Internet is abuzz with shock and awe about many of its aspects, particularly its high cost, the undermining of private health insurance policies, and the complexity of its administration, manifested in a host of new bureaucratic agencies to bring the joys of government health care into every nook and cranny of your pitiful and meaningless life.

One big-picture aspect of this huge transformation in American health care which seems to be receiving little or no attention is its heavy emphasis on preventive medicine. We have been hearing for some time about how preventive medicine will save substantial sums of money and thereby make the overall health care system far less costly. Of course, such rhetoric has an enormous appeal at a surface level — after all, if you can prevent diseases, you certainly don’t need to spend money to cure them.

Who could argue with this?

But this innocent-sounding, simplistic Trojan horse will prove deadly for American health care, and end up empowering the bureaucrats and politicians who will, in fact, gain the most from this change in direction.

When we talk about preventive medicine, we are generally speaking of two general areas: the screening and early detection of diseases, and lifestyle changes and therapy to reduce long-term medical risk. Screening and early detection of diseases is appealing concept, but devilishly difficult in practice. The idea sounds wonderful: do a simple, inexpensive test; detect the disease earlier, when it is simpler and less expensive to treat; and you will be healthier in the future, requiring far fewer health resources. The problem lies, as I have discussed elsewhere, in the malignant mathematics and sickening statistics of applying medical screening to large populations. Simply put, no screening test is perfect, and all such tests generate both false positives — telling you that you have a disease, when you do not — and false negatives — telling you you’re fine when you really have the disease. Even with an extraordinarily accurate test the problem lies in applying it to large populations. If you have a cancer screening test with a 1% false positive rate (an extraordinarily low number in the screening business), and have a disease which occurs in one patient out of every 10,000, applying the test to 10,000 patients will generate 100 false alarms (false positives) for every patient with the disease. These false positives all require additional testing or procedures to determine whether in fact the abnormal test really means you have the disease. And herein lies the economic trap: you will in fact spend an extraordinary amount of money on patients without the disease for every patient detected who does have the disease. This phenomenon has been well demonstrated in almost every study of screening — to wit: screening actually increases rather than reduces medical costs.

Of course many simple screening tests and procedures are used every day in medicine. When you go to the doctor, your blood pressure is checked, your cholesterol is measured, you stand on the scale and are weighed, and asked whether or not you smoke. If your blood pressure is high, you will likely be started on medication, and it is also likely that you will need to stay on this medication indefinitely. If your cholesterol is elevated, will be encouraged to exercise, make dietary changes, and lose weight (most of which you won’t do), but will also likely will be started on cholesterol-reducing medication, likely for the long-term. Of course, we recognize that this is appropriate for the reduction of risk from high blood pressure or high cholesterol. What may not be recognized, is that many people with high blood pressure or high cholesterol, unrecognized and untreated, may not have significant problems from these disorders for many years, if ever.

Suppose that 100 people with high cholesterol levels take statins, a common treatment for high cholesterol. Of them, about 93 wouldn’t have had heart attacks even if they had not taking the medication. Five people, on the other hand, will have heart attacks despite taking the statin. Only the remaining two out of the original 100 avoided a heart attack by taking the daily pills. In the end, 100 people needed to be treated to avoid two heart attacks during the study period --so, the number of people who must get the treatment for a single person to benefit is 50. This is known as the “number needed to treat” — and is a common way in which health researchers determine the cost and effectiveness of preventive therapy. Ideally, we will get better at selecting those patients at the front end who actually will benefit from taking the drug, and therefore avoid administering it in those who ultimately will not need it. But such health forecasting is far, far from perfect, and there will always be a need to treat patients perceived to be at risk even though time will ultimately find them not to be at risk at all. The human organism in health and disease is far too complex to eliminate this reality.

Problems such as these arise in every aspect of preventive medicine. It also goes without saying that implementing lifestyle changes, such as weight reduction, regular exercise, smoking cessation, and dietary modifications, is largely a fool’s pursuit. We humans love our addictions, and rarely overcome them even when they threaten our health and well-being.

The myth of the economic benefits of preventive medicine dies hard, however, and the pending changes in the health care system are placing a very large bet on this loser’s hand. The systemic manifestation of this crap shoot is the glorification and indemnification of primary care as the solution to all of our health care woes, economic or otherwise. Although the final details of the pending reforms of health care are still far from complete, it is clear that there will be a heavy emphasis on steering patients toward primary care physicians and away from specialists.

Health care bean counters have long known that care delivered by specialists is more expensive then that delivered by primary care physicians. It is the specialist who performs the expensive surgeries, procedures, and diagnostic studies which cost the government and health insurers a substantial percentage of their total outlays. When viewed from an economist’s standpoint, it makes perfect sense to reduce the utilization of more expensive specialty care, and increase the utilization of less costly primary care. Although the details remain to be fleshed out, it appears that there will be a substantial increase in reimbursement to primary care physicians, and reduction in reimbursement to specialists by eliminating higher payments for consultations, procedures, and surgeries. These changes are already beginning to be implemented in Medicare, even prior to passage of any large healthcare reform legislation. There are plans to bundle payments for chronic disease management, paying the primary care physicians who manage them higher rates, most likely on a fixed payment schedule designed to motivate physicians to reduce costs and improve outcomes.

Like most great ideas arising from the government, this is a day late and a dollar short.

The insurance industry came up with this idea over a decade ago, and implemented it in systems extensively, using the tools of capitation (bulk payments to physicians upfront for future care) and the gatekeeper model (having the primary care physician who receives such bulk payments control referrals to specialists, with a strong financial incentive not to send them there).

Many of you may recall how popular these programs were. What you may not have noticed is that virtually all insurers have dropped them.

There were a host of difficulties with this approach to medicine. First of all, it put the physician in a position of conflict of interest, by giving him or her a financial incentive not to order additional tests or make referrals to expensive specialists. While this incentive would obviously reduce unnecessary tests and referrals, it also gave the physician an economic incentive to defer or eliminate such tests and referrals, when in fact they were in the patient’s best interest. Simply put, your doctor made more money if he did not order your CAT scan, even if a CAT scan had a strong medical indication.

These policies led to no small amount of disgruntlement among patients covered under such plans. It became clear that patients could not get to see specialists when they needed them, because their physician or their insurance company refused to allow them. Even when the system worked as ideally designed — preventing referrals for unproven experimental or unnecessary treatments — patients nevertheless demanded these treatments, and often resorted to heart-rending media exposés on how the evil insurance companies had refused to pay for their experimental treatment for cancer. In one sense, this approach did work as intended: by restricting access to care, particularly specialist referrals and expensive diagnostic testing, HMOs and other similar insurance schemes did in fact reduce substantially the rise in medical costs. But they did so by rationing — and thereby sealed their own fate when this became enormously unpopular among patients, and (of course) exploited by politicians. Although some remnants of this system remain intact, particularly preauthorization for specialist referrals, certain procedures, and diagnostic imaging studies, the coercive restrictions in place during the height of this trend have greatly mitigated. Those restrictions which remain are still the most common source of discontent among patients and physicians, as insurance companies continue to refuse payment for medical services recommended by their physicians, or require onerous paperwork for their authorization.

As you can imagine, primary care physicians, who have been lobbying for higher reimbursement rates for many years (and not unreasonably so) find many aspects of a new financial emphasis on primary care to be attractive.

They should be careful what they wish for.

One of the deadliest traps of bundled payments such as capitation was the problem of medical outliers. Getting a payment every month for your entire patient population, to manage all their care, is a great deal if all your patients are healthy, as they cost you very little, and you get to keep the difference. The problem arises when your practice involves a large number of patients whose care is very expensive. Your lump sum payment begins to look very small when a large number of your patients require costly hospitalization, surgery, expensive medical therapy or drugs — the payment for which is coming out of your own pocket. This reality created an entire consulting industry to analyze patient populations versus capitation rates, with the goal of reducing the physicians exposure to such potentially disastrous financial consequences. Physicians and their consultants got very good at selecting populations of healthier patients — which often excluded those patients who needed medical care the most. Physicians who got burned on this difficult calculus often ended up terminating their relationship with specific insurance carriers, resulting in large numbers of patients abruptly losing their physicians, and forced to hunt around for new physicians who would accept their insurance.

For these and a host of other reasons such insurance models have largely died an ignominious and well-deserved death. but their rotting corpses are being raised to life again. The Undead will walk the earth, this time with even greater powers granted them the federal government.

With private insurers, physicians and physician groups at least have the option of terminating their contracts with insurance carriers whose reimbursements or capitation rates were insufficient to cover the risks of the patient populations they covered. With universal health care, especially one predominantly or exclusively provided by the government, this escape route will no longer be available. The primary care physician who finds his reimbursement improved for managing chronic diseases will also find himself burdened by a blizzard of additional paperwork to document that the “quality” of his care meets government standards — whether such standards are realistic, or even in the patient’s best interest. Furthermore, if such reimbursements do not cover the inevitable increase in management overhead, there will simply be no place else to turn. One cannot fire the federal government when they are the only source of payment for the medical services you provide. The only option available to physicians will be to opt out of medicine altogether — and you may anticipate the increasing numbers of physicians will do exactly this. Universal health insurance is not the same as universal health access — a lesson we are about to learn painfully if we continue down this path. A seat at the Captain’s table on the Titanic seems propitious until the chairs start sliding toward the bow of the sinking ship.

But there is another aspect to this heavy emphasis on primary care which has received virtually no attention. Although certainly not without problems and potential abuses, the simple fact remains that America’s specialist-intensive health care system is in fact the driving force behind its technologically advanced benefits. Simply put, we are not living longer, healthier lives because we have beloved family doctors who hold our hands and listen to our complaints. The huge advances in medicine in the past 50 years have occurred in large part because of the specialization of medicine. The extraordinary complexity of contemporary medicine has made its mastery by any one type of physician utterly impossible. Even the brightest internist or family practice physician cannot be master of all of the complex aspects of cardiology, surgery, oncology, or the management of increasingly-challenging infectious diseases. Certainly good physicians in primary care are well-versed in many of these areas, at some level, but it has long since been unrealistic to expect primary care providers to be masters of such vast and ever increasing knowledge and complexity in the different realms of specialty medicine. This is not to denigrate in any way the importance of primary care physicians, most of whom are highly accomplished at the health maintenance of large numbers of patients — a skill which has contributed greatly to our improved quality of life and longer lifespans. But our system provides the enormous benefits in high quality and longer, healthier lives because the primary care physician has a very deep bench of specialists at his beck and call.

At some point even the most skilled and capable primary care physician will encounter complex, difficult, or intractable problems which he or she simply is not trained or skilled to manage. Specialty care is indeed expensive — and it is expensive in no small part because the patients who need such care have more difficult or complex medical problems, which simply cannot be best treated without the expertise of specialists.

As our system increasingly steers patients away from such specialty care for economic reasons, it will do so at significant cost in a variety of realms. Much of the advanced medical innovation, which has given us longer and better lives, has arisen out of specialty care, and it is inevitable that significant restrictions on such care will blunt and slow such medical advances. But there are costs hidden in such an approach which will also become apparent with such an unbalanced emphasis. When we, through financial coercion, force primary care physicians to assume the care of increasingly complex patients for which they have neither the training nor depth of experience to manage, such care will inevitably end up being inferior in quality — and likely will end up in the long run, being far more costly. Without access to specialty support, primary care physicians tend to fall back on using more expensive medications, diagnostic studies, and therapies, sometimes inappropriately. The unusual skin condition, which can be promptly diagnosed and appropriately treated in a few visits to the dermatologist, may instead be treated with an increasing array of expensive and ineffective therapies or drugs by primary care providers who are unwilling or unable to avail themselves of specialty consultation and treatment. The insurance companies learned this long ago, and it was one of the factors motivating them to dismantle the gatekeeper model.

The enormous push toward primary care and preventive medicine embodied in the currently-envisioned transformation of the health care system being pushed through by Congress will be doomed to fail, brought down by the flawed premises upon which it is based. But it will, in one important regard, prove successful to those who are currently pushing its implementation. The system as currently designed, with its emphasis on primary care and preventive medicine, will not improve quality or reduce costs, but will give government a far greater degree of control over physicians and the nature of the care they provide. Increasingly it will be the government, and not the physician, who dictates what care you will receive, which specialists you will see (if any), and whether the medically appropriate care which you need will meet its financial standards for return on investment. As Obama has promised us, we will all be asked to “take the pain pill” rather than undergo the surgery we need and which will improve our lives.

It likely is too late to stop the perfect storm of health care reform, given the current makeup of our Congress and Administration. Be prepared for a brave new world in medicine.

And don’t be surprised if it is not to your liking.

UPDATE: Massachusetts, in deep do-do from their universal coverage, is treading this same hoary path: Massachussetts Health Plan Pushes for Capitation Megan McArdle spells out the problems nicely. Take-away quote: “This is why ‘paying for health rather than procedures’ never pans out.”

The Temperature of Hell

This is the second of two posts, much delayed, on the subject of Hell.

The first may be found here:
 ♦ The Death of Hell


On an earlier post about grace and Karma, a commenter posed this question:

I \'d like to ask you a question because you strike me as an intelligent man of faith. I was taught that hell is a place of eternal conscious torment, a nice euphemism for a torture chamber. Do you believe that those of us who fail to accept grace will be tortured? If not, why not? Augustine and Calvin seemed to believe it.

I began to answer this question in my prior post on the subject, tackling it from a mostly metaphysical perspective, basing a belief in Hell on four principal pillars: that man is a moral being, comprised of an innate sense of right and wrong, good and evil; that man is a transcendent being, with a nature which seeks out and relates to the immaterial, to the eternal, to the divine; that man has a sense of justice, with a desire for reward for good and punishment for evil; and that man is incapable of functioning without reference to absolutes — in practice, always, even when denying them intellectually — which infers a standard against which we are measured, and consequently implies a sentient and just deity — indeed a personal deity — as the source for such absolute standards.

Such premises cannot be “proved” — at least from the viewpoint of the two-dimensional determinism so prevalent in contemporary materialist scientism. The arrogated assumptions of the materialist preclude a priori anything of transcendent or immaterial nature as inherently beyond scientific proof, no more than mere whimsical fantasy or superstitious drivel, and consequently false (an interesting conclusion, this: as that which cannot be proved is not by necessity false, but rather, unprovable, is it not?). Yet these very presumptions are reasonable reflections of the observed nature of man, and the materialist’s moral judgment on transcendent beliefs as foolish, or even evil, belies his own deterministic worldview, which permits no transcendent absolute against which to judge such convictions as right or wrong.

So it is reasonable to believe (if not “provable”), that as transcendent, moral beings, something of our immaterial and conscious nature survives our physical demise, given that we relate to a Being unbound by time, physical existence, or mortality. It is therefore also reasonable that the nature of such existence after death itself has a moral and just dimension. Though we might ponder or dispute the moral criteria about which such a final determination of justice might be made, if there is justice at all, then there must be justice in the existence (in whatever form it may take) after death.

But what might such a state of retributive justice for evil be like? Is it, as our commenter suggest, a place where God “tortures” those with the audacity to disobey his dictates? Is it hot, cold, dark, or colorless? Are there levels of torture, as envisioned by Dante, or flaming lakes and fire and brimstone, as some Biblical passages suggest? What, indeed, is the temperature of Hell?

Such speculations, whether arising from literature, popular culture, or the inferences and metaphors of Scripture, are by necessity insufficient to grasp the nature of Hell, for we mortals are incapable of fully apprehending the nature of an eternal afterlife, inherent in its nature far beyond the capacity of mortal man to comprehend. Rather than fret over the fires or torments of Hell, or whether Hell abounds in pitchfork-wielding demons or endless Bacchanalian debauchery, it is perhaps a more fruitful source of insight regarding eternal punishment to focus instead on the nature of God and the nature of man, to understand the nature of Hell.

In the Judeo-Christian tradition, God is understood to have certain innate and unalterable characteristics, the most important of which are His holiness and His love. Holiness refers to his purity of motive and perfect goodness of character, manifested in His grace, His justice, His mercy, His patience, and a host of other virtues embodying perfect goodness. The love of God, which is the very essence of His nature, is not the superficial sentimentality nor maudlin physicality of our current culture, but rather the completely selfless devotion to the well-being, happiness, and success of those He loves, His creation. It is selfless to the point of self-sacrifice: unlike, say, the god of Islam, who commands the death or enslavement of unbelievers, the Christian God dies for unbelievers, that they may live in freedom.

Just as God is selflessly devoted to man, created in His image with the capacity to love — and therefore possessed of free will, without which love is impossible — man is designed to selflessly love God and serve Him. But sin — the tendency both innate and intentional to serve self rather than God — intervenes, and breaks the relationship. Man, now functioning autonomously on self-will, increasingly bears the fruit of his growing distance from the source of goodness. The natural result of this relational disruption and flight from the ultimate good is everywhere evident in man: hatred, pride, arrogance, decadence, evil behavior, fear, pain, suffering, purposelessness, despondency. Such is the natural gravity of rejecting God to serve oneself. The inexorable trajectory of life thus lived is misery, darkness, and hopelessness — though we strive mightily to mitigate the inevitable consequences a life thus lived through denial, blame, addiction, and the distractions of money, power, and materialism.

We are offered, in this life, the opportunity to change; to seek reconciliation, acknowledging our repudiation of God, seeking forgiveness, and the power to turn from our autonomy of the will to a place of submission which will lead us back to the joy and purpose originally intended for us in the plan of a loving, relational God. Yet free will being what it is, not all will make this choice; blinded by the deception that we may be happy only by being masters of our own life and destiny, we endlessly pursue this illusory and unobtainable goal down a path which only leads us away from the only source of true happiness. It is a path many pursue to the gates of death.

And thus, having squandered our many chances to turn back to God during our life, we arrive at the threshold of death, our wills fully steeled in determination to have our own will and our own way. And so our wish will be granted, for all eternity. Whatever the form or essence of that which we call Hell, it will be nothing more than the fullness of what we ourselves have chosen, with all the illusions and deceptions of this life stripped away. We will bear the full weight of our pride, our hatred, our fear, our rage, our selfishness and discontent, our profound loneliness, in an eternity of hopelessness and regret over what we have lost, irretrievably, in casting away the goodness and mercy of God in what was naught but a pure triumph of the will.

C.S. Lewis, in the The Great Divorce, wrote about the intransigence of spirit which is the essence of Hell:

For a damned soul is nearly nothing: it is shrunk, shut up in itself. Good beats upon the damned incessantly as sound waves beat on the ears of the deaf, but they cannot receive it. Their fists are clenched, their teeth are clenched, their eyes fast shut. First they will not, in the end they cannot, open their hands for gifts, or their mouth for food, or their eyes to see.

In our therapeutic culture, where all is tolerated but the good, the assertion that there are consequences for our behavior, either temporal, or especially eternal, is a truly noxious notion. The idea of Hell is perceived as an anachronistic anathema, promoted cynically by clergy controlling the poor, ignorant fools who follow them. Even those with a nominal belief in a deity will attest, with a pretense more wishful than wise, that a God of love would never condemn those who reject Him to Hell. In some sense–surely not that which the proponents of such pop theology intend–this may well be true. It will be, for those who enter that dark, hopeless, and agonizing eternity, not something dictated from on high by a vengeful God gleeful at our torture. It will be our own choice, fully, to reject the mercy and grace which has been offered to us without cost by Him who gave everything to draw us toward an eternal relationship, filled with unspeakable joy and peace, with Him.

The Children Whom Reason Scorns

Several weeks ago, Washington State logged a solitary but grim statistic: the first assisted suicide under a new law enacted by initiative last November. It seems fitting, therefore, to re-post the following essay, written some five years ago, occasioned by the decision in the Netherlands to legalize euthanasia for children. It is, I fear, a harbinger of things to come, far closer to home.

You Also Bear the BurdenIn the years following the Great War, a sense of doom and panic settled over Germany. Long concerned about a declining birth rate, the country faced the loss of 2 million of its fine young men in the war, the crushing burden of an economy devastated by war and the Great Depression, further compounded by the economic body blow of reparations and the loss of the German colonies imposed by the Treaty of Versailles. Many worried that the Nordic race itself was threatened with extinction.

The burgeoning new sciences of psychology, genetics, and medicine provided a glimmer of hope in this darkness. An intense fascination developed with strengthening and improving the nation through Volksgesundheit–public health. Many physicians and scientists promoted “racial hygiene” – better known today as eugenics. The Germans were hardly alone in this interest – 26 states in the U.S. had forced sterilization laws for criminals and the mentally ill during this period; Ohio debated legalized euthanasia in the 20’s; and even Oliver Wendall Holmes, in Buck v. Bell, famously upheld forced sterilization with the quote: “Three generations of imbeciles are enough!” But Germany’s dire circumstances and its robust scientific and university resources proved a most fertile ground for this philosophy.

These novel ideas percolated rapidly through the social and educational systems steeped in Hegelian deterministic philosophy and social Darwinism. Long lines formed to view exhibits on heredity and genetics, and scientific research, conferences, and publication on topics of race and eugenics were legion. The emphasis was often on the great burden which the chronically ill and mentally and physically deformed placed on a struggling society striving to achieve its historical destiny. In a high school biology textbook – pictured above – a muscular German youth bears two such societal misfits on a barbell, with the exhortation, “You Are Sharing the Load!–a hereditarily-ill person costs 50,000 Reichsmarks by the time they reach 60.” Math textbooks tested students on how many new housing units could be built with the money saved by elimination of long-term care needs. Parents often chose euthanasia for their disabled offspring, rather than face the societal scorn and ostracization of raising a mentally or physically impaired child. This widespread public endorsement and pseudo-scientific support for eugenics set the stage for its wholesale adoption — with horrific consequences — when the Nazi party took power.
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The Miracle of Forgiveness

A recent post on evil brought some very thoughtful comments, which meandered a bit, as comment threads are wont to do, onto the topic of forgiveness.

It is a topic I have visited before, and no doubt will visit many times again, in experience if not in writing. The issue of forgiveness is ever fresh in human experience, flowing inevitable from the wanton harms and evil which surrounds us and so often affects us directly. It is a subject among Christians which engenders a great deal of misunderstanding and sometimes foolishness. In what is certainly the most uttered prayer in Christianity — the Lord’s Prayer — we are called to both ask forgiveness for ourselves and extend it to others: “Forgive us our trespasses, as we forgive those who trespass against us.”

So what exactly is forgiveness?

Forgiveness requires, first of all, that there is some genuine harm done — real or perceived — to an individual, by another. The harm may be physical, emotional, or spiritual, affecting any one of a host of important areas: our pride, our emotional or physical well-being, our finances, our security, our relationships, and many other areas. The harm must be substantial — the injury must cost us something dear, thereby engendering the inevitable responses to such harm: fear, pain, sorrow, loss, anger, resentment, disruption of relationships. The need for forgiveness arises out of these natural defensive responses to the offense — defenses which have an unnerving tendency to be self-perpetuating and self-destructive.

Some of the silliness surrounding the act of forgiveness arises from the lack of such substantial harm. Choosing, for example, to forgive the Nazis for the Holocaust, or the terrorists for 9/11, for example, when we ourselves have never been affected by it directly in any way (or at best trivially so), becomes little more than pretentious posturing. It costs us nothing to say, accomplishing nothing but the appearance of self-righteous sanctimony. This form seem especially common in some Christian circles, where it serves little more than a veneer of righteousness, allowing us to sound “Christian” while sacrificing nothing.

False forgiveness commonly takes another form, driven by obligation to moral or religious dictates, and facilitated by denial. Having sustained some harm, we know the moral command to forgive, and therefore simply will ourselves to do so. When the inevitable anger arises again — as it always will, if there has been substantial harm — we simply force it under the surface, recommitting ourselves to the act while trying desperately not to relive the incident. Yet the anger and resentment never get resolved, and arise repeatedly — often in areas of life far removed from the direct injury, manifesting themselves in depression, irritability, and acting out in other relationships or domains of life. The forgiveness driven by moral compulsion or law far more enslaves the giver than frees him, and allows the poison to fester rather than lancing the boil.

True forgiveness at its heart is about sacrifice. It is an extension of grace, a humble admission that we too have harmed others — perhaps even been instrumental in precipitating by our own behavior the offense we have sustained. It arises from a profound gratitude at having been forgiven ourselves, by God, of far greater failings than those which have wounded us.

Yet there is more to forgiveness than just having the the proper spirit — there must be action. Forgiveness arising from the right spirit is still frail — the emotions, the hurt, the resentment remain all to close at hand, as the injury is relived time and time again. The feelings persist though the spirit forgives. The heart must be transformed — it must, in fact, be dragged to victory by the will manifesting itself in changed behavior toward the offender.

Corrie ten Boom and her family secretly housed Jews in their home during WWII. Their “illegal” activity was discovered by the Nazis, and Corrie and her sister Betsie were sent to the German death camp at Ravensbruck. There Corrie would watch many, including her sister, die. After the war she returned to Germany to declare the grace of Christ:

It was 1947, and I \'d come from Holland to defeated Germany with the message that God forgives. It was the truth that they needed most to hear in that bitter, bombed-out land, and I gave them my favorite mental picture. Maybe because the sea is never far from a Hollander \'s mind, I liked to think that that \'s where forgiven sins were thrown. “When we confess our sins,” I said, “God casts them into the deepest ocean, gone forever. And even though I cannot find a Scripture for it, I believe God then places a sign out there that says, ‘NO FISHING ALLOWED.’ ”

The solemn faces stared back at me, not quite daring to believe. And that \'s when I saw him, working his way forward against the others. One moment I saw the overcoat and the brown hat; the next, a blue uniform and a cap with skull and crossbones. It came back with a rush — the huge room with its harsh overhead lights, the pathetic pile of dresses and shoes in the center of the floor, the shame of walking naked past this man. I could see my sister \'s frail form ahead of me, ribs sharp beneath the parchment skin. Betsie, how thin you were! That place was Ravensbruck, and the man who was making his way forward had been a guard — one of the most cruel guards.

Now he was in front of me, hand thrust out: “A fine message, Fraulein! How good it is to know that, as you say, all our sins are at the bottom of the sea!” And I, who had spoken so glibly of forgiveness, fumbled in my pocketbook rather than take that hand. He would not remember me, of course— how could he remember one prisoner among those thousands of women? But I remembered him. I was face-to-face with one of my captors and my blood seemed to freeze.

“You mentioned Ravensbruck in your talk,” he was saying. “I was a guard there.” No, he did not remember me. “But since that time,” he went on, “I have become a Christian. I know that God has forgiven me for the cruel things I did there, but I would like to hear it from your lips as well. Fraulein,” — again the hand came out — ”will you forgive me?”

And I stood there — I whose sins had again and again to be forgiven — and could not forgive. Betsie had died in that place. Could he erase her slow terrible death simply for the asking? It could have been many seconds that he stood there — hand held out — but to me it seemed hours as I wrestled with the most difficult thing I had ever had to do.

For I had to do it — I knew that. The message that God forgives has a prior condition: that we forgive those who have injured us. “If you do not forgive men their trespasses,” Jesus says, “neither will your Father in heaven forgive your trespasses.” And still I stood there with the coldness clutching my heart.

But forgiveness is not an emotion — I knew that too. Forgiveness is an act of the will, and the will can function regardless of the temperature of the heart. “Jesus, help me!” I prayed silently. “I can lift my hand. I can do that much. You supply the feeling.” And so woodenly, mechanically, I thrust out my hand into the one stretched out to me. And as I did, an incredible thing took place. The current started in my shoulder, raced down my arm, sprang into our joined hands. And then this healing warmth seemed to flood my whole being, bringing tears to my eyes.

“I forgive you, brother!” I cried. “With all my heart!” For a long moment we grasped each other \'s hands, the former guard and the former prisoner. I had never known God \'s love so intensely, as I did then. But even then, I realized it was not my love. I had tried, and did not have the power. It was the power of the Holy Spirit.

To experience the miracle of forgiveness, we must relinquish our right to revenge, to serve justice on our enemies — for justice served in retribution is a toxic victory, shallow in satisfaction, engendering only hatred and bitterness and slavery. To be free, we must act: to make amends to those who have hurt us, when we have played a role; to pray for those whom we resent; to reach out and serve, if by pure will alone, to those whom we hate, that such hate may be transformed into transformational love. In this manner alone may we experience the deep miracle and healing that is true forgiveness.