Obama's Health Care Vietnam

Talk to the average physician about trying to care for patients in the United States today, and you’ll hear exactly the same sorts of sentiments as those expressed by American soldiers faced with the task of “winning the war” in Vietnam some fifty years ago.  For those on the front line of fighting illness, it is apparent that the Democrats' war on American medicine is not a path to cheap quality care, but a quagmire of rules and complexity that can make even the most basic care difficult to deliver.  Now that ObamaCare has directly or indirectly wormed its way into every aspect of care and payment, many patients are beginning to feel the pain as well. 

Examples are as close as your nearest clinic or doctor’s office, where medical experts with decades of training are now routinely required to obtain insurance approval for even the most basic tests, procedures, and medications.  A cardiologist tries to prescribe a refill of digoxin for a patient with an irregular heartbeat.  Despite the drug’s generic status and the fact that it’s been in use in some form since 1785, the patient’s insurance company insisted that he fill out a three-page form justifying his request.  His written reply: “ARE YOU KIDDING ME?”  An endocrinologist colleague of mine, an expert on the diagnosis and treatment of hormone-related disorders, reports that she can no longer prescribe testosterone for anyone without completing stacks of “Mother may I” paperwork and sending them off to insurance company functionaries – none of whom are doctors – for approval.  Primary care providers looking to refer patients to specialists must now obtain pre-authorization in order to do so; apparently the provider himself is too ignorant to know when a case is beyond his level of clinical expertise.  Patients trying to remain “in-network” for their surgeries often find that the networks of doctors and hospitals that they must use simply don’t overlap

Such tactical red-lining and second-guessing would be familiar to anyone on the front lines in Vietnam, where President Lyndon Johnson once bragged that U.S. pilots “can’t bomb an outhouse without my approval.”  The rules obstructing the actions of soldiers on the ground and in the air in that war were endless and frequently nonsensical.  Enemy fighter planes could not be attacked unless they showed “hostile intent.”  They created arbitrary “no fire zones” in which U.S troops could not fire at an enemy first, or sometimes at all.  Surface-to-air missile sites could not be attacked while under construction – only after they were active.  Once declassified by Sen. Barry Goldwater in 1985, these “rules of engagement” filled 26 pages of the Congressional Record.

Mind-numbing complexity is now the hallmark of medicine under ObamaCare – not the natural complexity of making diagnoses and fighting natural pathology, but new man-made complexity that destroys clinical productivity and creates long lines of patients waiting for care.  In 2009, the Obama administration and a Democrat-majority Congress essentially mandated that U.S. doctors install and “meaningfully use” expensive, unintuitive, and complex electronic medical record systems.  Repeated studies, including a 2013 report from the RAND Corporation, have found that technology interferes with face-to-face discussions with patients, requires physicians to spend untold hours performing clerical work, and degrades the accuracy of medical records by creating legions of lookalike template-generated notes.  Reporting requirements for everything from pay-for-performance programs to having lunch with drug reps have skyrocketed.

Since 1999, the amount of paperwork mandated by HHS has risen by 279% – far outstripping the growth rate of any other federal agency.  Insurance-mandated formularies, which can differ for every patient seen in a given day, have grown so complicated that simply determining what drugs to try prescribing can take literally hours.  In 2015, HHS will require every doctor and hospital in the country to switch over to a new disease classification system called ICD-10.  This mandate will increase the number of codes one must use to describe an illness more than fivefold, from 13,000 to 68,000, and will likely cost the average medium-sized practice up to $166,000 in lost productivity in the first year alone.

Reductions in clinical productivity have adverse real-world effects – a fact that simply escapes bureaucrats more interested in command-and-control than making the best use of scarce clinical resources.  Each new computer task, pre-authorization, formulary search, and “narrow network” limitation simply burns up time and resources that could have been used to deal with real medical problems or care for new patients.  In Oregon alone, 360,000 new people signed up for Medicaid under ObamaCare this year, only to find that doctors now have no time to see them.  Tens of thousands have been locked out of the state’s ballyhooed “coordinated care organizations” that were supposed to care for them due to a lack of provider capacity.  The result has been an increase in ER visits of up to 30% in some regions of the state.

The parallels between ObamaCare and the war in Vietnam are far from coincidental.  The strategies for both were created by eggheads in academia and government with no real-world front-line experience, but plenty of hubris.  (During Vietnam, these went by the name of REMFs, or “rear echelon mother-f*****s”.  In 21st-century American health care, they’re typically labeled “ivy-league professors” or “administrators.”)  Both campaigns were created by political operatives for political purposes, with little or no understanding of the problems they should be trying to solve in order to achieve any sort of tangible success for those fighting on the ground.  They deliberately justify their approach by use of hollow metrics such as “body counts” or “numbers of people with insurance” that bear no relation to what it really means to “win” for the people involved, or at what human and economic cost their statistical victories are achieved. 

When the people fighting for something as basic as health or democracy realize that politicians will never give them the freedom to win on the front lines, the overall cause is lost, regardless of how many lives or how much treasure is spent in the process.  In Vietnam, it took nearly 15 years for the message to sink in.  Under ObamaCare, the wait will be much shorter. 

There were days (most of them, in fact) when I much preferred going head-to-head with the enemy versus crossing swords with a rear-echelon dip****.  The enemy just wanted to kill me – that I could understand.  But try as I might, I never managed to decipher or comprehend most of the politically motivated decrees that flowed from the very people who were supposed to be supporting my efforts.

–Lt. Col. Mike Jackson, USAF (Ret.), Naked in Da Nang

Dr. Perednia is a physician and writer in Portland, Oregon.  He is author of the book Overhauling America’s Healthcare Machine: Stop the Bleeding and Save Trillions (FT Press, 2011).

Talk to the average physician about trying to care for patients in the United States today, and you’ll hear exactly the same sorts of sentiments as those expressed by American soldiers faced with the task of “winning the war” in Vietnam some fifty years ago.  For those on the front line of fighting illness, it is apparent that the Democrats' war on American medicine is not a path to cheap quality care, but a quagmire of rules and complexity that can make even the most basic care difficult to deliver.  Now that ObamaCare has directly or indirectly wormed its way into every aspect of care and payment, many patients are beginning to feel the pain as well. 

Examples are as close as your nearest clinic or doctor’s office, where medical experts with decades of training are now routinely required to obtain insurance approval for even the most basic tests, procedures, and medications.  A cardiologist tries to prescribe a refill of digoxin for a patient with an irregular heartbeat.  Despite the drug’s generic status and the fact that it’s been in use in some form since 1785, the patient’s insurance company insisted that he fill out a three-page form justifying his request.  His written reply: “ARE YOU KIDDING ME?”  An endocrinologist colleague of mine, an expert on the diagnosis and treatment of hormone-related disorders, reports that she can no longer prescribe testosterone for anyone without completing stacks of “Mother may I” paperwork and sending them off to insurance company functionaries – none of whom are doctors – for approval.  Primary care providers looking to refer patients to specialists must now obtain pre-authorization in order to do so; apparently the provider himself is too ignorant to know when a case is beyond his level of clinical expertise.  Patients trying to remain “in-network” for their surgeries often find that the networks of doctors and hospitals that they must use simply don’t overlap

Such tactical red-lining and second-guessing would be familiar to anyone on the front lines in Vietnam, where President Lyndon Johnson once bragged that U.S. pilots “can’t bomb an outhouse without my approval.”  The rules obstructing the actions of soldiers on the ground and in the air in that war were endless and frequently nonsensical.  Enemy fighter planes could not be attacked unless they showed “hostile intent.”  They created arbitrary “no fire zones” in which U.S troops could not fire at an enemy first, or sometimes at all.  Surface-to-air missile sites could not be attacked while under construction – only after they were active.  Once declassified by Sen. Barry Goldwater in 1985, these “rules of engagement” filled 26 pages of the Congressional Record.

Mind-numbing complexity is now the hallmark of medicine under ObamaCare – not the natural complexity of making diagnoses and fighting natural pathology, but new man-made complexity that destroys clinical productivity and creates long lines of patients waiting for care.  In 2009, the Obama administration and a Democrat-majority Congress essentially mandated that U.S. doctors install and “meaningfully use” expensive, unintuitive, and complex electronic medical record systems.  Repeated studies, including a 2013 report from the RAND Corporation, have found that technology interferes with face-to-face discussions with patients, requires physicians to spend untold hours performing clerical work, and degrades the accuracy of medical records by creating legions of lookalike template-generated notes.  Reporting requirements for everything from pay-for-performance programs to having lunch with drug reps have skyrocketed.

Since 1999, the amount of paperwork mandated by HHS has risen by 279% – far outstripping the growth rate of any other federal agency.  Insurance-mandated formularies, which can differ for every patient seen in a given day, have grown so complicated that simply determining what drugs to try prescribing can take literally hours.  In 2015, HHS will require every doctor and hospital in the country to switch over to a new disease classification system called ICD-10.  This mandate will increase the number of codes one must use to describe an illness more than fivefold, from 13,000 to 68,000, and will likely cost the average medium-sized practice up to $166,000 in lost productivity in the first year alone.

Reductions in clinical productivity have adverse real-world effects – a fact that simply escapes bureaucrats more interested in command-and-control than making the best use of scarce clinical resources.  Each new computer task, pre-authorization, formulary search, and “narrow network” limitation simply burns up time and resources that could have been used to deal with real medical problems or care for new patients.  In Oregon alone, 360,000 new people signed up for Medicaid under ObamaCare this year, only to find that doctors now have no time to see them.  Tens of thousands have been locked out of the state’s ballyhooed “coordinated care organizations” that were supposed to care for them due to a lack of provider capacity.  The result has been an increase in ER visits of up to 30% in some regions of the state.

The parallels between ObamaCare and the war in Vietnam are far from coincidental.  The strategies for both were created by eggheads in academia and government with no real-world front-line experience, but plenty of hubris.  (During Vietnam, these went by the name of REMFs, or “rear echelon mother-f*****s”.  In 21st-century American health care, they’re typically labeled “ivy-league professors” or “administrators.”)  Both campaigns were created by political operatives for political purposes, with little or no understanding of the problems they should be trying to solve in order to achieve any sort of tangible success for those fighting on the ground.  They deliberately justify their approach by use of hollow metrics such as “body counts” or “numbers of people with insurance” that bear no relation to what it really means to “win” for the people involved, or at what human and economic cost their statistical victories are achieved. 

When the people fighting for something as basic as health or democracy realize that politicians will never give them the freedom to win on the front lines, the overall cause is lost, regardless of how many lives or how much treasure is spent in the process.  In Vietnam, it took nearly 15 years for the message to sink in.  Under ObamaCare, the wait will be much shorter. 

There were days (most of them, in fact) when I much preferred going head-to-head with the enemy versus crossing swords with a rear-echelon dip****.  The enemy just wanted to kill me – that I could understand.  But try as I might, I never managed to decipher or comprehend most of the politically motivated decrees that flowed from the very people who were supposed to be supporting my efforts.

–Lt. Col. Mike Jackson, USAF (Ret.), Naked in Da Nang

Dr. Perednia is a physician and writer in Portland, Oregon.  He is author of the book Overhauling America’s Healthcare Machine: Stop the Bleeding and Save Trillions (FT Press, 2011).