11 Temmuz 2012 Çarşamba
10 Temmuz 2012 Salı
9 Temmuz 2012 Pazartesi
Quick update
The moving is going well. We've at the new place since Sunday and it's feeling and looking more like a home now. We still need to get our internet sorted out so we can have MythTV, wireless internet etc., but that should all be set up by Monday hopefully.
We still need to empty our storage area, the last bits and pieces from the kitchen and closet, and a few other random things lying around from the old place, but otherwise we're almost there!
The new house is definitely bigger, the old place seems so small when I go back now! But the extra space and many windows we now have means it's significantly colder! The back yard area is really nice - there's lots of squirrels and birds out there, so I need to get some feeders out so the kitties can watch them :) The cats are settling in ok. Smudge is loving it, she's now back to following me everywhere, exploring everything, and generally seems pretty happy. She also loves the back yard. It's got a high fence, so I'm happy for her to explore out there without worrying she'll escape. Lily is generally staying under the bed during the day, but she's happy enough otherwise - she comes out regularly for pats, cuddles with me at night, and explores mostly at night time. She comes out to eat, drink and use the litter tray, so that's fine. I now have their small cat tree in our bedroom by the glass sliding door to the balcony, so she can sit there and watch the critters which she seems to like.
So generally, all is good :)
Busy busy!
The month of February has just flown by! The main things that happened:
- I had my second trimester echo and also got an EKG due to some palpitations I'd been getting. Everything is looking great, and my heart is holding strong - woo!
- We spent a fair bit of time just tidying up and organising the house.
- We went and saw the Cirque du Soleil show Ovo in San Jose, which was fabulous.
- Work got started on our kitchen remodel. The old kitchen has been ripped out, the walls patched up and repainted, new circuits installed, and recessed lighting installed. The cabinets have arrived, and tomorrow they'll start installing them.
- Andrew and I went to New York. I stayed for 3 and a bit days, Andrew was there for a week. We had a lovely time walking through Central Park, catching up with friends, and also got to go down to Philadelphia for a day to explore there. We really enjoyed it, and are glad we can cross another city and state off our To Do list :-) Photos are here for Philadelphia, and here for Andrew's snowy days in New York after I left.
We've bought a crib, and today I bought a stack of gDiapers, which will be a nice alternative to old school cloth, but with the convenience of disposables. I still need to get a glider chair for nursing/soothing, and some decorations for the little one's room. I'll probably get a bunch of these cute animal print cards from Wee Gallery, and maybe some of their wall graphics too. I need to get some curtains for her room, and then I think that's about it, we should be good.
I'd love to get one of these mamaroo bouncers, which look awesome, but are kinda pricey. For the moment I'm just trying to win one :D
The quandaries of an animal lover
As I'm sure anyone who reads this blog knows, I am an animal lover. After reading the story of the whale Tilikum killing one of the trainers, I am once again thrown into confusion.
On the one hand I have been to SeaWorld and seen the Shamu show, and loved it. It was so cool. On the other hand, I thought it very sad seeing such huge creatures kept in tanks too small for them. They're not "small", but compared to a life of exploring the ocean, it's small. It doesn't surprise me that such a large whale saw a dangling ponytail and decided to play with it. The whale didn't understand he was killing a trainer - it was just doing what it does.
I love going to zoos and seeing my favourite creatures up close, and being able to interact with them, but it breaks my heart when zoos have no animal conservation plans in place, aren't trying to give back to the animal kingdom, and don't plan enclosures that keep with the natural environment.
I kind of assumed at SeaWorld they used mostly rescue animals and trained them up - in fact I hadn't really thought about it too much. Then I read that Tilikum has fathered 10+ offspring in his time at SeaWorld. Really?? I know that the conservation status of killer whales is considered "data deficient" due to so many unknowns. I am very interested to know if Tilikum's offspring were released into the wild, or kept as show animals. As far as I'm concerned, the only animals that should be bred in captivity are those that are of a Threatened or near threatened conservation status.
The best zoo I have ever been to is Singapore Zoo. It truly is fantastic, and it's also the reason I now don't like going to other zoos - nothing can compare. For a start, they put a lot of effort into conservation initiatives and breeding programs. According to their website "To better meet the healthcare needs of its animals and working towards its aspiration to become a leading global centre of excellence for veterinary healthcare and research, a purpose-built Wildlife Healthcare and Research Centre was set up in March 2006."
Walking through Singapore was an amazing experience. All of the enclosures were size and animal appropriate, and each animal had a good write-up of the species, location etc. I've been to some zoos where it will have the name of the animal, and that's it. The other thing I loved was that it was very interactive. A lot of the animals had feeding times, and you could join the Feeding Trails, where a keeper would feed a few different animals in the one area. This is one of the Afternoon Feeding Trail schedules:1.05pm 1.15pm 1.25pm 1.35pm 1.40pm 2.00pm 2.10pm 2.20pm 2.30pm Polar Bear White Rhino African Lion Giraffe* Gibbon Treetops Trail Otter White Tiger Pygmy Hippo
So you would just follow the keeper around, and they would do a short feeding of each animal and give detailed information about the animals, and you could ask questions along the way, and I found we learnt so much more about the animals this way. You could pretty much stay with different Feeding Trails all day if you wanted to. That was probably the thing that impressed me most. It was so interactive - not with the animals themselves, although there was plenty of opportunities to feed different animals along the way, but with the keepers, and you could watch all the animals being fed. A fabulous learning experience and gave us a much better appreciation for the animals.
The other zoo I really enjoyed was Western Plains Zoo in Dubbo, Australia. Because there was so much space, they had room to create huge spaces for the big animals, where they could graze happily. There were almost no fences as such, just moats, or ditches or whatever was necessary to keep animals in and people out! We hired bikes for the day and got around like that, and it was well and truly worth it to see the big animals in a more natural environment.
On the contrary, I think the worst zoo I have been to was Bronx Zoo in New York. It was about 10 years ago now, and I hated it. Each animal was in a tiny cage. Birds of prey were kept in small cages. Pack animals were on their own. There was no education of the animals themselves. It was packed with people, there was no keepers around, and the zoo seemed more intent on making money through selling hot dogs and merchandise than providing an educational experience. I felt sick after going there. I hope that things have improved there since.
But back to the event that set this off, I've been annoyed reading reports of PETA demanding for the whale's release, and other groups demanding the whale's euthanasia. The whale CANNOT be released, because it's been in captivity too long, and putting him to sleep is also unthinkable - in the wild, killer whales are no threat to humans. WE brought the whale into captivity, WE pay to see him perform, WE make SeaWorld dependent on those shows to make money, so WE the human race are the ones to blame, not the whale.
Update
Time is flying by! I finally did my phlebotomy externship in March, which was 2 days a week for 4 weeks. The externship was at San Francisco General Hospital, and boy did those 4 weeks fly by! I think I was about 28 weeks pregnant when I started, so was pretty tired, and the drive up to SF plus full days of being at the hospital really wore me out. I enjoyed it though, and am glad to be done. I have sent off all my information, so should get my license soon - yay!
I am now 35 weeks pregnant and feeling it. My belly has really grown over the last 2 weeks, and I am feeling more tired now.
I have non-stress tests twice a week where they check the baby's heart rate, movement and monitor for contractions. This little rascal takes forever to pass the tests. They want to see 3 periods of movement where the baby's heart rate increases by 15 BPM for I think 10-15 seconds. This little ones wriggles around, but doesn't get her heart rate up, so I spend an hour in there for each appointment rather than the 20-40 minutes they tell you it should take. A few times she's just slept through the whole thing, with pretty much no movement and just a steady heart rate. She moves plenty when I'm at home, so I'm not too worried. The nurses end up using a "Vibro Acoustic Stimulator" on her, which is the same device people who have larynx problems hold to their voice box to allow them to speak. It makes a sound that wakes up the baby (and essentially gives them a fright), so the heart rate goes up, and they wriggle around plenty. Once she gets buzzed, she wakes up, wriggles around, and passes the test, and it's gotten to the stage now that as soon as they establish her baseline they will just buzz her immediately rather than waiting 45 minutes to decide she's not cooperating AGAIN :) Hopefully this means we'll have a nice, quiet baby on our hands! Either that, or a stubborn one...
At today's obstetrician appointment, the doctor locked in a c section date. I'm hoping for a vaginal birth this time around, but given we can't be sure if the previous stillbirth WAS due to a cord accident, the OB isn't keen to let me go too late. And because I've had a previous c section, they won't induce labour because the risk of a uterine rupture is much higher. So unless she comes on her her own, I'll be delivering by c section on Friday, May 14, at which point I'll be 38 weeks and 4 days. I don't mind it being a bit early. While I would prefer to avoid another c section, my number 1 priority is to deliver a healthy baby, and the sooner the better!
We're keeping our fingers thoroughly crossed that everything goes well!
Introducing Zoe Dianne Pollock
Zoe arrived last Monday, May 3rd at 12:30pm. Her due date was May 24, so she was 3 weeks early. We had been planning a c section on May 14 if she hadn't come on her own by then, but we had a scare last Monday where she wasn't moving in what was normally her most active time of the day. We went to the hospital where they did a non-stress test to monitor the baby's heart rate and activity, and she was fine, but being pretty quiet. That's normal for her, but given the last baby was stillborn, and how much stress it was causing me worrying about her, the docs asked if I wanted to deliver that day. I was in complete shock, and Andrew and I talked it over, and my OB upgraded his advice to a recommendation to deliver that day. We agreed to it, and asked when they would do it, and they said they had a c section for 1:30pm (it was about 10am), so they could do it immediately before the next person - eep!
We asked if Andrew had time to run home and get the camera, and they asked where we lived, and they said "yes, but hurry" :-) By the time he got back, I was hooked up to IVs, had spoken with anesthesia, and generally been prepped ready to go. Andrew arrived, and soon after I was walking into the OR.
The c section went smoothly, and it really is the most bizarre thing. Having someone inject stuff into your spine is weird to start with, it's kinda painful, but more of a really odd sensation. Andrew just reminded me today that they tasered me to make sure the spinal was working - I'd forgotten about that. Andrew said it really did look like a taser! They started low on my abdomen, and worked their way up until I said OWWWW!!! They decided the spinal had worked fine, and they started.
About 30 minutes later, I was feeling strong pushing and shoving on my belly, and knew they were starting to get Zoe out. I was still feeling shell shocked, and starting to get really nervous too. Andrew let out a huge gasp and had stood up and was taking photos, and I just remember thinking "come on baby, please cry". Seconds later I heard the WAHHHHHH, and was overcome with emotion. Andrew and I were both sobbing, and he got to go and hold Zoe, and give her her first cuddle :-) He brought her up to me, but I was feeling very zonked, and the drape they have up was right under my chin, so I felt too scared to try and hold her. Zoe scored 9 and 9 on her APGAR tests (10 being the highest), so was in perfect health. We had been warned that while she should be fine, being 3 weeks early, and delivered by c section, she may have some minor lung issues (vaginal deliveries assist with pushing fluid and muck out of baby's lungs as they pass through the birth canal)
Andrew and Zoe went off to the Well Baby Nursery where she got weighed, measured and checked in general. She weighed 6lb 7oz, was 19.5 inches long, and had hair on her sweet little head.
They finished putting me back together, and I was moved to the recovery area, where Andrew and Zoe eventually arrived, and I was able to finally hold her, and she had a go at breast feeding.
The next few days in hospital were fairly non-eventful. I recovered from my c section, we had a private room, so Andrew was able to stay through the night which was a huge help, and we started learning how to look after a newborn.
Zoe is a great little baby, she sleeps really well, doesn't really cry, and loves to snuggle :-) Her weight dropped as expected in hospital, and she had a full day of breast feeding, but being so small, it completely wore her out and the next day she refused to breast feed. Her weight had dropped to 5lb 13oz, and they were worried because she was sitting right near the 10% weight loss mark. So we stopped breast feeding and pumped milk and bottle fed that to her to ensure she got all the nutrition she needed without having to expend too much energy.
We have had a couple of weight checks at the pediatricians since coming home on Thursday, and Friday she had lost another 1/2 ounce, Saturday she'd put on 3 ounces, and today she was another 3 ounces up. I'm still predominately pumping and bottle feeding which is nice because Andrew can help feed her, and they can have bonding time - it's about the only time she's really awake! The pediatrician said today they find babies don't start to do really well at breast feeding until they reach 7 lbs. So we'll continue to pump and bottle feed, and try to put her on the breast when she's alert and calm. If she's super sleepy, or worked up she has no interest in boob, but if she's had a really good sleep she does ok.
She is incredibly sweet, and just loves snuggling up with us. She's sleeping in her crib by day, and in a bassinet next to me at night. In the morning, I generally put her in bed with us, and we watch her squirm, and stretch and make funny facial expressions until she wakes up :-) If she's unsettled at night after her feed, I can put her in the crook of my arm in bed, and within minutes she's fast asleep and can be put back in her bassinet.
I've been letting her demand feed the last couple of nights (they wanted us to not let her go more than 3 hours between feeds when she was losing weight), and she generally does 3 1/2 hours between feeds, although last night she had a 4 1/2 hour stretch! That was probably a little long, but she woke up happy and fed really well after it.
We're so in love with this perfect little person in our lives, and are enjoying every moment of parenthood (although the first feed of the night I struggle to wake up, and Andrew generally sleeps through - I would too, except I HAVE to get up to pump as well).
Anyway, here's a couple of photos of our little poppet.
Zoe entering the world
Gooey!
My first cuddle with Zoe
She found her thumb pretty fast
Family photo
Snuggling in the hospital bed
Gangsta baby!
Zoe with her daddy
Morning feed with dad
Peaceful baby :-)
8 Temmuz 2012 Pazar
Muscle soreness after marathon-what do the muscle biopsies show?
This phenomenon is called delayed onset muscle soreness (DOMS).Although lactic acid buildup was once said to be the cause now the thinking is that the key element is eccentric exercise with damage to the muscle fibers and lactic acid exonerated.Neither post exercise icing nor use of NSAIDs seem to help but there is some fairly unconvincing data suggesting that post run massage might mitigate the soreness a bit.Well it feels good anyway.
In recent years there is no significant post race soreness in the thighs at anything near the level experienced earlier in my running odyssey. I developed the habit (obsession) of typically covering a long training distance on the weekends, running about 20 miles on a typical Saturday with no soreness on Sunday.
What do muscle biopsies demonstrate after marathons?
Here is a full text article from the American Journal of Pathology 1985 by M.J. Warhol. Muscle biopsies were done on the lateral gastrocnemius muscle of forty runners 48 hours after a marathon and again at one week, one month and 8-10 weeks. Light and electron microscopy were done.
At 48 hours there was damage to the myofibrils with abnormal findings evident in the mitochondria and sarcoplasmic reticulum. The damage was patchy and quite variable in extent from one runner to the next, with some demonstrating very little damage. Type II ( fast-twitch) fibers seemed to be more damaged. By day seven, "ghost cells" (empty muscle cells) were seen and satellite cells appeared. By one month there was continuing evidence of muscle cell regeneration but the pathological changes had largely resolved. There was no inflammatory cellular response reported in this paper but another report did describe some inflammatory cells.Some runners showed evidence of fibrosis. By 12 weeks there was continued electron microscopic evidence of muscle cell regeneration.
Similar light microscopy findings were reported earlier by RS Hikida ( with senior author D Costell ) in the Journal of Neuro Science 1983,May 59(2),195-203. However, their results differed in that they reported evidence of inflammation while Warhol suggested those changes were due to the trauma of the biopsy. Hikada also did pre-race biopsies showing some of the same changes prompting the suggestion that the intensive training for the marathon may have caused similar cellular changes.
A pattern emerges of damage to muscle cells that drop out and are replaced by new cells.
If the type II fibers are disproportionately affected perhaps my slower times and less participation by my type II fibers might account for the lack of post race soreness. Type II fibers kick in as the energy output increases moving toward the maximal oxygen uptake and when glycogen stores are depleted.Further the sarcopenia of aging also disproportionately targets type II cells so I may have less muscle cells at risk and I run so slowly that my fast twitch fibers for the most part have the day off.
What data are available regarding morphological changes in the muscles of athletes who exercise at high levels for many years? So far I have been unable to find any.
Cahoots ,Obamacare and Big Pharma
Now, we have good reason to believe that Big Pharma was in cahoots with the democrats to pass Obamacare.What did Big Pharma get out it? Eliminating the part of the proposed legislation that would allow reimporting of prescriptions drugs and at least resisting price controls for a while. See here for the comments from the blog Health Care BS. See here for the WSJ report for details of the involvement of drug companies in pushing for the passage of ACA using astro turf type front groups (i.e two 501(c)(4) organizations).
WSJ points out that at least Big Pharma got something for their support.What AMA is alleged to have been lobbying for (the doc fix) was not part of the bill.Well,swimming with the sharks (also known as "a seat at the table") has its risks but at least the AMA leadership was able to have claimed a victory for social justice.
The gift that keeps giving-the stimulus to the electronic medical record industry
Stimulus for whom? Physicians do receive a relatively small payment ( about 40 -60 k) for agreeing to install EHR systems (electronic Medical records system) but were there large numbers of the rank and file physicians out lobbying for that part of the stimulus bill? I think not.But legislative packages do not arise at random out of thin air,there are folks at work lobbying for things that provide them favors.Economists call this behavior rent seeking. .There was much rent seeking going on the stimulus bill .
Maybe we should look to companies that sell the products and services that the goverment was giving money to physicians to purchase. Several of them worked with former Republican presidential candidate N. Gingrich's consultancy known as "Center for Health Transformation" which among other initiatives championed the electronics health record as a means of improving health care. These including Allscripts,Microsoft,Siemens and GE Health Care.
The underlying principle of the universe,there is no free lunch,applies to the faux beneficiaries- the physicians. The golden rule applies .He who has the gold makes the rules. The gift to the docs comes with strings,lots of them linked to Medicaid and Medicare payments. The 19 billion ( or 27 billion,depending on what source you read )given to the EHR companies through the physician checkbooks is just a drop in a big bucket as physicians will now have the obligation to keep the soft and hardware running and of course update regularly with new versions of the various software packages and update their systems as Federal requirement evolve.
Docs will also be tasked with proving their new system are demonstrating "meaningful use" a goverment term of art with very specific details that physicians practices will have to learn and try to comply with.See here for a reference for an explanation of the 25 criterion for meaningful use. Failure to achieve this level of use will at the end of the day ( a five year day) result in decrease in the CMS payments for services to the physicians who are meaninglessly utilizing their EHR.
Many- if not most- examples of rent seeking simply involves transferring tax payer money to a
the entity that successfully lobbyed for the favor. That happened here , of course, but additionally physicians will obliged to keep the systems running providing a continuing income stream to the EHR industry in perpetuity and providing a means of increasing control of the physicians practices.Part of the meaningful use requirements is to maintain a data base registry of patients with a given condition so that the doc can then demonstrate to the central authority the degree to which his practice complies with this or that guideline.
As if that all were not enough to push the older docs to decide right now to retire, part of the stimulus bill ( AKA American Recovery and Reinvestment Act of 2009) contains more stringent and detailed requirement and new penalties under HIPPA, See here for that.
We are the from the government ,we are here to help .
Obamacare's IPAB is not just unconstitutional but is anti-constitution -Cato
I have written about IPAB on several occasions. See here for some of my comments about IPAB and the concept of an "entrenchment provision" which a legal scholar discusses here offering tepid assurance that such a thing could not really happen. Entrenchment means that a legislature passes a law and includes within that statute a provision that prohibit future legislature from repealing or altering the law. There is such wording in ACA.
According to the Cato paper referenced above, the Obama administration has said that of course, IPAB could be abolished by congressional action even though Cato's paper said that statement conflicts with the clear wording of ACA. The legal analysis quoted above does say that apparently the Supreme Court has said they will not allow entrenchment.Whether IPAB is really entrenched on not,one has to assume that the authors of that section wanted IPAB to be an immutable,eternal entity.
So maybe (hopefully) that aspect of IPAB is just a tempest in a teapot but there is much more to be very,very worried about with IPAB . The Cato paper written by Diane Cohen and Michael Cannon discusses those issues in detail.If their analysis is correct the power that this appointed body will have is more than mind numbingly frightening.
Here is a good summary on Cato's web site giving a brief summary of the paper referenced above.
AMA joins the "gangwaggon" to guilt doctors to become stewards of society's resources
Dr. Perednia quotes Med Page regarding AMA's actions.
CHICAGO — Providing effective medical care includes an “obligation” to prudently manage healthcare resources, according to a report approved by the American Medical Association’s House of Delegates on Monday.
In fact, managing healthcare resources “is compatible with physicians’ primary obligation to serve the interests of individual patients,” the report reads. It further states that considering the welfare of only the patient currently being treated when making recommendations does “not mesh with the reality of clinical practice.”…
So the obligation (whenever the hell that obligation came from) to manage healthcare resources seems to preclude "considering the welfare of only the patient currently being treated".Are they are throwing the fiduciary duty of the physician to the patient out of the window?Patients seek medical help to get the best advice for their given condition not to engage in some self sacrificial exercise in forgoing the optimal treatment for the nebulous and undefinable good of society . How much concern do you think a worried parent in the physician's office with a sick child cares about some abstract conservation of society's resources or furtherance of social justice.
In contrast to the gobbledygook of such phrases as "doesn't mesh with reality of clinical practice" and the gratuitous assertion of an operationally meaningless obligation. and the unwarranted assumption that physicians all have a collectivist philosophical mindset, Dr. Perednia makes these valid arguments:
The first principle is that, in Western democratic cultures, when any of us seek out a physician for care, our primary goal is finding a solution to our own particular medical problems rather than a cure for the ills of society. In this role and in our minds, a doctor is supposed to be the equivalent of our “medical lawyer”:
- We provide the facts of the case as we know them.
- Our physician is supposed to gather any other relevant evidence and, using his special knowledge, outline all of the possible courses of action we might take and suggest the one that is most compatible with our goals and the resources available to us.
- He is supposed to looking out for our best interests rather than the interests of others. When a doctor or lawyer takes your case, he is supposed to be working for you: not your opponent, not insurers, not government, not world peace or society as a whole.
The New Professionalism brainchild of ACP and friends did not quite say that social justice and the equitable allocation of scarce medical resources was an ethical obligation of physicians but the New Ethics Manual of the ACP made it explicit. It was a definite ethical game changer.See here for earlier comments on that development.
With many (most) professional medical associations mindlessly signing on to the New Professionalism and now with the AMA imprimatur I have little hope that the next generation of newly minted physicians will enter the field inculcated with the (now obsolete) notion that the physician's primary and fiduciary duty is to the patient.
I offer the following in partial proof on this fear as one "leader with ideas" has suggested
that "cost-consiousness and stewardship of resources be elevated by the ACGME and the ABMS to the level of a new seventh general competency." In other words, residents should be schooled and graded on their mastery of the skill set necessary to be good stewards of [society's] resources. ( reference, The Idea and Opinions Section, Annals of Internal Medicine,20 Sept 2011,Vol.155 no.6, by Dr. Steven E. Weinberger,of the American College of Physicians.
What could be more advantageous to the HMOs,ACOs and medical insurance companies than to flimflam the medical profession into accepting an new ethical paradigm that conveniently coincides with the bottom line of those organizations?
The concept "physicians as stewards of society's medical resources" is , in one sense a meaningless abstraction, and in another, a useful fiction. Useful to the HMOs,ACOs and insurers who now can enjoy to a much greater degree than before, physicians working to bolster their bottom line but decreasing costs also known as providing less to patients.
The socially conscientious physician might feel somewhat at loss as to how he might carry out the massive,pretentious and ambiguous task of stewarding society's resources.He should feel reassured ,though, because all it will take will be "follow the guidelines" and by doing so he will do what it right for that patient and for society as a whole. Wasn't that easy.
7 Temmuz 2012 Cumartesi
Treatment of Adenomyosis
Adenomyosis naturaly goes away when menopause, thus treatment may rely on how close you're to that stage of life.
Treatment choices for adenomyosis include:
- Anti-inflammatory medicine. If you are nearing menopause, your doctor may have you try anti-inflammatory medications, like ibuprofen (Advil, Motrin, others), to control the pain. By beginning an anti-inflammatory drugs 2 to 3 days before your period starts and continuing to take it throughout your period, you can reduce menstrual blood flow additionally to relieving pain.
- Hormone medications. Controlling your menstrual cycle through combined estrogen-progestin oral contraceptives or through hormone-containing patches or vaginal rings may reduce the serious bleeding and pain related to adenomyosis. Progestin-only contraception, like an intrauterine device containing progestin or a continuous-use contraception pill, usually leads to amenorrhea — the absence of your menstrual periods — which can give relief.
- Hysterectomy. If your pain is severe and menopause is years away, your doctor may counsel surgery to get rid of your uterus (hysterectomy). Removing your ovaries is not necessary to control adenomyosis.
The litigation to allow seniors to refuse Medicare Part A goes deeper in the rabbit hole
The case has proceed slowly through the legal system and now a three judge panel has ruled against the plaintiffs. It seems that there is a CMS rule book regulation that states if a person refuses Medicare Part A he will not receive the social security benefits he would have otherwise be eligible for. If one accepts Medicare A and then later decides to decline this "entitlement"he will stop receiving SS payments and have to repay what he had previously received. Earlier a judge in the case said in effect that Medicare benefits were a "mandatory entitlement".
Note this draconian rule was not written into the Medicare law or anything else that should have statuary power and came into existence in something called the Program Operations Manuel System (POMS) which apparently is simply advice for the program administrators and never went through any formal rule making process.
See here for the latest development in this case.
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How do you turn a mandate into a tax-just say the magic words
The individual mandate of ACA was called a mandate because , well, it was considered by the legislators as a mandate. The supporters of ACA claimed it was perfectly constitutional under the commerce clause because it-and as best I can tell almost everything-has something to do with interstate commerce and congress has the authority to regulate interstate commerce.
The Court ruled that the mandate was not constitutional under the commerce clause but it was when considered to be covered by the taxing authority of congress.But what about the Anti-injunction Act that says you cannot appeal a tax before it is paid?Well, in that regard it is not a tax.
When I use a word,' Humpty Dumpty said in rather a scornful tone, 'it means just what I choose it to mean — neither more nor less."
"The question is," said Alice, "whether you can make words mean so many different things."
"The question is," said Humpty Dumpty, "which is to be master— that's all."
George Will , in his commentary, argued that the limitation of the commerce clause that he believed occurred with the Court's ruling was actually a major victory for the forces that are striving to limit the power of the federal government since so much of the growth of federal power has been carried out under the cover of generous interpretations of the commence clause. Will is hopeful that that trend may now be thwarted by this ruling.
On the other hand it may be the case that now the court has offered a precedent that allows a mandate to stand because the penalty for failure to comply with the mandate is a tax and congress can tax pretty much anything it wants and thereby makes mandates willy-nilly if they can be construed to "really" be a tax. Law Professor Ilya Somin makes that argument here.
Quoting Professor Somin:
Pretty much any other mandate could be magically converted into a tax by the same sleight of hand - so long as the penalty for violating it is a fine similar to the one that enforces the individual mandate. The danger here is not just theoretical. Numerous interest groups could potentially lobby Congress to enact a law requiring people to buy their products, just as the health insurance industry did.
In rejecting the federal government’s argument that the mandate is authorized by the Commerce Clause, the chief justice emphasized that the Constitution denies Congress the power to “bring countless decisions an individual could potentially make within the scope of federal regulation and ... empower Congress to make those decisions for him.” Yet he has allowed the government to claim that same power under the Tax Clause
The revolving door turns for health care agencies and health care business as well
See here on his blog Health Care Renewal for his investigative report on just two instances of the revolving door between government agencies regulating health care and the big players who provide various aspects of health care.
Here is Dr. Poses' next to last paragraph:
As we wrote before health policy in the US, in particular, has become an insiders' game. Unless it is redirected to reflect patients' and the public's health, facilitated by the knowledge of unbiased clinical and policy experts rather than corporate public relations, expect our efforts at health care reform to just increase health care dysfunction.
"Insider's game" is the exact appropriate characterization.
Affordable Care Act (ACA) as example of The Bootlegger and the Baptist phenomenon
In it he coined the term "Baptist and the Bootlegger" ( B and B) which explicates the marriage of high sounding values with narrow self interest to bring about regulation.
The B and B theory takes its name to instances in which Baptists were opposed to alcohol consumption on Sunday and were joined in their promotional and lobbying efforts by the bootleggers realizing that they, being skilled in criminal acts, would enjoy a comparative advantage in illegal alcohol sales.Of course, they urged prohibition of the sale and not the consumption of alcohol. With regulations passed the Baptists were happy about the incremental decrease in sin and the bootleggers enjoyed a Baptist originated cartel ( if only for one day a week).
Years later, Yandle offers this retrospective assessment of the "B and B"theory with discussion of the spotted owl episode of the 1990s leading to increased profits for timber growers and how the 1977 Clean Air Act's mandating scrubbers on newly constructed coal fired electrical plant favored the eastern coal companies and their high sulfur coal at the expense of the low sulfur coal producers in the west. In each instance the special interests joined forces with the environmentalist organizations to urge for regulations that were to ostensibly (or actually) further the public interest.
B and B theory is not just of historical interest.It was alive and well in the run up to the Affordable Care Act (ACA).
Candidate Obama distinguished himself from his rivals in the democratic primaries by opposing an individual mandate to purchase health insurance and favoring ultimately a health care system with a single payer.
Ron Williams , then the CEO of Aetna, met on numerous occasions with the President Obama and testified to a number of congressional committees.Others in the health insurance industry played less visible but still active roles in lobbying for the individual mandate. So here we have health insurance carriers lobbying for a law that would require people to buy their product. It is clear who plays the role of the bootlegger here. The Baptists are various spokes people who adhere to the progressive vision,favor redistribution and believe that health care is a right that should be provided by the government.Many are sincere,though in my opinion misguided,but some are likely bootleggers in Baptist robes as in astro turf advocacy groups.
See here for further details about the antics of Mr. Williams in lobbying for ACA as well as his intriguing and perhaps ill advised recanting of his position just prior to the SCOTUS decision.
The outrageous length and complexity of ACA makes it likely that the insurance industry was not the only bootlegger at work in planning and promotion of the bill. Big Pharma and Big Hospital comes to mind. Question: Should AMA in its role in supporting ACA be considered a bootlegger?
Professor Yandle has the following subtitle on his retrospective:
"The marriage of high flowing values and narrow interests continue to thrive"
5 Temmuz 2012 Perşembe
Robot for Transcranial Magnetic Stimulation (TMS)
Duke University’s Department of Psychiatry and Behavioral Sciences employs a coil positioning robot for Transcranial Magnetic Stimulation (TMS) at their Brain Stimulation Center.
The SmartMove is a robotic TMS coil positioning system, developed by Advanced Neuro Technology (ANT) that closely follows slight head movements of the patient to precisely target the same spot in the brain..
From an ANT the press release:
ANT’s SmartMove System is a solution for field visualization and temporally accurate targeting within the subject’s cranium. The Visor Neuro Navigational system is included with ANT’s system as a component. Like other neuro navigational devices, the Visor allows for users to construct digitized 3-D brain models from a patients MRI or other brain image (i.e. fMRI, PET, CT, etc.). The Visor’s software allows users to actually see the depth, location, and shape of the magnetic field in relation to the subject’s brain in real-time, on a computer monitor. Users can use markers for target locations once they are identified (such as the dorsa-lateral prefrontal cortex for the treatment of MDD) which then can be imported into the SmartMove’s software. Using the SmartMove, the TMS coil can be accurately positioned over any preselected brain region. The robot ensures consistent targeting, regardless of movement by the subject, via motion-detection technology. Furthermore, a Researcher is able to pre-program multiple locations for stimulation, varying duration if they like as well. This particular feature will allow the researchers at Duke to set certain stimulation schedules or protocols to save valuable time. The ability to visualize the magnetic field, and continually pinpoint any given target opens up exciting new possibilities for the capabilities of the Researchers at Duke.
Researchers know exactly where they are ‘targeting’, but it is nearly impossible for any human to aim at a precise location of 1mm radius for more than an instant without the aid of a machine of some sort. Since subjects also move, the struggle for accuracy becomes compounded. For a computer and a robot, these tasks are much easier with proper programming and hardware.
Press release: Researchers at Duke among the first to explore robotic TMS applications …
Product page: SmartMove …
View the original article here