HEALTHPLANUSA . NET	QUARTERLY NEWSLETTER
Community For Affordable Health Care	Vol V, No 2, July, 2006

Utilizing the $1.4 Trillion Information Technology Industry

To Transform the $1.7 Trillion HealthCare Industry into Affordable HealthCare

In This Issue:

1. Featured Article: Civilization? Take a Lesson from Russia.

2. In the News: Why Are Americans so Angry?

3. International Medicine: Poppycock, By THEODORE DALRYMPLE

4. Medicare: Hidden Administrative Costs: A Comparison of Medicare and the Private Sector

5. Lean HealthCare: Do We Need More Heroic Leaders or More Farmers?

6. Medical Myths: To Test or Not to Test? From the Placebo Journal

7. Overheard on Capital Hill: To Kill an American

8. What's New in US Health Care: End of Care, From The Placebo Journal

9. Health Plan USA: Milton Friedman’s Prescription for Curing the Health Care System

10. Doctors Restoring Accountability in Medical Practice by Non Participation in Insurance and Government Programs

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1. Feature Article: Civilization? Take a Lesson from Russia.

[My successor as editor of Sacramento Medicine was extolling the virtues of the socialized welfare state. This was in the period where Russian communism was failing, and East Germany was in serious financial straits. I reminded him that state control has never worked and was failing in all countries. His reply was that it had never been correctly applied. The United States would get it correct. These other countries allowed too much individual freedom. To be successful, everyone has to conform or else.

[It is hard to believe that we have citizens in this country that believe that Stalin, Hitler, Mussolini and Mao allowed so much freedom that the United States should allow less in order for the government to take over health care?

[This lengthy editorial in the WSJ recently points out the struggles of people when autocracy rules. They get so used to being controlled that they are unable to fathom a free society. Even in the UK after 55 years of state controlled healthcare, very few doctors are able to believe that doctors can run their practice for the good of the patients and their country in a freedom state. This makes it all the more important that the United States, as the most free remaining society, makes every effort to prevent encroachment on our freedom by state interventionists to control our most prized personal possession – our own bodies, our health. When the state dictates what we can strive for in our human health endeavors, the entire war for freedom will be lost. For how long? As far as our lifetime is concerned, this editorial would suggest that 300 years is really forever.]

What Is Russian Civilization? By EDVARD RADZINSKY, The Wall Street Journal, July 10, 2006

Russia is an exceptional place. In the 20th century, over a single lifetime -- 70 years -- it saw three civilizations. Each of the first two was rejected by its successor, forcing people to renounce their convictions. You can imagine the chaos of ideas and beliefs in their hearts.

The era of Muscovite czars and the following 300 years of Romanov reign was one of ruthless autocrats. The opportunity to destroy the autocracy appeared rarely, but it did appear. For example, in the early 1540s, the boyars (or nobility) ruled the country as regents of an infant czar. They could have established an aristocratic republic. Instead, they squabbled furiously, without forgetting the main occupation of Asiatic bureaucracy -- stealing. The military governor in Pskov robbed the city so thoroughly that, as a chronicler recorded, "There were no rich or poor left -- everyone became impoverished." While the boyars argued and stole, the fledgling czar grew up. Teenaged, he set his hounds on the most highborn boyar before the boyars' own eyes. And the people sighed in relief, for stealing by officials in Russia could only be limited by the choke-leash of a czar. But amazingly, the boyars themselves sighed in relief because their habitual servility before the czar was restored. As an historian wrote, "It is easier to imagine Russia without the people than without a czar." The teenage czar grew to be Ivan the Terrible.

The Time of Troubles

The suppression of the dynasty of Muscovy czars led to the Time of Troubles (from 1598 to 1613). But upheavals and chaos, even as they take away the people's well-being, are supposed to give rise to new ideas. One would think that Russia, having lived through years of turmoil, would start building a new order when the old collapsed. But it ended the way it began. Muscovy gave birth, again, to an Asiatic autocracy -- the Romanov dynasty. The foreshadow of 1917 lay in the 17th century.

The reign of Alexander II was another of those rare times when autocracy could have been transformed. This Russian Lincoln not only emancipated the serfs in 1861; he became the father of perestroika, reforming all parts of Russian life. But he was a typical Russian reformer, a Janus with one head facing forward, the other looking back. The reforms stopped in the first half of his reign. A contemporary wrote what could serve as the epigraph to all Russian perestroikas: "For some reason everything good in Russia is fated to start but not conclude. With one hand we create . . . improvements, with the other, we undermine them . . ."

The czar was hated by liberals for stopping reforms, and by conservatives for starting them. Russia was still an autocracy, and the young -- seduced by the reforms -- felt deceived. They thirsted for a parliament and a constitution, but were repressed. Alexander II, as did Gorbachev a century later, came to understand a bitter truth: If starting reforms is dangerous, it is much more so to stop them. An unprecedented terrorist organization was born in Russia, and in some measure, the czar was to blame. The nihilists called terrorism "the strength of the powerless." The most insightful realized that the child they had created was long-lived. "When we are gone, there will be others," wrote their leader. The "young people pure of heart," as a contemporary called them, gradually turned into cold killers, assassinating Alexander II in 1881. When the prosecutor spoke -- at the regicides' trial -- of the innocent bystanders who were killed, the terrorist leader laughed. The prosecutor's response, repeated throughout Russia, was: "When people weep, they laugh."

"Balancing on the edge of the abyss" was Dostoyevsky's description of Russia then. After Alexander II's death, society was persuaded that the way forward was the way back. His son, Alexander III, returned Russia to the ruthless autocracy so dear to the hearts of its rulers. He dreamed of reverting to the times of his grandfather, Nicholas I (1796-1855), who had said, "Despotism exists in Russia because only it is in accordance with the spirit of the people." But toward the end of his reign, Alexander III asked his adjutant-general: "[T]here is still something wrong in Russia, isn't there?" The reply should be memorized by all of Russia's rulers: "Your majesty, imagine an enormous steam boiler filled with simmering gases. But there are people with hammers around it diligently riveting the smallest openings. One day the gases will break though a section that they will not be able to rivet back." The czar, according to accounts, "groaned, as if in pain."

His son, Czar Nicholas II, became the victim of the explosion. That is how the first Atlantis, the autocracy of the Romanovs, perished.

* * *

Astonishingly, it was members of the ruling class, the intellectual nobility who would not accept autocracy, who fomented the revolution. A poet wrote in the 19th century: "In Paris the cobbler revolts to become a landowner -- that's understandable. In Russia, when the nobility makes a revolution, is it because they want to be cobblers?" In Russia, poets are often prophets. The son of a shoemaker, Joseph Stalin, became the first Bolshevik czar, and the No. 3 man in his government was a former shoemaker.

The fantastical came to pass as a result of the Russian Revolution. In pious Russia, unknown radical Bolsheviks took power. Lenin seized power with the dream of destroying the state, only to create the most ruthless state, and of destroying the bureaucracy, only to create the most powerful bureaucracy. The Romanov Atlantis drowned, but autocracy was immortal. The essayist Alexander Herzen predicted back in the mid-19th century: "Communism is merely Nicholas I's barracks transformed." The Bolshevik state created by Lenin became ridiculously similar to Nicholas I's ruthless monarchy. The barracks were completed by Stalin, child of the Russian Thermidor, an Asiatic Napoleon come to consummate the new Bolshevik civilization.

This civilization was astounding. It had a Nocturnal Life and a Daytime Life. In the Daytime, the population awoke to the unsilenceable radio, zealously rushed to work, enthusiastically attended daily rallies where they condemned the enemies of the USSR, and attentively read the thin newspapers with reports on the trials of the enemies of the people, which proved the reliability of the NKVD, the Bolshevik secret police. Deprived of freedom, not daring to have their own opinion, leading miserable lives with several families to a communal flat, they sincerely pitied the exploited workers in the West, the oppressed Negroes and everyone else who did not have the fortune to live in the USSR.

On Bolshevik holidays, they went with their families to Red Square and joyously recounted how they had seen Stalin. Did they fear the NKVD? They would have been outraged by the question: The NKVD was feared only by enemies. Did they know about the arrests, the hundreds of thousands of their fellow citizens in the camps? Of course! Many of their acquaintances had been arrested. But they were obliged to believe, and did believe, that they had been enemies. They were surrounded by enemies! Anyway, arrests usually took place after midnight, in the Nocturnal Life. They did not affect them.

The Daytime Life was like the one William Shirer described in Nazi Germany: "The observer would be surprised to see that the Germans did not consider themselves victims of threats or pressure from a heartless and cruel dictatorship. On the contrary, they supported that dictatorship with unfeigned enthusiasm." Stalin worked at creating a sense of conquest in the people. The radio blared cheerful marches, as it should in the land of conquerors. They had conquered czarism and the monarchists. Now they were conquerors in their Daytime Life: In the course of two or three Five-Year Plans they were going to surpass the rest of the world. At every trial, they conquered enemies and spies. And they had conquered religion: All that was left of Holy Russia were beheaded churches.

But Stalin had studied in a seminary, and said that Russia needed god and czar. He gave it a new religion: Asiatic Marxism. As befitted medieval religions, dissent was heresy, punished ruthlessly by death. The greatest temple was the Mausoleum, where, following the model of the imperishable saints, lay the body of imperishable Lenin. Many in the West did not believe in the "eternally living Lenin" and insisted that there was a wax dummy in the Mausoleum. In the 1930s, Stalin decided to prove the great power of the party that had conquered death to a group of Western journalists. Louis Fischer, a biographer of Lenin, was among them. He wrote: "Zbarsky [the biochemist who mummified the body] opened the glass case, and . . . pinched Lenin's nose and then turned his head right and left. We all could tell that it was not wax. It was Lenin." The passionate atheist and iconoclast had been turned into a holy relic. The Mausoleum workers felt like priests, keeping watch over that horrific parody of the Lord's Coffin. (Zbarsky recounted: "I was on call to the Mausoleum 24 hours a day. I taught the workers there: If even a fly gets into the sarcophagus, I categorically forbid you to get rid of it without me. All my life I had this nightmare -- they call from the Mausoleum: 'Comrade Zbarsky, there's a fly in the sarcophagus!?' And I jump up and rush over like a madman… Then I would wake up in a cold sweat.") . . .

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Carnivals for Labor

The collective, the masses, were everywhere, as befits a barracks: The collective at work and at home (since most apartments were communal). The collective at rest: All the professions had their own holiday (Day of the Miner, Day of the Construction Worker, Day of the Metallurgist, etc.), so that the collectives could have a day to drink and be merry (together, of course). At the height of the terror, in 1938, there were carnivals for labor collectives in Moscow's Central Park of Culture and Rest. Millions relaxed insouciantly, happily. This constant massivity, this dissolution of the individual in the collective, brought about the most valued attribute of Bolshevik civilization: collective conscience. Personal responsibility died out and collective responsibility remained. Woe to those who felt the stirrings of personal conscience. The writer Arkady Gaidar ended up in a psychiatric ward and described his symptoms to a friend: "I am tormented by a thought -- I've lied too much… Sometimes I feel close to the truth… sometimes it's ready to leap from my tongue, but some voice harshly warns me: Beware! Don't say it! Or you'll be lost!" He left the hospital only when he stopped hearing that call of the truth.

Stalin gave the country a new religion and he gave it czar and god in one person. Lavrenty Beria, chief of his security apparatus, explained the task of the film, "The Vow," to its director during production: "'The Vow' must be an exalted film, where Lenin is the biblical John the Baptist and Stalin is the Messiah Himself." Stalin's name was repeated all day on the radio. "Stalin this and Stalin that. You can't go to the kitchen or sit down on the toilet, or eat lunch without Stalin pursuing you: He got into your guts, your brain, he filled in all the holes, he ran nipping at your heels, called into your soul, got under the covers with you, and shadowed memory and sleep," wrote a woman in her diary. At the end of his life, Stalin signed a resolution to create a statue which could be compared only with the Colossus of Rhodes. Almost 50 meters tall, it was erected on the Volga-Don canal, built by convicts. One day, the keeper discovered that birds liked to rest on the head. You can imagine what the new god's face would look like. You couldn't punish birds, but the local authorities, smelling danger, found a solution: high-tension electricity passed through the giant head. Now the statue stood surrounded by a carpet of dead birds. Every morning the keeper buried the little bodies, and the earth, so fertilized, flowered.

This was the symbol of the Bolshevik civilization built by Stalin, the second Atlantis, which drowned in 1991.

* * *

Now is the time of the third civilization. Russia, a sphinx that seemed to have fallen asleep forever beneath the strict supervision of its autocrats, woke up not long before the end of the second millennium -- and did so rather peacefully, as never before in its history. Mikhail Gorbachev and Boris Yeltsin -- the two names of the last rulers of the 20th century -- will be side by side in Russian history, despite the fact that they heartily disliked each other. This is not a paradox, but is very Russian. As an 18th-century nobleman said: "We Russians don't need bread, we devour one another and are sated."

Gorbachev began the path toward freedom, Moses moving eternally through the desert. It was a difficult journey. The republics spoke up. Stalin had built the USSR in an inviolable way, the republics held together by economic chains. Gigantic collapse was looming. The center did not want separatism, but the republics did. Young people in the republics, hot-headed, were ready to die for independence. Civil war stood on the doorstep of a country filled with nuclear warheads. A world catastrophe was very near.

The peaceful dissolution of the USSR will be Yeltsin's greatest contribution to the history of the new Russia, which is only starting on its path. How difficult it is to build capitalism in a country where the unrighteousness of wealth is a beloved popular idea, a country without rule of law for a millennium, where the concept of "law" successfully substitutes for the concept of "justice," and where the bourgeoisie is brilliant at making money and totally useless at governing. The sad fact of Russian history is that the bourgeoisie has no experience of state leadership. How difficult it is to build democracy in a country where the dream of equality always trumped the dream of freedom. How difficult it is -- not only for the rulers, but, alas, for the people as well -- to reject ruthless autocracy in a country where it has reigned for centuries.

A major reason for Gorbachev's fall was that he did not understand this. He tried to become an ordinary politician, a political dancer -- step to the left, skip to the right. But the public, after a millennium of autocracy, needed yet another czar, albeit in democratic garb. A czar does not dance, a czar commands. Yeltsin was like that. If an American president commanded the dollar to stop falling, he would certainly be deemed mad. But during the default of 1998, outraged by the ruble's capricious behavior, Yeltsin commanded it to stop falling. And, for a period, the ruble froze in fright.

Yeltsin's tragedy was that he was an autocrat who sincerely tried to be a democrat. He forced himself to put up with what is most odious for a czar -- freedom of speech, that is, public insults from Communists and other opposition parties. He knew how to shut them up, of course. He knew, but did not do it, for he was a democrat, and what would his best friends -- Friend Clinton and Friend Kohl -- say! This constant tension, of knowing what to do but not being able to do it, made him seek solace in the bottle and destroyed his colossal health. The end of his reign was marked by chaos and wild corruption.

An Unknown Person

So once again, the people, as in the days of Ivan the Terrible, wanted a strict father. Yeltsin's majesty lay in doing the impossible for a Russian czar: voluntarily giving up power. Surprising the country, he turned the reins over to an unknown person. His fantastic sixth sense did not let him down. He selected a man the country wanted to see. After a president who made people wonder whether he would be able to get up from a chair, came a normal, modern and young man. He skied, and spoke breezily, without notes. He was probably the first Russian leader that teenage girls got crushes on.

Vladimir Putin has ended the era of Kremlin ancients who elicited sarcasm in the West. He decisively executes what the majority wants from him: Authority has been strengthened, stability established, and the concept of "super power," without which Russians cannot live, is being returned to Russia. He deals with the oligarchs in a manner that befits a czar. (As Paul I, son of Catherine the Great, said: "In Russia an important person is only the one I am talking to and only as long as I am talking to him.") But besides the will of the people there is the will of History, and they do not always coincide. Does History want a continuation of Yeltsin's royal democracy? Or does it demand an understanding of what Alexander II saw much too late? -- that it is dangerous to begin reforms in Russia, but much more dangerous to stop them.

"Russia! Where are you speeding? Answer me!" the great Gogol once asked, in vain. In 1916, in a village above the Polar Circle, where it gets to 40 below, lived an exiled prisoner. He was 38, his wife was dead; he belonged to a pathetic, underground party, with most of its members in prison and the rest fled abroad. He would spend days at a time lying in bed, face to the wall. Who would have guessed that just two years later that exiled Georgian, Joseph Stalin, would be in the Kremlin, ruler of half the world? Who would have guessed that a middle-aged provincial party functionary, Boris Yeltsin, appointed to lead the Moscow Communists, would destroy the USSR just a few years later?

Gogol gave the only truthful answer to the question he asked Russia: "It does not answer."

To read the entire Op-Ed article (subscription required), please go to http://online.wsj.com/article_print/SB115248692737401858.html.

Mr. Radzinsky is the author of "Alexander II: The Last Great Tsar" (Free Press, 2005). (This essay was translated from the original Russian by Antonina W. Bouis.)

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2. In the News: Why Are Americans so Angry? By Rep. Ron Paul, MD, speech delivered before the House of Representatives on June 29, 2006.

Our leaders are like a physician who makes a wrong diagnosis and prescribes the wrong medicine, but because of his ego can’t tell the patient he made a mistake. Instead he hopes the patient will get better on his own. But instead of improving, the patient gets worse from the medication wrongly prescribed."

I have been involved in politics for over 30 years and have never seen the American people so angry. It’s not unusual to sense a modest amount of outrage, but it seems the anger today is unusually intense and quite possibly worse than ever. It’s not easily explained, but I have some thoughts on this matter. Generally, anger and frustration among people are related to economic conditions; bread and butter issues. Yet today, according to government statistics, things are going well. We have low unemployment, low inflation, more homeowners than ever before, and abundant leisure with abundant luxuries. Even the poor have cell phones, televisions, and computers. Public school is free, and anyone can get free medical care at any emergency room in the country. Almost all taxes are paid by the top 50% of income earners. The lower 50% pay essentially no income taxes, yet general dissatisfaction and anger are commonplace. The old slogan “It’s the economy, stupid,” just doesn’t seem to explain things

Some say it’s the war, yet we’ve lived with war throughout the 20^th century. The bigger they were the more we pulled together. And the current war, by comparison, has fewer American casualties than the rest. So it can’t just be the war itself.

People complain about corruption, but what’s new about government corruption? In the 19^th century we had railroad scandals; in the 20^th century we endured the Teapot Dome scandal, Watergate, Koreagate, and many others without too much anger and resentment. Yet today it seems anger is pervasive and worse than we’ve experienced in the past.

Could it be that war, vague yet persistent economic uncertainty, corruption, and the immigration problem all contribute to the anger we feel in America? Perhaps, but it’s almost as though people aren’t exactly sure why they are so uneasy. They only know that they’ve had it and aren’t going to put up with it anymore. . .

We all know that ideas do have consequences. Bad ideas, even when supported naively by the people, will have bad results. Could it be the people sense, in a profound way, that the policies of recent decades are unworkable-- and thus they have instinctively lost confidence in their government leaders? This certainly happened in the final years of the Soviet system. Though not fully understood, this sense of frustration may well be the source of anger we hear expressed on a daily basis by so many.

No matter how noble the motivations of political leaders are, when they achieve positions of power the power itself inevitably becomes their driving force. Government officials too often yield to the temptations and corrupting influences of power.

But there are many others who are not bashful about using government power to do “good.” They truly believe they can make the economy fair through a redistributive tax and spending system; make the people moral by regulating personal behavior and choices; and remake the world in our image using armies. They argue that the use of force to achieve good is legitimate and proper for government-- always speaking of the noble goals while ignoring the inevitable failures and evils caused by coercion.

Not only do they justify government force, they believe they have a moral obligation to do so.

Once we concede government has this “legitimate” function and can be manipulated by a majority vote, the various special interests move in quickly. They gain control to direct government largesse for their own benefit. Too often it is corporate interests who learn how to manipulate every contract, regulation and tax policy. Likewise, promoters of the “progressive” agenda, always hostile to property rights, compete for government power through safety, health, and environmental initiatives. Both groups resort to using government power-- and abuse this power-- in an effort to serve their narrow interests. In the meantime, constitutional limits on power and its mandate to protect liberty are totally forgotten.

Since the use of power to achieve political ends is accepted, pervasive, and ever expanding, popular support for various programs is achieved by creating fear. Sometimes the fear is concocted out of thin air, but usually it’s created by wildly exaggerating a problem or incident that does not warrant the proposed government “solution.” Often government caused the problem in the first place. The irony, of course, is that government action rarely solves any problem, but rather worsens existing problems or creates altogether new ones.

Fear is generated to garner popular support for the proposed government action, even when some liberty has to be sacrificed. This leads to a society that is systemically driven toward fear-- fear that gives the monstrous government more and more authority and control over our lives and property.

Fear is constantly generated by politicians to rally the support of the people.

Environmentalists go back and forth, from warning about a coming ice age to arguing the grave dangers of global warming.

It is said that without an economic safety net-- for everyone, from cradle to grave-- people would starve and many would become homeless.

It is said that without government health care, the poor would not receive treatment. Medical care would be available only to the rich.

Without government insuring pensions, all private pensions would be threatened.

Without federal assistance, there would be no funds for public education, and the quality of our public schools would diminish-- ignoring recent history to the contrary.

It is argued that without government surveillance of every American, even without search warrants, security cannot be achieved. The sacrifice of some liberty is required for security of our citizens, they claim.

We are constantly told that the next terrorist attack could come at any moment. Rather than questioning why we might be attacked, this atmosphere of fear instead prompts giving up liberty and privacy. 9/11 has been conveniently used to generate the fear necessary to expand both our foreign intervention and domestic surveillance.

Fear of nuclear power is used to assure shortages and highly expensive energy.

In all instances where fear is generated and used to expand government control, it’s safe to say the problems behind the fears were not caused by the free market economy, or too much privacy, or excessive liberty.

It’s easy to generate fear, fear that too often becomes excessive, unrealistic, and difficult to curb. This is important: It leads to even more demands for government action than the perpetrators of the fear actually anticipated.

Once people look to government to alleviate their fears and make them safe, expectations exceed reality. FEMA originally had a small role, but its current mission is to centrally manage every natural disaster that befalls us.  This mission was exposed as a fraud during last year’s hurricanes; incompetence and corruption are now FEMA’s legacy. This generates anger among those who have to pay the bills, and among those who didn’t receive the handouts promised to them quickly enough.

Generating exaggerated fear to justify and promote attacks on private property is commonplace. It serves to inflame resentment between the producers in society and the so-called victims, whose demands grow exponentially.

The economic impossibility of this system guarantees that the harder government tries to satisfy the unlimited demands, the worse the problems become. We won’t be able to pay the bills forever, and eventually our ability to borrow and print new money must end. This dependency on government will guarantee anger when the money runs out. Today we’re still able to borrow and inflate, but budgets are getting tighter and people sense serious problems lurking in the future. This fear is legitimate. No easy solution to our fiscal problems is readily apparent, and this ignites anger and apprehension.

Disenchantment is directed at the politicians and their false promises, made in order to secure reelection and exert power that so many of them enjoy. . .

Remember, the original American patriots challenged the abuses of King George, and wrote and carried out the Declaration of Independence.

Yes Mr. Speaker, there is a lot of anger in this country. Much of it is justified; some of it is totally unnecessary and misdirected. The only thing that can lessen this anger is an informed public, a better understanding of economic principles, a rejection of foreign intervention, and a strict adherence to the constitutional rule of law. This will be difficult to achieve, but it’s not impossible and well worth the effort.

To read a reprint of Dr Paul’s speech, please go to www.quebecoislibre.org/06/060806-4.htm.

To read the official transcript from the U.S. House of Representatives, please go to www.house.gov/paul/congrec/congrec2006/cr062906.htm.

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3. International Medicine: Poppycock, By DR THEODORE DALRYMPLE, The Wall Street Journal, May 25, 2006

In 1822, Thomas De Quincey published a short book, "The Confessions of an English Opium Eater." The nature of addiction to opiates has been misunderstood ever since.

De Quincey took opiates in the form of laudanum, which was tincture of opium in alcohol. He claimed that special philosophical insights and emotional states were available to opium-eaters, as they were then called, that were not available to abstainers; but he also claimed that the effort to stop taking opium involved a titanic struggle of almost superhuman misery. Thus, those who wanted to know the heights had also to plumb the depths.

This romantic nonsense has been accepted wholesale by doctors and litterateurs for nearly two centuries. It has given rise to an orthodoxy about opiate addiction, including heroin addiction, that the general public likewise takes for granted: To wit, a person takes a little of a drug, and is hooked; the drug renders him incapable of work, but since withdrawal from the drug is such a terrible experience, and since the drug is expensive, the addict is virtually forced into criminal activity to fund his habit. He cannot abandon the habit except under medical supervision, often by means of a substitute drug.

In each and every particular, this picture is not only mistaken, but obviously mistaken. It actually takes some considerable effort to addict oneself to opiates: The average heroin addict has been taking it for a year before he develops an addiction. Like many people who are able to take opiates intermittently, De Quincey took opium every week for several years before becoming habituated to it. William Burroughs, who lied about many things, admitted truthfully that you may take heroin many times, and for quite a long period, before becoming addicted.

Heroin doesn't hook people; rather, people hook heroin. . . . I have witnessed thousands of addicts withdraw; and, notwithstanding the histrionic displays of suffering, provoked by the presence of someone in a position to prescribe substitute opiates, and which cease when that person is no longer present, I have never had any reason to fear for their safety from the effects of withdrawal. It is well known that addicts present themselves differently according to whether they are speaking to doctors or fellow addicts. In front of doctors, they will emphasize their suffering; but among themselves, they will talk about where to get the best and cheapest heroin.

When, unbeknown to them, I have observed addicts before they entered my office, they were cheerful; in my office, they doubled up in pain and claimed never to have experienced suffering like it, threatening suicide unless I gave them what they wanted. When refused, they often turned abusive, but a few laughed and confessed that it had been worth a try. Somehow, doctors -- most of whom have had similar experiences -- never draw the appropriate conclusion from all of this. Insofar as there is a causative relation between criminality and opiate addiction, it is more likely that a criminal tendency causes addiction than that addiction causes criminality.

Furthermore, I discovered in the prison in which I worked that 67% of heroin addicts had been imprisoned before they ever took heroin. Since only one in 20 crimes in Britain leads to a conviction, and since most first-time prisoners have been convicted 10 times before they are ever imprisoned, it is safe to assume that most heroin addicts were confirmed and habitual criminals before they ever took heroin. In other words, whatever caused them to commit crimes in all probability caused them also to take heroin: perhaps an adversarial stance to the world caused by the emotional, spiritual, cultural and intellectual vacuity of their lives.

It is not true either that addicts cannot give up without the help of an apparatus of medical and paramedical care. Thousands of American servicemen returning from Vietnam, where they had addicted themselves to heroin, gave up on their return home without any assistance whatsoever. And in China, millions of Chinese addicts gave up with only minimal help: Mao Tse-Tung's credible offer to shoot them if they did not. There is thus no question that Mao was the greatest drug-addiction therapist in history.

Substitution of one drug for another is at best equivocal as a means of treating drug addicts. No doubt if you gave every burglar $10 million, each would burgle far less in the future; but this treatment of the disease of burglary would scarcely discourage burglary as a social, or rather antisocial, phenomenon. And the fact that there would be a dose-response relationship between the amount of money given to burglars and the number of burglaries they subsequently committed does not establish burglary as a real disease or money as a real treatment for it.

Why has the orthodox view swept all before it? First, the literary tradition sustains it: Works that deal with the subject continue to disregard pharmacological reality, from De Quincey and Coleridge through Baudelaire, Aleister Crowley, Bulgakov, Cocteau, Nelson Algren, Burroughs and others. Second, addicts and therapists have a vested interest in the orthodox view. Addicts want to place the responsibility for their plight elsewhere, and the orthodox view is the very raison d'être of the therapists. Finally, as a society, we are always on the lookout for a category of victims upon whom to expend our virtuous, which is to say conspicuous, compassion. Contrary to the orthodoxy, drug addiction is a matter of morals, which is why threats such as Mao's, and experiences such as religious conversion, are so often effective in "curing" addicts.

Mr. Dalrymple is the author of "Romancing Opiates" (Encounter, 2006).

To read Dr Dalrymple’s entire Op-Ed article (subscription required), please go to http://online.wsj.com/article_print/SB114852365443262675.html.

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4. Medicare: Medicare’s Hidden Administrative Costs: A Comparison of Medicare and the Private Sector By Merrill Matthews, Ph.D. (Based in Part on a Technical Paper by Mark Litow of Milliman, Inc.) January 10, 2006

Executive Summary

One of the most common, and least challenged, assertions in the debate over U.S. health care policy is that Medicare administrative costs are about 2 percent of claims costs, while private insurance companies’ administrative costs are in the 20 to 25 percent range.

It is very difficult to do a real apples-to-apples comparison of Medicare’s true costs with those of the insurance industry. The primary problem is that private sector insurers must track and divulge their administrative costs, while most of Medicare’s administrative costs are hidden or completely ignored by the complex and bureaucratic reporting and tracking systems used by the government. This study, based in part on a technical paper by Mark Litow of Milliman, Inc., finds that Medicare’s actual administrative costs are 5.2 percent, when the hidden costs are included.

In addition, the technical paper shows that average private sector administrative costs, about 8.9 percent – and 16.7 percent when commission, premium tax, and profit are included – are significantly lower than the numbers frequently cited. But even though the private sector’s administrative costs are higher than Medicare’s, that isn’t “wasted money” that could go to insuring the uninsured. In fact, consumers receive significant value for those additional dollars.

We also raise an important, although heretofore unrecognized, issue that gives Medicare an inherent advantage on administrative costs. Because of the higher cost per beneficiary, Medicare administrative costs appear lower than they really are. If the numbers were adequately “handicapped” for comparison with the private sector, they would be in the 6 to 8 percent range.

Finally, like the private sector, Medicare also has to obtain funds to pay claims. But the cost of raising that money, or borrowing it if the government doesn’t collect it from taxpayers, is excluded from Medicare administrative cost calculations. While we don’t in this paper draw any conclusions about what we shall call the “cost of capital” and its impact on Medicare’s administrative costs, we do want to highlight that those costs exist and that taxpayers, both today and in the future, must bear those costs.

To read the entire report, please go to www.cahi.org/cahi_contents/resources/pdf/CAHI_Medicare_Admin_Final_Publication.pdf.

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5. Lean HealthCare: Do We Need More Heroic Leaders or More Farmers?

[Jim Womack, CEO of Lean Enterprise Institute, recently sent the following email; Administrative Physicians, Nurses and Healthcare Leaders should take note. Do we want to be Toyota or Ford?]

I recently met with the chief executive of a very large American corporation organized by business units, each self-contained with its own product development, production, purchasing and sales functions. I asked what a CEO does in this situation and got a simple answer: “I search for heroic leaders to galvanize my business units. I give them metrics to meet quickly. When they meet them, they are richly rewarded. When they don't, I find new leaders.”

I noted that his firm, like many others I've examined, has a high level of turnover in its business unit heads. So I asked a simple question: “Why does your company need so many heroes? Why don't your businesses consistently perform at a high level so that no new leaders are needed? And why do even your apparently successful leaders keep moving on?"

The answer was that business is tough, leadership is the critical scarce resource, and that a lot of turnover indicates a dynamic management culture. But I couldn't agree. As I look at this and many other businesses I encounter on my walks, I usually see three problems apparently unnoticed by the heroic leader at the top rolling out the latest revitalization program.

These are confusion about the business purpose of the organization's core processes, poorly performing product development, production, supplier management and sales processes that tend to get worse instead of better, and dispirited people operating these broken processes at every level of the enterprise. Needless to say, there are also mini-heroes at every level devising workarounds for the defective processes.

What's needed instead? More farmers!

Let me explain by means of a second example. Recently I received a copy of the leading motor industry magazine with its annual listing of the fifty most influential (read “heroic”) leaders in the global motor industry. Bill Ford at Ford. Carlos Ghosn at Renault/Nissan. Rick Wagoner at GM. Etc.

What I found striking was that the list contained no “leaders” from Toyota, except for one American in a U.S. marketing job. Yet Toyota is the world's most successful car company. How could the most successful company have practically no heroes? Because its managers still think like the farmers around its headquarters in the remote Aichi region of Japan where the company was created.

The job of the hero is to tackle a situation in which everything is out of control and quickly impose some semblance of order. And sometimes heroes are necessary. Taiichi Ohno, Shotaro Kamiya, Kenya Nakamura, and Kiichiro Toyoda certainly took heroic actions at Toyota at moments of crisis as the company's core processes were being defined after World War II.

But heroes shouldn't be necessary once an organization is transformed. Instead every important process should be steadily tended by a “farmer” (who we often call a value-stream manager) who continually asks three simple questions: Is the business purpose of the process correctly defined? Is action being steadily taken to create value, flow, and pull in every step of the process while taking out waste? Are all of the people touching the process actively engaged in making it better? This is the gemba mentality of the farmer who year after year plows a straight furrow, mends the fence, and obsesses about the weather, even as the heroic pioneer or hunter who originally cleared the land moves on.

Why do we have so many heroes, so few farmers, and such poor results in most of our businesses? Because we're blind to the simple fact that business heroes usually fail to transform businesses. They create short-term improvement, at least on the official metrics, but it either isn't real or it can't be sustained because no farmers are put in place to tend the fields. Wisely, they move on before this becomes apparent. Meanwhile, we are equally blind to the critical contribution of the farmers who should be our heroes. These are the folks who provide the steady-paced continuity at the core of every lean enterprise.

I hope that as you think about your job you will become a lean farmer who takes responsibility for the processes you touch and that you will work every day to plow the straight furrow, mend the fence, and obsess about the weather. These are the real value-creating aspects of management. When present they insure that no heroes will be needed in the future.

Best regards, Jim Womack, Chairman and CEO, Lean Enterprise Institute (LEI), www.lean.org/.

[Shall we call these farmers physicians? Kaiser Permanente has become the worlds most successful integrative health care system. That’s because Kaiser Health Plan and Kaiser Foundation Hospitals do not control the physician in the trenches of medical units spread all over the countryside. Permanente physicians practice as each physician deems it’s best and never has to request a prior authorization or a treatment authorization request from either the health plan or the hospital foundation. When the Permanente Physician-in-Chief visited every physician unit and asked whether they wanted to continue to be the cheapest and garner all the state contracts or be the best, the physicians (farmers in the field) voted unanimously they wanted to be the best. Sounds like the Toyota story all over again.]

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6. Medical Myths: To Test or Not to Test? From The Placebo Journal by Doug Farrago, MD

In our current health care system, doctors ordered $200 million unnecessary laboratory tests or procedures from 1997 to 2002.  The June issue of the American Journal of Preventive Health did a study showing that doctors ordered such things as useless urine and blood tests, EKGs and x-rays all of which weren’t evidence-based.  They used the U.S. Preventive Services Task Force as the gold standard.  A lot of these tests led to false positive results which led to more tests and on and on.  Some of the reasons doctors do this is:

• Defensive medicine
• Habit
• Not embracing evidence-based medicine
• Patient demands

All this sounds bad for the doctor. In defense of them is the fact that every organization has their own recommendations that may or may not jive with the USPSTF guidelines. Also, there are lots of patients who are cyberchondriacs who come in with a pile of paperwork making their case for a test.  Personally, I have been in that position a ton of times. It is tough to say no especially if they are forceful or convincing. The article quoted one physician who said, “I have not heard of a lawsuit because of overtesting”.  That line says a lot.

Read the Placebo Journal to Keep your Finger on the Prostate of Medicine. www.placebojournal.com/shopexd.asp?id=165

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7. Overheard on Capital Hill: To Kill an American

You probably missed it in the rush of news last week, but there was actually a report that someone in Pakistan had published in a newspaper an offer of a reward to anyone who killed an American, any American. So an Australian dentist wrote an editorial the following day to let everyone know what an American is. So they would know when they found one. (Good one, mate!!!!)

"An American is English, or French, or Italian, Irish, German, Spanish, Polish, Russian or Greek. An American may also be Canadian, Mexican, African, Indian, Chinese, Japanese, Korean, Australian, Iranian, Asian, or Arab, or Pakistani or Afghan.

An American may also be a Comanche, Cherokee, Osage, Blackfoot, Navaho, Apache, Seminole or one of the many other tribes known as native Americans.

An American is Christian, or he could be Jewish, or Buddhist, or Muslim.
In fact, there are more Muslims in America than in Afghanistan. The only difference is that in America they are free to worship as each of them chooses.

An American is also free to believe in no religion. For that he will answer only to God, not to the government, or to armed thugs claiming to speak for the government and for God.

An American lives in the most prosperous land in the history of the world.
The root of that prosperity can be found in the Declaration of Independence, which recognizes the God given right of each person to the pursuit of happiness.

An American is generous. Americans have helped out just about every other nation in the world in their time of need, never asking a thing in return.

When Afghanistan was over-run by the Soviet army 20 years ago, Americans came with arms and supplies to enable the people to win back their country!

As of the morning of September 11, Americans had given more than any other nation to the poor in Afghanistan. Americans welcome the best of everything...the best products, the best books, the best music, the best food, the best services. But they also welcome the least.

The national symbol of America, The Statue of Liberty, welcomes your tired and your poor, the wretched refuse of your teeming shores, the homeless, tempest tossed. These in fact are the people who built America.

Some of them were working in the Twin Towers the morning of September 11, 2001 earning a better life for their families. It's been told that the World Trade Center victims were from at least 30 different countries, cultures, and first languages, i