I’m not in that charitable a mood at present. The Germans, in their precision, have a word for this: Schadenfreude — the pleasure in the discomfort of others.
For the liberals accuse the conservatives and religious of being, stupid, ugly, and worse, breeding. But their peak time has come, if not a few years ago, then now. This warmed the cockles of by stony heart.
Not coincidentally, the delays punt implementation beyond congressional elections in November, which raises the first problem with defending Obamacare: The White House has politicized its signature policy.
The win-at-all-cost mentality helped create a culture in which a partisan-line vote was deemed sufficient for passing transcendent legislation. It spurred advisers to develop a dishonest talking point—”If you like your health plan, you’ll be able to keep your health plan.” And political expediency led Obama to repeat the line, over and over and over again, when he knew, or should have known, it was false.
Defending the ACA became painfully harder when online insurance markets were launched from a multi-million-dollar website that didn’t work, when autopsies on the administration’s actions revealed an epidemic of incompetence that began in the Oval Office and ended with no accountability.
Then officials started fudging numbers and massaging facts to promote implementation, nothing illegal or even extraordinary for this era of spin. But they did more damage to the credibility of ACA advocates.
Finally, there are the ACA rule changes—at least a dozen major adjustments, without congressional approval. J. Mark Iwry, deputy assistant Treasury secretary for health policy, said the administration has broad “authority to grant transition relief” under a section of the Internal Revenue Code that directs the Treasury secretary to “prescribe all needful rules and regulations for the enforcement” of tax obligations, according to The New York Times.
Yes, Obamacare is a tax.
Advocates for a strong executive branch, including me, have given the White House a pass on its rule-making authority, because implementing such a complicated law requires flexibility. But the law may be getting stretched to the point of breaking. Think of the ACA as a game of Jenga: Adjust one piece and the rest are affected; adjust too many and it falls.
I work in a state run health care system. The local budget for mental health in my region (400 000 people) has just been cut from 89M to 87M. We are being ordered to cut clinical services and jobs while the managers remain intact — dealing with a central planning and regulating department that demands more information, does not provide clinically useful feedback, and requires we do more with less. That holds up regions that underspend as models of care, even when they are clinically dangerous. (I speak here with some knowledge: one of the drivers that led to me moving to Dunedin was that I considered it was a matter of time before I was in front of the regulators defending my actions after a psychiatric tragedy). Anyone who thinks socialized health is not political is not only a fool but willfully ignorant: for the UK NHS has had more than its fair share of scandals, driven by managerial ambition to meet mandated goals at the cost of patient care.
News that a hospital has been tampering with patient records to improve its waiting times for cancer treatment, potentially putting patients at risk, is truly shocking.
The issue is so serious that the police has been asked to investigate Colchester General Hospital.
Such a situation is unprecedented in the NHS – and as a result the temptation is to dismiss it as a one-off that should be seen in isolation.
Unfortunately, it would be complacent to do so.
What this case demonstrates is the problem inspectors have in identifying some issues in organisations as complex as hospitals.
The Care Quality Commission did not find the dodgy records. It was told where to look.
During the spring Colchester was subject to an inspection as part of the Keogh Review into mortality rates.
The review – launched after the Stafford Hospital public inquiry – investigated the 14 trusts with the highest death rates.
Problems were identified, including with the ways complaints were handled, staffing rates and leadership weaknesses, but not this.
The concerns that were identified were not even considered important enough for Colchester to be placed in special measures.
When the results of the review were announced Colchester was one of only three trusts that escaped the sanction.
But towards the end of the Keogh process a whistleblower raised concerns about the tampering of records.
This was passed on to the CQC which carried out its own inspections in August and September.
These led to Tuesday’s report that showed different information was being entered into the hospital’s system than was on the patients’ notes so their cancer performance data looked better than it was.
What we have, at present, in many countries, are leaders who mistrust and fear the very population who elected them.
This fear leads to micromanagement: as if we can regulate and make right on paper the very messy and human business that is caring for the mad, the sick, and the damaged. Where things go wrong: where communication does not always occur smoothly, and where being in the room seeing the person, regularly, building a working relationship with them, is as important or more important than what therapies you use. Because if the patient does not at some level trust you, they will, quite sensibly, avoid taking the medicines, doing the therapy homework, or attending the clinic. One of the reasons we get better results with people who have psychosis in the Commonwealth than the USA is because clinicians get right into people’s lives and do not let them leave services (and get court orders that allow it at times), accepting that our job is to work with the unwilling much more than the willing.
But this often means the paperwork is messy. Or incomplete. Or that criteria are bent so that people get the care they need. A sensible government lets this happen — for most of the knowledge in these services is held by the clinicians and families who are directly involved in healthcare.
But untrusting governments micromanage. And that leads managers to use some of the old Soviet techniques. I’m not sure if I am spelling this word correctly, but in the Gulag the quotas were met by Tutka — the books were cooked. The output did not matter: what mattered was what was in the books. And most Russians were sensible. They did not believe the figures, for they knew everyone inflated them.
In our hubris we have thought we can make a new liberal man — change human nature — make health care without risk. By increasing regulation. And when the clinicians record (in the clinical notes) one thing, managers, desirious of promotion, face a moral hazard. For accepting that there is a risk and complications will happen erratically does not fit the plan. Instead they try to make the books good.
Denying problems.
This has consequences. People disbelieve the statistics: for they see what is happening in their lives. There is a disconnect between the official propaganda and what people see on the streets and in their families. When that point is reached even correcting the corruption will not instantly restore trust.
And that is where peak liberalism has left us: a president assuming tyrannical powers so he can undo laws and delay the very laws he expended all his political capital on. Peak liberalism has arrived: ironically at the time Thatcher predicted — just as the money is running out.
And the best thing to do is minimize one’s involvement with it. This is not an option in mental health in my nation (there is virtually no insurance for psychiatric conditions). But for my colleagues… private work is far, far more attractive, and if the remnant of goodwill is lost between the hospital and senior medical and nursing officers, then the system will fall.
