CDC Can Do More on Swine Flu

Looking up the CDC website on swine flu guidance reminded me of an old joke about a balloonist who was swept away by the winds and got lost.

He lowered himself next to a tall office building. He wrote "Where Am I?" on a placard and held it up for the people inside the building windows to see. Those people responded with their own placard that said "You Are in a Balloon 100 Feet Up in the Air." That answer was however enough for the balloonist to know that he was at the Microsoft headquarters in the Seattle suburb of Redmond. For going by its help feature in its products only Microsoft could provide an answer that was completely correct and yet so irrelevant and useless.

How's this related to swine flu? About two weeks ago I briefly came down with the sniffles and a mild fever that lasted less than a day. Then over this Labor Day weekend we drove to Pittsburgh where Anita's nephew had similar symptoms. We isolated the affected person (me and our nephew) and considered the obvious question of whether to seek testing, and if yes, where.

Testing would help the authorities to compile statistics and monitor the spread of the disease. Patients testing positive would know what to watch out for and be extra careful about exposing others. Recovered patients presumably acquire immunity, and needn't worry about subsequent exposure, or getting inoculated when the swine flu vaccine becomes available.

On the other hand, patients arriving in large numbers in medical facilities could put providers and other patients at risk, and strain scarce resources. Also, uninfected patients can acquire the H1N1 virus from others in the very clinic that they visit.

Weighing these pros and cons we looked at the CDC and other official websites for guidance. Despite all the other information crammed in there, we found nothing addressing these obvious questions. Countless other patients and American families may be similarly confused and frustrated.

The closest answer I got after clicking through links and menus was an indirect one, under "Home Care Guidance: Physician Directions to Patient / Parent." It said that you should see a doctor or seek medical help if you develop certain serious symptoms, presumably meaning that you shouldn't if these don't occur. It needs to be a lot more explicit and easy to find.

The new health care and CDC leadership under the Obama administration has been in place for quite some time, with Director Thomas Friedan confirmed in May 2009. They should have personally scrutinized their agency's website and confirmed there are no glaring omissions. They don't seem to have adequately done so, but this is fixable. Having worked in government these are the obvious added steps I would take in regard to swine flu were I directing CDC or the HHS in regard to the flu:

1) Prominently feature in the Frequently Questions (FAQs) and other parts of their website, as well as in briefs to the media

• Advice to persons with typical symptoms and parents on whether and when to get tested for swine flu, and when not to
• Similar advice on when to seek medical help or visit a doctor, and when to hold off out of concerns of spreading or contracting infection
• Some information about the cost of testing, the best places to go to (doctor's office, clinic or hospital emergency room?) and the reliability of the tests. Add more "layman" information about the benefits - and the downside or risks - of anti-viral treatments like Tamiflu and Relenza.

2) Have an interactive feature on the website where users can enter their address or zip code. They then get a listing with addresses and contact information of nearby medical facilities that have special swine flu treatment arrangements and / or accept patient samples for testing. To keep pricing transparent and competitive, such facilities should disclose their prices for standard testing and treatment, and this information should also be displayed. If an interactive feature is beyond CDC's scope they can at least provide links to state and local government resources that provide this information. It will specially help the uninsured, and many insured patients as well.

3) Engage and coordinate efforts with large providers and test labs to expand capabilities to handle swine flu patients. The CDC can also issue standard guidelines and practices (e.g., separate windows and rapid turnover waiting areas for flu patients in emergency rooms with proper signage, to limit cross-infections) that help providers and patients alike. The CDC can even use its power to disseminate information to have "suggested prices" for testing and treatment. Coupled with inviting providers to include their prices in the links on the CDC website as at (2) above, this will encourage lower prices.

4) Orchestrate a system to enable healthy family members to get sterile vials or containers from labs, collect patients' samples like nasal swabs, and submit these for testing. This way patients being tested get to stay at home and again limits inconvenience and the spread of infection.

5) Encourage or help set up a system of home visits to patients by health workers. Such workers should have either already contracted and recovered from H1N1 infections, or have been vaccinated after this treatment becomes available, so that they are immune.

Similar steps can be taken to disseminate detailed information about the swine flu vaccine which is expected to be widely available very soon. The CDC and the HHS are large organization with multiple responsibilities. So ideas like these may not have been considered. I hope they are responsive once they see them. Since H1N1 flu has now spread worldwide, other countries can also adopt similar practices.

Another Red Herring

This cover story in the current Atlantic "How American Health Care Killed My Father" by David Goldhill has attracted a lot of attention. David Brooks in the NY Times in a September 2 column even calls it "brilliant." But I find its conclusions about required steps to be misleading and adding to the confusion about health care reforms.

It has some nuggets of insight. Like health insurance is currently not just insuring against unforeseen events as other kinds typically do, but generally paying for almost all care however routine or minor. Or that patients don't concern themselves with expenses or limit needless treatment, when someone else (the insurer) is picking up the tab. Or that hospitals restrict competition by lobbying against new entrants and through consolidation, and deliberately overprice emergency room care to inflate their charitable services component. Or that for hospitals and providers, the real customer is not the patient - it's the payer of their bills.

Goldhill summarizes at one point: "A wasteful insurance system; distorted incentives; a bias toward treatment; moral hazard; hidden costs and a lack of transparency; curbed competition; service to the wrong customer. These are the problems at the foundation of our health-care system, resulting in a slow rot and requiring more and more money just to keep the system from collapsing. "

Goldhill then suggests starting completely afresh, taking a lot more time to think and plan, and "to move away from comprehensive health insurance as the single model for financing care. And a guiding principle of any reform should be to put the consumer, not the insurer or the government, at the center of the system." His outlined solution is to essentially tweak the marginally successful system of individual consumer health savings accounts (HSA) coupled with catastrophic insurance that has been in place since 2005.

Even some smart and logical people seem to have been swayed by Goodhill's logic. Here for example is the reaction of Hari, a seasoned Silicon Valley engineer:

"Despite some flaws in the solution the author proposes, I actually agree with his description of the fundamental problem of why medical costs are so high, medical care is not commensurate with cost and all solutions from insurance to government will eventually lead to cost overruns. I actually think that a combination of private HSA savings account, catastrophic-only insurance and government maintenance of Medicaid is the way to go..."

Why is this HSA approach so deficient? Jonathan Starr, also an engineer and a single payer advocate, gave this apt response to Hari that captures a lot of my thinking as well:
"The author identifies some important concerns regarding cost-control, good-practice, and accountability. But, I do not agree with the solutions he offered, such as the ones you mention.

Regarding reliance on HSA accounts as a major part of paying for health care:
1) Assuming these are tax-deductible accounts, they are inherently regressive. The higher a person's income, the more that person can afford to put into such a tax-sheltered account. The higher the person's marginal tax-bracket, the larger the tax-deduction that person receives for any amount put into that account.
2) For most people, it is impossible to predict future medical needs, and how much they will cost, so it is impossible to determine how much any particular person should put into an HSA account.
3) Insurance, single-payer or otherwise, pools risk to make coverage available when some members of the pool need it. By pooling the financial resources of a large group, most of whom at any one time are healthy enough not to need to draw significantly on those resources, those who do need to draw heavily on the pooled resources are able to do so. With HSA accounts, there is no pooling of risk. Resources are distributed in as fragmented a manner as possible. So, financial resources in most accounts may sit around unused, while those people who need health care service exhaust their own little financial pool quickly. Pooling of risk through some type of insurance is a great innovation with enormous public benefit, all of which relying on HSA accounts forgoes.
4) Individual customers, with just their own HSA accounts, have little leverage, or expertise, for negotiating for favorable prices and rates for pharmaceuticals, medical equipment, and health care. Large aggregations of resources, such as in insurance plans (again, single-payer or otherwise), can have far greater expertise and leverage in negotiating and pressuring for such cost-reductions.
5) Fragmenting the customer pool reduces the capacity for aggregating information about health care outcomes and for advocating and enforcing best-practices.

In short, there is great power in numbers for controlling costs through bulk-purchasing and negotiation, and for gathering, evaluating, and distributing information and requirements about best-practices to control costs and improve outcomes. This is increased with large insurance programs, and maximized with a single-payer program; in contrast, it is minimized through reliance on individual HSA accounts, which maximize the fragmentation of the pool of end-users.

Also, the low-hanging fruit reducing health care costs is in reducing administrative overhead. Hospitals and other care-providers must pay large costs to handle the billing of innumerable insurance policies. If instead, they have to bill an exponentially larger number of individual people and HSA plans, that makes this administrative overhead even higher. Furthermore, care-providers must build into their price-structure higher fees to those who do pay in order to cover those who do not. If every person is being billed individually, the number who ultimately do not pay undoubtedly will increase. This not only increases the costs for collection, it also inevitably raises the fees that must be paid by those who do pay.

In a single-payer system, the need for such billing overhead is drastically reduced. There is a single program to deal with, instead of innumerable policies, or even more innumerable individuals. Furthermore, payment by single-payer systems are reliable, so that fees do not need to be padded to cover those who do not pay. In practice, one of the reasons doctors and other care-providers have been willing to accept the lower-than-market-rate fees paid by Medicare is precisely this reliability of payment.

If the HSA-based system still includes reliance on, or even just availability of, private insurance, then not only is there the administrative overhead that must be built into healthcare costs, there is also the profit, marketing, billing, lobbying, and administrative costs of the insurance companies themselves. This is more money that is paid nominally for healthcare, but actually goes to something else, which adds to the cost of the system.

Also, providing insurance, or even just administering HSA accounts, is a competitive burden on American companies. With a single-payer system, this burden is relieved; with everyone having HSA accounts, it instead could be increased."

President Obama is (finally) set to exercise leadership and press his own specific proposals for health care reforms for Congress to pass, rather than passively let a bill bubble out for him to sign. That's the good news. But he has already failed to strongly speak out for a strong public option (if not an outright single payer system) so that public support has eroded due to the propaganda and misinformation by reform opponents. There are signs that he's willing to drop insistence on this option that is vital to cost containment. If that happens it may be a big indicator not only of his success on health reforms, but of his vision and overall ability to lead.

Easily Conned?

Last Friday I traded in our ancient minivan to buy a new SUV under the highly popular "Cash for Clunkers" program.

As I was signing the final papers, the manager at the GM dealership lamented the bureaucratic wringer and technical glitches that have plagued the program. The government website (for uploading claims) would remain unavailable or keep crashing. Paperwork was tedious and claims were rejected for trivial reasons. Four weeks after filing the first claims the dealership had yet to receive any money.

"The government messes up everything, and now it's trying to take over our health care," said the auto manager. I asked him what he thought of the public option, and he said he is dead set against it.

That stopped me short. Here was someone who was (a) not a health provider or insurer, (b) not a $250K+ earner who would see taxes hiked up, and (c) not a lawmaker (Republican or Blue Dog Democrat) bribed by the industry to safeguard its interests. Moreover, he is in the business of selling new and used cars. That's someone who should be savvy enough to tell facts from fiction.

Yet even he swallowed the industry claims and counter-arguments against reform. He objected to the public option because his employer may then drop his private insurance (why should it matter if the public plan is better, or he can still see the same doctors?) When asked about the popular Medicare for seniors, and why not offer it to all Americans, he said Medicare will be out of funds (if it's cheaper, the funding is just a matter of allocating enough to it.)

This underscores just how easy it can be for reform opponents to confuse (or sucker) the average Joe about changes to the system. The Obama administration certainly hasn't helped with its mixed and conflicting messages on its commitment to the public option.

It doesn't have to be this way. Here's a link I received from Jonathan Starr of an MSNBC "Morning Joe" discussion between Republican host Joe Scarborough and Congressman Anthony Weiner (D - NY). Weiner advocates a single payer system and his logic for it even gets Scarborough (to his credit) thinking hard and admitting he's impressed "and speechless." Why isn't Mr. Obama making this case?

Paul Krugman has criticized Obama in today's Op-Ed in The Times. He also repeats that "Reaganomics has failed to deliver what it promised, yet people still believe that government intervention is bad, and leaving the private sector to its own devices is good."

A remarkable national survey result also shows that a majority of Americans believe most of the 19 myths floated by reform opponents.

Republicans also have some (a few, I wish they had more) good ideas on health reforms that are being ignored by Democrats. Chief among these is the need for malpractice reforms. It may bring down some health care costs, or at least remove one major reason (or excuse) advanced by providers for high costs.

Then there are reforms that neither party stresses, like vastly expanding the supply of doctors and other providers, and curbing hospital market power. A reason reforms are so difficult is that each interest group has powerful leverage and lawmakers protecting them. Strong public demand can pressure the politicians to do the right thing. For this to happen President Obama needs to stop being so passive and overlearning from the Clintons' 1993 experience. He should instead imagine how Hillary would act now if she were in his place.

And Americans like my auto dealer need to better judge industry claims.

Sell-Out By Obama?

In the past day or so I've been struck by three news items about health reforms.

First, former DNC Chairman Howard Dean flatly stated in a TV interview that health reforms without a public option were not worth having.

Second, the New York Times today carried an Op-Ed by President Obama himself on the need for health reforms. He seemed to want everyone on board with it, touting support by provider groups including the AMA. But that may just be the problem.

Third, as also reported in the NYT the White House in its anxiety to pass any type of health reform package seems ready to compromise by dropping the call for a public insurance option. “The public option, whether we have it or we don’t have it, is not the entirety of health care reform” Mr. Obama said. “This is just one sliver of it, one aspect of it.”

Actually, the public option is a huge deal, given that the government buying clout is needed to counter the market power of providers controlling scarce resources or facing little competition. Without it the cost-containment component of health reforms suffers a severe setback even if we manage to expand coverage of the uninsured. Howard Dean realizes this, as does Paul Krugman who reiterated this view in his Op-Ed today in the NYT.

President Obama could have used his speeches and town hall meetings to expose the special interests and their misinformation about the public plan. This could also have deterred Democratic senators like Ben Nelson and Kent Conrad who have apparently been bought over by industry interests. Instead, Mr. Obama seems anxious to pass a reform plan that placates the opposition, even if it is weak and ineffective at reining in costs, and then calling this a victory for his administration (and of course "the American people.") Let's hope I'm wrong.

Don't Confuse Corruption With Centrism

In his July 27 column in the New York Times, Paul Krugman exposes the flawed objections of the Blue Dog or so-called centrist Democrat lawmakers to crucial aspects of proposed health care reforms. Krugman says he's not cynical enough to believe these Democratic holdouts are simply acting to protect special interests who buy them off. But it's hard to see it any other way.

After all, Blue Dogs tout fiscal responsibility and their objections to health reforms are supposedly about how to pay for it and to contain costs. Yet they are the ones also (a) seeking higher payments for selected providers, (b) opposing the public option that is the most effective way of lowering the prices charged by providers benefiting from engineered scarcities or non-competitive practices, and (c) opposing employer mandates that prevent shifting a greater burden on to public funds.

I'd have understood and even welcomed these "centrists" seeking additional cost containment measures. These could include more vigorous support for comparative effectiveness and treatment cost effectiveness studies and criteria, and direct negotiation of drug prices by the government for publicly funded plans. Another of importance is malpractice caps and tort reform that is opposed by liberal Democrats who are beholden to their own lawyer lobbies. Incidentally, Paul Krugman is also silent about this last one, and I'd like to see him be more of an honest broker by attacking this sacred (and also very wasteful) cow on the left. But Blue Dogs by and large are conspicuously quiet on all these issues.

The Republican lawmakers are of course even more sold out to the anti-reform lobbies. They trot out meaningless slogans ("socialized medicine") and flawed logic that a reasonable audience should clearly see through. Still, a recent Gallup poll shows that such attacks gained some traction and support for health care reforms is decreasing. Krugman in his August 7 column also notes this trend - the average Joe can apparently be swayed and misled quite easily. So President Obama needs to step up his roles of countering propaganda, and exposing lawmakers seeking to water down reforms - especially Democrat "centrists" - so they're pressured to do the right thing.

The role of industry lobbies and special interests in obstructing health care reforms should also be seen in the context of a larger problem. That's our failure to have an enlightened approach to pay our lawmakers well and to adequately fund their elections with tax dollars. I've talked about this, including in a separate May 29 blog post on the misplaced outrage over the UK MPs' expenses. Campaign finance reform can also go much further with universal adoption of a clean elections system.

However compelling the logic, lawmakers are seen and portrayed as self-serving if they try to give themselves huge raises. A strong case should instead be made on their behalf by opinion leaders like Paul Krugman, Tom Friedman and respected media publications like the Wall Street Journal. Sadly, the WSJ just continues to take cheap shots as in its August 8 front page article and August 10 headlines about petty lawmaker expenses on Congressional trips.

Parsing Counter-Arguments Against Health Reform

Talk of contrasts between two articles. There is a great one in July 15's New York Times (NYT), and the other is a hack job in an Op-Ed back from July 1st in the Wall Street Journal (WSJ).

The NYT article "Why We Must Ration Health Care" by Princeton professor Peter Singer makes a thoughtful and compelling case for wisely providing AND rationing publicly funded health care. The few who can afford to pay out of pocket can be left free to buy much less restricted coverage, but a sound rationing policy for utilizing available resources will vastly benefit the general populace. This piece, along with an earlier excellent one of June 17 about how a sub-optimal de facto rationing already exists, should insulate readers from slogans by reform opponents about "rationed care."

The WSJ Op-Ed titled "Parsing the Health Reform Arguments" by George Newman offers a pointwise counter to reforms. However, he goes about it like a hack - using mostly arguments that he should know are misleading. I liken it to Johnny Cochrane defending O.J. Simpson, trying to sway a jury even though he doesn't believe his own logic, or the cause of his client.

Newman's talking points are likely to be used by anti-reformists in TV short debates and sound bytes that can influence gullible viewers. His article is long, but here are my comments on his main contentions:

• Newman dismisses the cost of health care rising 2-3 times as fast as inflation by saying health care now is so much better than that in the past. He says "That's like comparing the price of a hamburger 30 years ago to a filet mignon today and calling the difference inflation. Or the price of a 19 inch B&W TV 30 years ago with the price of a 50 inch HDTV today."

Actually the CPI compares prices irrespective of technological advances for all services and products, including items like computers or cars that have improved over time just as healthcare has. Incidentally the hamburger to filet mignon analogy is false as both products have existed over this period. As for the TVs, the color TV was invented over 60 years ago, and the cost ratio of a 19 inch B&W TV back then to a 50 inch HDTV today will be pretty much in proportion to the change in general CPI.

There is a valid argument that higher health care costs are also due to a greater quantity of health care being delivered per capita due to the rising needs of an aging populace. But that doesn't explain the egregious escalation in prices of health care (as in a day of stay in a hospital, or an hour of a doctor's time) as compared to a general increase in the CPI. The BLS CPI urban data (CPI-U) compiled by category shows that from 1982-84 to June 2009, the overall prices rose 116% while prices for professional (doctor) services rose 220% and for hospitals they rose 464%.

An international comparison of changes in health expenditures invalidates Newman's "normal health cost increase in the US" assertions in another way. The 2009 OECD health data shows that for all OECD ("developed) countries, the median health expense as a percent of GDP rose 30% from 7% in 1982-84 to 9.1% in 2007, while the increase was nearly double in the US from 10.1% to 16% of GDP over the same period.

• Newman also explains away health care representing a rising proportion of our US income as "perfectly natural" by categorizing it as a "discretionary, income-elastic expense" that forms an increasing share of a prosperous economy.

Health care is part luxury good, with an inelastic ("necessity") component. Expenses rise with with resources going into increasing longevity of the population and also because older patients need more care. But again, there is no reason for such expenses to be rising faster in the US than elsewhere, and for their absolute level to be so much higher than in peer economies. Given the political and the right reforms we can actually expect US expenses to fall for a few years as US costs are brought closer in line with the rest of the first world.

• About the problem of the 45 million uninsured, covering this 15% of the population risks destroying a system that works for the vast majority. Universal coverage will push up not only overall costs, but also health care prices as higher demand for services chases the same supply. A public payer option won't help since there is already enough competition among private insurers.

First, the current system is way too expensive, with prices twice those in Europe, so it isn't really "working." Simply extending insurance to those not covered will indeed exacerbate scarcities and tend to raise prices. That's why a public option is vital and is not just like another private plan. It concentrates buyer power that counters the pricing leverage of providers of scarce services. The savings should partly pay for covering the uninsured, though extra funds may be needed in the short term, at least till other reforms free up more resources over time.

Also on July 1 in the Washington Monthly, Steve Benen and several readers dissed Newman's contention about 1500 private plans offering enough competition.

• A taxpayer funded universal healthcare will not ease competitive burdens of US businesses that no longer have to pay high healthcare costs for their employees. That's because the employees still pay for healthcare costs through higher taxes, as funds "do not fall from the sky."

This logic is false for two reasons. First, as the European experience shows, the single payer public system is much more efficient, so the overall health cost burden is less. Second, if taxpayers rather than businesses pay employee health expenses then for the businesses their employees don't directly cost them extra healthcare dollars in that country. Of course, the current US reform proposals (sadly) do not go all the way towards a purely taxpayer funded system. Instead in a half-measure they propose (all but the smallest) employers should pay for their employees' health insurance or contribute towards a public plan.

• A public option will drive out private plans. So contrary to reformer's claims, people won't be able to keep the private insurance that they have. Congress will inevitably favor the public plan and harass private plans into extinction.

It is true that a public plan with its concentrated buyer's power has a huge advantage over fragmented private plans. Most people will want to switch to the public plan because it will be a better deal, and will lower costs. That's the whole point. And yes, private plans will shrink dramatically as a result. But they will still be around for the, say, 10% - 15% of the Americans who still want them. Why should Newman expect Congress to unjustly favor the public plan that cannot even give lawmakers anything in return? The danger is exactly the opposite. It is private funded lobbies and groups that can typically buy over or influence lawmakers with favors. In sum I expect a public plan to win out because of inherent efficiencies, and not because of tampering by Congress.

This WSJ article has some other counterclaims as well. To me they are weaker and devoid of merit, but I leave it to you to find the flaws, or enquire in "comments" if you're very interested.

The Vast Left-Wing Courtspiracy

Almost all the good ideas on health reforms so far have come from Democrats. Republican have mainly launched hack attacks against such Democratic initiatives. "Hack" here means trying to sway opinions by using any means necessary, including misleading and irrelevant arguments that even the author doesn't believe to be valid.

For example, partisan hacks use phrases like "socialised medicine" or "a bureaucrat coming between a patient and his doctor" to denounce the public insurance option. Never mind that our socialized armed services, socialized police force, socialized public school system and socialized Medicare program seem widely preferred to purely privately run alternatives. Or why should a private insurer whose payouts directly decrease profits be better at serving patients and paying doctors, compared to an automatic Medicare style system of public billing?

But the June 30 Op-Ed by law professor Richard Epstein of the University of Chicago is different. He spells out several reasons why the dysfunctional US malpractice system is much worse than that in other developed countries. This is an issue that Democrats and even their most effective spokesmen for reforms like Paul Krugman completely ignore. While malpractice payouts are less than 1% of total healthcare costs, they cause much larger damage by inducing the practice of defensive medicine.

In that sense health industry groups traditionally aligned with Republicans are more "efficient" in enriching themselves. The annual US health care tab is inflated by hundreds of millions of dollars due to overpricing, including by doctors benefiting from managed scarcities, and by hospitals and insurers facing inadequate competition. But at least this money flows more directly to the recipient interest group.

In contrast, defensive medicine and "excess" malpractice insurance costs as much as 10% of the total health bill or over $200 billion annually if we believe some studies. Yet trial lawyers get at most half of the total malpractice payout of about $6 billion annually, or under 1.5 % of the cost imposed on the system. To misquote Winston Churchill, never have so many paid so much to benefit so few. Even as they push for other changes, Democrats have no excuse to block malpractice reforms.

Epstein says the main reasons the US system (as different from others as in Europe) drives up malpractice costs are:

• Jury trials that can veer out of control and introduce significant uncertainty, coupled with a contingency fee system and each side bearing its own costs. This encourages trial lawyers to litigate excessively, as they have a good chance to win big with little downside if they lose.
• American judges frequently allow juries to decide whether honest mistakes are negligent, and to infer medical negligence from the mere occurrence of a serious injury. American plaintiffs sometimes aren't required to identify any particular acts of negligence, or showing the connection between the negligent act and the injury.
• Damage awards in the US tend to dwarf those made elsewhere.

As a result, Americans file claims about 3.5 times more often than Canadians. Yet the frequency of medical malpractice in Canada is about the same as in the US (so much for the deterrence of the costly US system) - for about a tenth of the total cost.

I agree with Epstein's recommendation to (a) replace juries with specialized commissions like those in France that reduce litigation expenses and promote uniformity in case outcomes across regions, and (b) have a national cap on damages for pain and suffering, such as those already enacted in over 30 states that are set between $250K and $500K.

Two concluding caveats to Epstein's article, though. First, not everyone agrees that malpractice coupled with defensive medicine imposes such heavy costs. A 2004 report titled "Limiting Tort Liability for Medical Malpractice" by the Congressional Budget Office uses terms like "weak", "inconclusive" and "ambiguous" to describe a lot of the evidence. Second, Epstein couldn't leave well enough alone, and took a pot shot at the vitally needed (in my opinion) public option in his concluding sentence: "Market-based solutions that make the private sector more responsive should in turn undermine the case for moving head-first into a government-run health-care system with vast, unintended inefficiencies of its own."