A friend forwarded a link to Markos Moulitsas HuffPo article today, and asked what I thought. I read the article, and when I stopped laughing, I responded:

He paints all conservatives with the same broad brush. He doesn’t qualify his assertions, and he makes statistical leaps which in any other context, even you would scoff at. He conjures up half truths to make a point, ignoring the rest of the truth he quotes (e.g. the conservative response to the DHS alerting law enforcement about right-wing extremism, or invoking the Park51 Mosque – not that anyone is denying them their right to build it, but exercising their right to speak out about it, much as so may liberals speak out about historical religious symbols in – or near – public places and demand – via ACLU lawsuits which are settled pretrial due to cost – that they be removed).

He invokes “violent acts” from the right, as if that is the mainstream right, likening them and their “violent humor” to the Taliban, or worse. But fails to mention acts of violence from the left – from SEIU thugs beating a conservative at a protest, to lefty Journ-o-list members calling for – and hoping for – the agonizingly painful death of those that disagree with them.

He vilifies those that based on faith would “impose their will on the broader populace.” But fails to mention the millions on the left who had faith (because no one read the bill) that Obamacare would save lives, reduce costs and reduce the deficit, and sought to impose THEIR will (based only on faith) on us all.Their faith was proven misguided, in spite of Ms. Pelosi’s assurances that we should have faith, we’ll like it when they pass it an we can see what’s in it (e.g. “Have faith”). Even now, the political left has advised their members not to “go there” with regards to costs and deficit reduction.

Finally, he fails to distinguish the Conservative leadership from conservatives. Rather, he conflates them. After all, it is not the leadership on the right that he claims “leads the nation in teen pregnancies, divorces, and gay online subscriptions.” No. It is the population of the Bible Belt, which he assumes is nothing but conservatives. I suppose he polled all of the pregnant teens in the bible belt and all of the gay subscribers, and found them to be members of the American Taliban? Or is he just making an assumption about the political bent of people in a certain geographical region? Even if those areas of the country are predominately conservative, it is a logical fallacy to assume that the distribution of pregnancies, homosexuals, and divorces is the same as the distribution of political philosophy. Then again, he had to fire the pollster he was using to collect data for this book because of faulty methodology and outright data manipulation. But to my point, he cannot claim to be describing only the leadership, and using the populace as examples. But there it is.

On another note, he is certain to sell lots of books.

As a physician, it’s hard to dismiss a repeated pattern of signs and symptoms in a multitude of people. Coincidence becomes less likely, and we may be witnessing a syndrome. It has happened before. We witnessed 8 years of unfettered rage against a President, first and foremost, for winning an election, and subsequently any reason, real or imagined, the afflicted could come up with.

One would think that 17 months after said President has been replaced, that the rage would subside, and the energy would be redirected into reforming those matters toward which the rage had previously been directed. One would think that as the rise of the oceans began to slow, and the planet began to heal, so too would those so afflicted by their unfettered rage. Well, the rage has abated to a degree, but this particular affliction may have chronic, long term consequences.

The rage has given way to a new set of signs and symptoms. Those affected seem to have lost an appreciation for the continuity of time. They have become distractible and tangential, unable to focus on matters at hand, in favor of revisiting the past. Oddly, they seem to have an uncontrollable desire to direct the attentions of others to the past as well.

In the last 68 days of the Deepwater Horizon Gulf disaster, much could have been done or said in an effort to find solutions to stop the leak, preserve the environment, and prevent further economic damage. But the afflicted seem to be unable to focus on this problem, so distracted are they by the past.

The afflicted have the uncanny ability to recognize a problem, say, unemployment or oil spill preparedness, and time warp back a few years to review the actions taken by former administrations, questioning them, blaming them, and distracting themselves and the rest of us from the more practical question: what is the current Administration/Congress going to do about it? This is almost reflexive. There is a problem today, but rather than question the current power structure’s actions of the last week, month, or 17 months, they are distracted by actions of several years ago, and carry on as if to demand those of the past to just stop it.

Never do they point out some issue, fault, or perceived cause of current events in the past, and ask, why hasn’t the administration of the last 17 months done something about this? To do so would draw attention to the current administration, raising those questions, which the afflicted apparently would rather not have answered. It might not be consistent with their delusion. They demand answers from the past, and none in the present.

Fortunately, there is a treatment for this affliction. Its effects are not immediate, and recovery is slow. If they take my advice, they just might recover. And here it is:

Don’t vote for Bush in the next election.

Why Obama’s Proposed Hiring Tax Credit is the Wrong Answer for Small Business.

The administration has recently proposed several measures to “stimulate” small business and encourage hiring. There are four components of the proposed plan: 1) a $5000 per worker tax credit for each net new hire, 2) a reimbursement of the increase in social security taxes incurred as a result of the net new hires, 3) elimination of capital gains taxes on investment in small business, and 4) additional SBA funding and loan guarantees.

As a small business owner, I can certainly appreciate the good intentions of the administration in attempting to help business succeed and grow. But, as a small business owner, I also understand the barriers to growth and new hiring, and I can see how the aforementioned proposed measures are unlikely to help.

In the current environment, there are a few reasons why a small business may be reluctant or unable to hire. First, the business may simple not have the capital or revenue stream to support an additional employee, or enough to reinvest in growth. Second, a small business who might have the capital or revenue stream may be reluctant to hire or grow because of uncertainty about the ongoing costs. Is revenue sustainable? Are there unforeseen new costs down the road that would make a new hire unsustainable? Are there foreseeable costs that appear to exceed any potential increase in revenue?

These issues boil down to one thing: uncertainty. The future for small business is more uncertain now than it has been in years. Are there new taxes coming? Will a cap-and-trade bill, or health care reform increase costs? As a physician, I ask, What will Congress do with the SGR formula this year? Will the Bush tax cuts expire, causing a new decrease in income to the business owners, that makes a new hire unaffordable?

Unfortunately, the Obama proposals do nothing to address these concerns. What they do is exacerbate them. Will a new hire, that a small business owner can now just barely afford, thanks to federal largesse, result in a sufficient increase in revenue so that the new hire is sustainable when the credit expires next year? Is the small business willing to take the risk that they will improve revenue sufficiently to avoid the cost of laying off the new hire, one year from now? What is the potential effect on the business’s unemployment rating?

Try this thought experiment: You run a small business. You would like to hire a new employee, and grow your business, but you have not been able to do so. For the sake of argument, your cost of a new hire is $40,000. Now, thanks to the Obama proposal (should it pass) you can get the same hire for about $33,000. (You get a $5000 credit and save your share of social security tax on this employee’s income.) You couldn’t afford the employee for $40K (else you would have hired them already), but perhaps you can at $33K. Will you be able to afford the employee a year from now? Will the expiration of the Bush Tax cuts make this $33K too expensive next year? Will the long term effect of laying off this employee next January offset any potential gains? What about Cap-and-Trade, health care mandates, and the SGR fix?

No – this small business is not likely to hire. (I am in this sort of position, and the 5K+ is not enough to induce me to hire). A larger “small business”, across town, that has more revenue and capital, was thinking about hiring five or six new employees already. Now, thanks to the tax credit, maybe they can afford to hire seven. The risk to this business is much less than the risk to the smaller business. But, being smart business people, they hire the six they were going to hire anyway, and apply the tax credit for the six to the bottom line. If they grow, maybe they’ll need the seventh hire next year, maybe not.

So you see, the proposed plan does very little to increase jobs. It rewards businesses that are ready to hire anyway with some additional cash. After all, even those businesses can recognize that the credit will expire next year – better to apply the credit to the bottom line.

So what, then, can be done to stimulate businesses that are not ready to hire, to hire? The administration could take actions which increase confidence among business owners that the environment they operate in today will exist tomorrow. Tax credits don’t help. Lower overall tax rates, which stimulate business even in the absence of hiring, will improve cash flow and improve the health of businesses so that they can grow and hire. Making the Bush tax cuts permanent, for example, would provide at least some certainty that there will not be a new, increased federal income tax bill next year. For medical businesses, Congress could fix, once and for all, the broken SGR formula. The administration could take a more measured approach to “reforms” such as health care and clean energy.

Otherwise, we will spend 30 billion rewarding businesses for doing what they would have done anyway, with no real net gain in jobs. Except of course the new IRS hires that will be required to administer the new credits.

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The recent negotiations between Labor and the White House have compelled me to write. It is becoming increasingly clear to me that the so-called health care reform package will have many consequences that may not have been anticipated by the President, nor by Congress.

In November, the Congressional Budget Office reported that the reform package will likely cause an increase of 10-12% increase in premiums for those with non-group coverage. Ostensibly, this increase is caused by “Guaranteed issue” (providing coverage for those who were previously “uninsurable” or those with pre-existing conditions), mandated benefits, and community rating. Now we learn that those with so-called “Cadillac” insurance plans will pay a further 40% excise tax on their premiums, which will be increasing. The recent negotiations define these plans as those costing $8,900 or more for individuals, and $24,000 or more for family coverage. While these thresholds are above the reported averages for my state and others, they are by no means uncommon. I would assert that most physicians buy such plans for themselves and their office staff. Paying a 40% excise tax on premiums that will be increasing by virtue of the passage of this bill is adding insult to injury.

Inasmuch as the increase in premiums, and therefore an increase in the excise tax will fall on physicians and physician practices, physicians have a vested interest in helping to keep the premiums down.  Physicians can certainly have little impact on the cost of mandated benefits and community rating. Physicians can, however, have an impact on the cost of providing care to those with pre-existing and chronic conditions, which heretofore may have rendered these people “uninsurable.” We can redouble our efforts, and focus our attention on those previously uninsured to encourage better outcomes, and therefore, hopefully, lower costs for their insurers, and lower premiums (and excise taxes) for those of us unable to engage in collective bargaining and be shielded (until 2016) from the tax on our health benefits.

While much attention has been focused on the uninsured, and in obtaining insurance coverage for them, there has been little or no focus on the supply side of healthcare. Primary care providers – internists, pediatricians, family practitioners – are already very busy providing care. There has been little effort on the part of government to increase the supply of primary care physicians, and any such effort would take several years time to have any impact. On the contrary, the SGR formula and the unwillingness in Congress to address this chronic pay problem for physicians once and for all, deters potential physicians from entering primary care fields, or the profession at all, for that matter. Physician incomes have declined substantially, when adjusted for inflation, and primary care incomes have been hardest hit.

Inflation adjusted physician incomes.
Source: Losing Ground. Physician Income 1995-2003. Center for Studying Health
System Change

Jeffrey P. Harris, MD, FACP, president of the American College of Physicians (ACP), has testified before the House Energy & Commerce Health Subcommittee “The United States is experiencing a primary care shortage the likes of which we have not seen.” He goes on: “The demand for primary care in the U.S. will grow exponentially as the nation’s supply of primary care dwindles.” As the population of those previously uninsured or uninsurable obtains coverage, the demand for services will increase, straining even further an already-strained system of primary care.

This is the perfect storm of increase demand, dwindling supply, unequal taxation and increases in healthcare premiums  well over 50% (If premiums increase 12%, the total increase in cost will be 56.8%) which is likely to spur physician activism. How can a physician, facing skyrocketing healthcare costs for himself, his family, and his staff, make an impact on these costs? He or she cannot join a labor union. The courts have ruled that independently employed physicians may not engage in collective bargaining. It seems to me that the physician can best improve the situation by working to improve outcomes for those who were previously uninsured or uninsurable. These are newly insured people, the overwhelming proportion of whom are not likely members of labor unions (or they would have been insured already).

Demand will far outpace supply in primary care, and physicians will be able to afford to pick and choose their patients. It is not a stretch, then, to imagine that physicians might choose to dissociate themselves from health plans whose members are exempt from paying the same taxes the physicians pay, and focus on those patients whose outcomes have a direct impact on the escalating health care costs paid for by their practices.

Draw your own conclusions.

Cross-posted to The Partisan Project.