#rube-comments input-no

[cuitpie92]

not getting notice for what i did doesn't surprise me anymore i try and go with the flow but when its complained about that i didn't do it when i obviously did bothers me disagreements when i know i did something and certain people just say i didn't 

[isaacscrawford]

MedPAC Sinks Deeper Into the MACRA Tar Pit

By KIP SULLIVAN, JD

The Medicare Payment Advisory Commission (MedPAC) has done it again. At their October 4, 2017 meeting they agreed to repeal the Merit-based Incentive Payment System (MIPS), an insanely complex and evidence-free pay-for-performance scheme within the larger program known as MACRA. Instead of examining how they made such a serious mistake in the first place (MedPAC has long supported turning fee-for-service Medicare into a giant pay-for-performance scheme), they repeated their original mistake –- they adopted yet another vague, complex, evidence-free proposal to replace MIPS.

MedPAC’s history gives us every reason to believe that when they discuss their “repeal and replace MIPS” proposal at their December 2017 and January 2018 meetings, they will refuse to discuss their “replace” proposal in any detail; they will not ask for evidence indicating their proposal is safe and effective; and in their March 2018 report to Congress they will foist upon CMS the dirty work of figuring out how to make their lead balloon fly. CMS will dutifully write up a gazillion pages of gibberish describing how the new program is supposed to work, it won’t work, MedPAC will return to the scene of the crime years later and, pretending they had no part in creating it, propose yet another evidence-free tweak. And so on.

MedPAC is caught in a trap of their own making. They endorse health policy fads without any evidence and without thinking through the details; then when the fads don’t work, rather than review their defective thought process, they endorse other iterations of the fads, again without evidence and without thinking through the details. The tweaked version of the fad fails, and MedPAC starts the cycle all over again. Two analogies for this trap or vicious cycle occur to me. One is the tar pit where mastodons got stuck and died; struggle only caused the dimwitted creatures to sink faster. The other is the hedge fund that gradually becomes a Ponzi scheme. Investors like Bernie Madoff make bad investments, and when the investments go south, instead of admitting their mistakes, they induce their investors to throw good money after bad.

In this comment I will explain why MedPAC’s MIPS-repeal-and-replace scheme deserves ridicule. In my next comment I will describe the process by which MedPAC built the MACRA tar pit or, if you like, the intellectual Ponzi scheme, that now traps them.

Excellent diagnosis

The October 4 meeting opened with a statement by MedPAC staffer David Glass about why MIPS was bound to fail. The staff’s most fundamental objection to MIPS is that it’s not possible to measure accurately the “merit” or “total performance” (to use MACRA’s goofball language) of individual doctors. They cited several reasons for this, including: Small sample size; the freedom CMS gives to doctors to select their own “quality” measures from a list of “around 300” (page 5 of the transcript of the meeting ), which guarantees apples are not being compared to apples; and the poor correlation between most of these “quality” measures and, um, quality.

Oddly, Glass’s otherwise thorough critique of MIPS failed to mention the attribution problem. In order to measure physician “value” or “merit,” one must first decide which patients “belong” to which doctor. The MACRA statute instructs CMS to follow a bizarre attribution scheme based on whether the doctor was the “lead” doctor or a “supportive” doctor, and whether the condition was acute or long-term (see my discussion of this section of MACRA here). Understandably, CMS totally ignored these instructions and adopted a slightly less bizarre method of attribution: Medicare beneficiaries are attributed to doctors based on the plurality of primary-care services provided. This plurality method guarantees that doctors are rewarded and punished for patients they never see or, in the case of patients they do see, for treatment decisions made by other doctors. The attribution problem by itself guaranteed MIPS would be difficult to administer and that MIPS scores would be useless or at best difficult to interpret.

Despite overlooking the attribution problem, MedPAC’s staff reached the right conclusion: MIPS’ grading system is useless, both to physicians and to patients. As Glass put it, “[I]t is extremely unlikely that clinicians will understand their score, or what they need to do to improve it” (p. 7). The staff noted in addition how costly MIPS is to physicians. “CMS estimates that the clinician cost to comply with MIPS in the first year of the program is over $1 billion,” reported Glass (p. 6). Glass offered no information what it costs CMS to administer MIPS.

Evidence-free cure

This would have been an ideal time for the staff and commissioners to stop, take a deep breath and ask, “How the hell did we fool ourselves into recommending a whacky pay-for-performance scheme to Congress, and why did it take us two-and-a-half years after MACRA was enacted to admit MIPS can’t work?” Or even: “How could we have done a better job of warning Congress not to pass such a useless bill?” That, of course, is not what happened. There would be no looking back to learn from history.

When Glass was done explaining why MIPS was a disaster in need of repeal, his colleague Kate Bloniarz presented two vague entities that might replace MIPS. Bloniarz and the other staff did not refer to these options as ACOs (they called them “groups”), but I will because they walk and quack like ACOs. The two options were: “Virtual” ACOs that doctors (with gobs of free time on their hands) will start up and “voluntarily” join; and geography-based ACOs that CMS will force upon all the retrograde physicians who refuse to move into “virtual” or existing Medicare ACOs (or other MACRA “alternative payment models”). The only information Bloniarz offered about these entities was that they had to be “sufficiently large to have statistically detectable performance on population-based measures” (p. 12) such as use of “low-value” services, “healthy days at home,” and the ever-popular “potentially preventable admissions” and a cost measure (“relative resource use”), all poorly adjusted for factors outside provider control. Doctors will, allegedly, be inclined to join some flavor of ACO –- virtual, geographic, or existing –- and be rewarded and punished for “performance” on “population measures” because, according to the staff’s proposal, if they don’t they will lose 2 percent of their Medicare FFS payments.

The one feature of Bloniarz’s vague proposal worth praising was the removal of the expensive MIPS reporting requirements. Bloniarz proposed that CMS calculate grades on the “population measures” using claims data only, that is, data doctors are already reporting.

If you were a commissioner and you had been exposed to Bloniarz’s annoyingly vague MIPS replacement proposal, what questions would have occurred to you? You’d want to know, among other things:

What the staff meant by “sufficiently large;”

how Medicare beneficiaries would be assigned to the new ACOs;

whether it’s possible for CMS to risk-adjust accurately the quality and cost scores and, if not, whether ACOs would avoid inviting doctors with sicker and poorer patients to join them;

whether ACOs of any stripe (existing, virtual, or geographically defined) will be available to all doctors;

whether doctors in any ACOs, but especially the “virtual” and geographically-based types, would have any way of influencing each other or knowing why their group was being punished or rewarded; and

whether ACOs anywhere are making enough money to at least offset the expenses of starting and running an ACO so that doctors would have some incentive to join.

With the exception of the attribution question, the commissioners as a group did a good job of posing every important question a rational person would think to ask. (Sloppy attribution is an obstacle to accurate measurement of physician “merit” at both the individual physician level and the ACO or group level.) But, sad to say, not one of those questions was answered by the staff or Chairman Crosson. The staff and Crosson either remained silent, or offered non-answers. To impress upon you how poorly prepared the staff was to defend their vague, Rube Goldberg proposal, I’ll use the rest of this comment to illustrate the non-productive, one-sided conversation between commissioners and staff.

Ask and you shall not receive

The commissioners who spoke first focused on whether it is reasonable to expect that ACOs in any of the three flavors will be available for all doctors to join. The importance of this question is obvious: If doctors are going to be robbed of 2 percent of their Medicare payments for not joining an ACO, they should at least have the opportunity to join one. These commissioners noted that the problem of ACO accessibility is two-fold: ACOs are not available everywhere, and many existing ACOs will want to avoid clinics and hospitals that serve poorer, sicker and more expensive people, such as clinics in rural areas and doctors who specialize in treatment of addiction. All the staff could say was that CMS might be able to create a “fall back option” for clinics and hospitals in rural or poor areas. (Note the staff did not say, “Excellent question, WE will figure out a good answer and not ask CMS to do the dirty work we refuse to do.”)

Commissioner Kathy Buto asked about “isolated providers” who might find it difficult to form groups large enough to create pools of patients large enough for statistical accuracy and, if in the event that large numbers of isolated providers could be herded into one ACO, whether they would feel they had any input into or control over the ACO’s decisions (pp. 18-19). All Glass could say is those problems afflict all ACOs. Commissioner Dana Gelb Safran asked, “[A]re we creating a kind of mini-version of the problem we had with the SGR where individuals really aren’t accountable to each other, even though they are grouped together…?” (p. 58) No one answered her.

Commissioner David Nerenz asked how big an ACO’s pool of attributed patients would have to be to make “population measures” accurate (by MedPAC’s low standards, I would have added). Bloniarz answered 1,000 to 10,000 depending on the “measure.” When Nerenz asked how it would be possible to apply a common set of measures to all ACOs if some didn’t have big enough patient pools for all measures, Bloniarz had no answer. When Nerenz rephrased his question to ask how many doctors an ACO would have to have, Glass replied, “It’s hard to say.”(pp. 20-22) When Nerenz asked how the staff proposed to weight the half-dozen “quality” measures and the cost measure prior to deriving an arbitrary “composite” score, Bloniarz excused the staff’s inability to answer on the ground that their proposal is “a bit exploratory.”

When Commissioner Pat Wang asked the only question any commissioner raised about attribution, staff dodged again. Wang asked if attribution would be prospective (meaning ACOs know in advance which patients are “theirs”) or retrospective (ACOs don’t find out till the end of the performance year who “their” patients were). Bloniarz replied, “I don’t think we have weighed in on [that issue].” “I don’t think we had a reaction to that,” added Director Mark Miller helpfully. (pp. 24-25)

When Commissioner David Grabowski asked what would happen to providers who take care of a disproportionate number of dual eligibles, Bloniarz replied, “I don’t think we have a great answer for that,” and then added wistfully, “[T]here would be risk adjustment,” as if CMS’s grossly inaccurate risk-adjustment method would solve the problem. (p. 29) Grabowski seemed dissatisfied. “If you don’t get the risk adjustment right …, you’re going to magnify disparities,” he replied. “You’re going to widen that gulf between the haves and the have nots.” (p. 31) Staff had no further comment.

Nerenz also warned that inaccurate risk adjustment put the poor and the sick at risk. He urged the commission to adopt criteria for the “quality” and cost measures that would guarantee they can measure quality and cost accurately. Nerenz quoted an article from BMJ that found that failure to adjust readmission rates for socio-economic factors punished hospitals in poorer regions. He warned that if the staff’s proposal was “rolled out” today it would “exacerbate socio-economic disparities.” (p. 72) Nerenz also cited a paper that found that quality of care is better in small clinics than in large networks, and yet the staff’s proposal will encourage further consolidation of the medical sector into large groups. The only reply Nerenz got was a “thank you for that” from Crosson and an “amen” from Commissioner Coombs.

Commissioners Safran and Craig Sammitt asked how the virtual and geographic ACOs would differ from existing ACOs. Neither Crosson nor staff answered.

Summarizing the unintelligible

At the end of the MIPS segment of the October 4 meeting, Chairman Crosson attempted to summarize the unproductive conversation that he and his staff had forced upon the commissioners. He began by saying “I’m going to try to summarize where I think we are. (p. 83) ….We have very close to consensus that MIPS should be repealed.” After that, his ability to construct complete, meaningful sentences deteriorated rapidly. I quote him at length so you can see for yourself what I mean: “I think we have consensus that it would be good to advance population health as the basis for accountability. [84] …. Where we had a difference was like how to do that –- well, I guess, whether we can do that at all with a replacement which would be the – – well, let’s just replace MIPS –- I mean let’s just eliminate MIPS and leave nothing with respect to measuring accountability for cost and quality in that practice environment. I think my notion was that we could take that direction, but we ought to try, before we do that, to think through whether or not there are some ideas that we could put forward which would — I guess I ‘m not sure I like the term ‘replacement of MIPS’ but to substitute something ….” (p. 85)

Will the other 16 commissioners insist on answers to their questions before they authorize the staff to write up some vacuous version of the staff’s MIPS replacement proposal and send it over to Congress? Don’t bet on it. The commission has caved into their staff and chairman repeatedly throughout its history. The commissioners are capable of asking obvious questions about the half-baked proposals their staff and chairman cook up, but they have never shown an ability to force the chairman and staff either to clarify a proposal and cite evidence for it, or to throw it away.

In my next comment I will explore the history of this habitual failure. I will focus on the commission’s endorsement of pay-for-performance in 2003 and how that endorsement led the commission into the MACRA tar pit.

Article source:The Health Care Blog

[isabelledirtydesign-blog]

Reflective Text

Over the course of the semester we experimented with a number of drawing machines, visual aids and processes that have heightened our awareness of the relationship between humans and machines. Specifically, we have explored how these relationships are evolving with emerging technologies, and shaping how we design. We have explored how our own design practice is affected by making an outcome with a ‘machine’ of our own invention.

We experienced a series of lectures on various design practitioners and design styles and also undertook various group projects. Our ‘solo’ projects were inspired by this accumulation of knowledge, research and skill and we carried these out over a series of steps, prototyping and developing our own mark making systems.

The lectures gave us important insight into what ‘came before us’ and helped us to situate our work in context. This idea of situating ourselves/our work in regards to what has already been done by others was really interesting. Rather than designing ‘in a vacuum’ we acknowledged - this is what has been done, this is how this person did this, and this is what we are doing.

All of the lectures and the group projects allowed us to practice this idea of building on what has come before us. For example we in small groups created our own ‘Rube Goldberg Machines” and then merged the groups together into one big chain reaction. Throughout the semester I personally struggled with the idea of a ‘machine’ (any autonomous or semi-autonomous system that assists humans). Our mish-mash of objects and nicknacks was a ‘machine’ and I struggled to comprehend this. I am so used to thinking of things like cranes and printers as machines, so it felt foreign to call something we pieced together with random things a ‘machine’. That being said, I got a lot of enjoyment from this activity and particularly enjoyed the performative aspect of this, and seeing our machine work all together.

Our process changed again and again as we experimented with the wide array of materials. The part that I found most interesting was the contrast between the impact made by different elements. Some parts of the sequence would be carried by a tiny marble rolling along quietly, and some would be a massive crash of a mousetrap or chain. The elements were unpredictable, we had to test them so many times. It took multiple tries to get the sequence to flow all the way through.

I liked starting our sequence with the ‘human’ element of the chair being sat on. Kind of makes me think of the butterfly effect, and also the effect that we as humans have on our environment and how small things we do can impact non human aspects of life. These were the small things that eventually helped me to come to terms with  the idea of the final assignment. We weren’t just looking at machines we were looking at how they are integrated into our lives.

To further this experience and add to our knowledge and research, we did some work shops around drawing machines. The sense of uncontrollability I had been feeling with this new way of thinking and designing remained with the experimentation we did with drawing robots due to the ‘messy’ nature of this work. However I really enjoyed this session. Vinny and I created ‘Dotty’ using a paper cup and some metal wire. This small machine moved around powered by the small battery motor. We experimented altering the pens, weight, balance, leveling, batteries, path, obstacles, obstructions. The dotty circles that resulted are what gave our little guy his name - “Dotty”. The movement of the machine (at this stage) gave it a ‘personality’ and thereby gave it a name, which in turn gave it a human element. It was interesting to realise that we had an emotional connection with this machine because we made it, and because it took on a little life of its own when we set it free to roam around and draw.

A benefit of the lectures was getting exposed to the work of a multitude of artists, this was a great launchpad into our own research and encouraged me to investigate artists with spinning, pouring and dripping elements. I looked at Damien Hirsts’ spin paintings. He throws the paint onto a spinning canvas. The erratic way the paint falls and spreads out in his works kind of takes the control out of the artists hands in some way. Theres not really a guarantee on how its going to look in the end. You can control the colour and speed, but the rest depends on physics. Linda Benglis was one of the people that stood out to me in the lectures for her work pouring paints because of the free nature of her works.

Some insights from my research were creations in which gravity contributes as well as the contrast between the idea of control, rigidity and structure vs freedom and mess. I documented these explorations on my tumblr and found it weird but cool when classmates mentioned images they had seen on my tumblr. I guess thats part of the reason the tumblr is valuable, that we were able to get an idea of what others were learning and in turn learn from that too. I made a conscious decision to comment on other classmates posts, and even reposted a couple in the spirit of open communication and collaboration.

We had an incursion by Karen ann Donnachie, who taught us the basics of Processing, the open-source coding platform for artists and designers. She demonstrated how to create a number of typographic animations.

Andy posed the question “Could this become another tool for you to explore human-machine relationships within your project, or your design practice in general?”

I had been lacking direction with my project and feeling a bit lost, so I took this on board and really thought about how I could explore processing. I liked the human/machine interaction of the coding Karen showed us, as each input would create a reaction which still needed to be ‘unlocked’ by an human. For example how we put into the computer certain coding (machine) - which we could also customize (be that the shape, size, colour) and then clicked, moved the mouse around (human) to determine the outcome.

To further explore the human-machine relationship I thought I could try and do portraits of people or things, using processing - with either an actual description of the person or a poem relating to them, or written by them. The portrait would be made up of their ‘story’ or them in words. Furthering the human-machine relationship.

This could be a really interesting thing to explore independently. However I did not pursue this path in the course.

I was intending to use a record player to do some trials of some kind of spin art but in the mean time, I explored my back shed and discovered an old fan. This sparked my attention and having undertaken the course so far I had a renewed perspective and didn’t (as i would have previously) immediately discount this as useful or usable. I took the fan out, and preceded to take it apart, lay it down and got to work. By taking of the wire face of the fan, and unscrewing the safety cap I was able to remove the blades.

By securing various canvases to the fan blades I had a means to then attach the canvases to the fan with the fan blades and rotate them this way. An important element here was balance. Having the canvas centered and properly secured ensured that the canvas would spin properly. I found that if it was unbalanced the fan would make weird noises as if it was not functioning properly- clicking. In one of my initial trials with firstly just spinning a blank canvas, it flew off as i hadn’t secured it tight enough. From then on I taped the canvases extensively and also worked up the speed settings slowly to test that it could take it. I used weights to hold the head of the fan in place as it is not designed to work horizontally. The ‘neck’ of the fan was fairly flimsy in this horizontal position and also quite light, so the force of the fan would unbalance it. The weights improved this dramatically. This prototype was the beginning for me feeling passionate and actually driven. I felt like it had all sort of clicked and I was getting the idea of the whole thing. I think I needed to go through all the lectures and workshops, AND the confusion/doubt to get to this point. My brain was constantly questioning things, and it finally had a direction.

Once the machine was a working prototype I began to test it with the substances. I began by placing the paint on the canvas before commencing the spinning. The spinning motion of the machine caused the substance to spin out over the canvas due to the speed and rotation of the fan.

The outcome can be varied however depending on where the paint is placed by the human. This had similarities to the work of Abraham de la Torre. In the outcome there appeared to be a source point then the pint splayed out from it. I wanted to take away more control from the outcome and then tried pouring the paint as the canvas span, so rather than having a source point, or applying the paint directly like Brian John I then tried pouring the paint as the canvas was spinning. I was really excited by these outcomes and it really gained momentum as I got futher and further along.

I started attempting to use the spinning method to do a hat and tshirt. Kind of overdid these ones to be honest. Too much ink kind of ruined them. The shape of the hat didnt work well in creating a visually appealing pattern with this method of applying ink. With the shirt the ink also spread because of the material and didn’t retain much contrast. However by taping off the edges of the shirt around the canvas it created this crisp border around the ink markings that works really well think.

There was not much balance or good use of space in the hat trial and I think thats what came down to it being a failure. In this case mess was not more. The spinning with these attempts did little in the way of spreading the substance, unlike in the canvas trials as it is absorbed quickly onto the surface. With the paint on canvas, the spinning motion draws the paint out impacting the shapes and space. The designs were determined by where i held the ink bottle above the spinning surface and how much pressure I applied on the bottle. I don’t think this is a favorable result. I preferred the spinning to have a greater impact on the result and to create interesting outcomes. However, as I had found momentum at this stage, this only kind of spurred me on. I knew now what didn’t work and what did, and it gave me goals.

I refined my skills, and undertook the creation of my final works. I looked over the previous work and developments, both canvas and clothing and analyzed what was good, wasn’t so good and why. I was pleased with my final result and felt like as an edition they worked really well together. I really developed my design thinking and challenged myself by persevering with the notion of human - machine design interaction.

[titheguerrero]

More Dumb Things Politicians and Political Appointees Say About Health Policy

As we previously discussed, the fierce debate about whether to revise, or "repeal and replace Obamacare", more formally, the Affordable Care Act, continues in the US.  The legislators in the US House of Representatives, and then the US Senate who have written "repeal and replace" bills have done so without any obvious input from health care professionals, health care policy experts, or patients, much less legislators from the opposition party, and so far have impeded any consideration of these bills by legislative committees.  Nonetheless, many of the politicians involved in the debates, and other politicians who have addressed relevant issues, seem to feel free to comment on health care policy issues with reckless abandon. We have recently found some more remarkable examples, discussed in chronologic order.  Senator Ron Johnson (R - Wisconsin): Someone with a Pre-Existing Condition is Like "Somebody Who Crashes Their Car" As reported by RawStory on June 25, 2017,

The Wisconsin Republican pointed to Obamacare rules that forbid insurance companies from charging more for people with preexisting conditions. 'We know why those premiums doubled,' he opined. 'We’ve done something with our health care system that you would never think about doing, for example, with auto insurance, where you would require auto insurance companies to sell a policy to somebody after they crash their car.'

The last phrase suggests Senator Johnson might be talking about people who deliberately crash their cars, or at best people who were at fault in a car crash.  Setting aside the consideration that sometimes fault in a car crash is hard to assign, he seems to be implying that all people with pre-existing conditions are at fault for for their conditions.  Yet, accidents thay may cause permananent injury are accidental.  Diseases are caused by many factors, or by factors unknown to modern science.  It is very hard to think of a disease whose occurrence is purely caused by choices made by the patient who is afflicted with it.  So it appears that Senator Johnson's argument rests on a logical fallacy: false analogy, in this case between car accidents and pre-existing conditions. Middletown, OH, Councilman Dan Picard: Town Emergency Medical Technicians Should Deny Naloxone Treatment to Narcotic Addicts Who Have Overdosed Two or More Times Previously As reported by the Huffington  Post on June 26, 2017,

'I want to send a message to the world that you don’t want to come to Middletown to overdose because someone might not come with Narcan and save your life,' Picard told Ohio’s Journal-News. 'We need to put a fear about overdosing in Middletown.'

Also,

But Picard seems to believe that EMS crews are working a bit too hard to stem the tide of overdoses, and is upset that taxpayers are footing the bill to revive people, many of whom are transients and not residents of Middletown, he says. Picard also proposed that instead of immediately arresting or jailing overdose victims, they should receive a court summons and be required to work off the cost of treatment by completing community service. But there’s a catch. 'If the dispatcher determines that the person who’s overdosed is someone who’s been part of the program for two previous overdoses and has not completed the community service and has not cooperated in the program, then we wouldn’t dispatch,' said Picard.

Narcotic overdoses left untreated are often fatal. The article also quoted

Martins Ferry Police Chief John McFarland said some people have begun taking these casualties as a foregone conclusion. 'You hear from the public, ‘Why don’t you let them die?’' McFarland told the Dispatch. 'We’re not God; we don’t decide who lives or dies. … We have the ability to save them, so we do.'

That is the point. Emergency medical services have a duty to attempt to treat people with acute conditions that can be immediately fatal, otherwise they would be "playing God."  At best, Mr Picard seems unaware of the mission of emergency health services.  Note that a Washington Post story on Mr Picard's new policy idea, published June 28, 2017, which quoted this argument the Councilman made in favor of his proposal,

a decision to not save repeat overdosers would be one of many that communities make about how much care they'll provide to dying people. 'If you have a toothache and you call Middletown, we’re not coming,' he said. 'For your heart attack, we’re not going to do the stint or your bypass. Decisions have been made about what services we’re going to provide. We need to make a decision about overdoses.'

Of course, this is another, and whopping example of a false analogy. Revascularization procedures for myocardial infarctions (coronary artery stents or coronary artery bypass grafting) cannot be done by emergency medical technicians and must be done in a hospital given current technology. So decisions about when to deploy these treatments are not made by EMTs, or City Councilmen for that matter. By the way, the Huffington Post article noted that Mr Picard was not the first one to come up with the policy of withholding Naloxone to save money.  Maine Governor Paul LePage (R) apparently floated something similar in 2016. As reportedy by the Huffington Post in April, 2016:

LePage explained Wednesday that he blocked a bill to increase access to a life-saving overdose medication because the people it could save are just going to die later anyway. 'Naloxone does not truly save lives; it merely extends them until the next overdose,' LePage wrote. It was not the first time LePage had shared such a belief, but attaching it to his veto elevated it to a statement of official policy.

The state legislature later over-rode his veto. Note that Governor LePage apparently based his article on a faulty perception of the prognosis of patients who overdose.

'Creating a situation where an addict has a heroin needle in one hand and a shot of naloxone in the other produces a sense of normalcy and security around heroin use that serves only to perpetuate the cycle of addiction,' he wrote. While a staggering number of people have died as the result of the heroin and opioid epidemic, many have also recovered, and many more are waging battles with addiction they will eventually win. LePage’s assertion that everyone who overdoses once and lives will surely overdose again, rather than seek treatment and recover, is divorced from reality.

Counselor to the President Kellyanne Conway: Instead of Getting Medicaid, Able-Bodied People Should Find Jobs "Then They'll Have Employer-Sponsored Benefits Like You and Me" As reported by Fortune on June 26, 2017,

In an interview on ABC's This Week on Sunday, Conway, counselor to President Trump, said that Obamacare expanded Medicaid to those who did not truly need it, because they were able to work. She was defending the Senate's proposed health care bill, which would make big cuts to Medicaid, by lowering the income limit for those who qualify, among other measures. 'Obamacare took Medicaid, which was designed to help the poor, the needy, the sick, disabled, also children and pregnant women, it took it and went way above the poverty line and opened it up to many able-bodied Americans,' she said. Those 'should probably find other — at least see if there are other options for them.'

She continued:

'If they are able-bodied and they want to work, then they'll have employer-sponsored benefits like you and I do.'

This was just a straight-forward, but important factual error.  Per Fortune,

Many Americans who are covered by Medicaid are already working, often in lower-paying jobs that may not have health insurance benefits, according to a report by the Kaiser Family Foundation, cited by CNBC.

Representative Paul Ryan (R-Wisconsin): If Insurance Prices Go Up, "It's Not Like People are Getting Pushed Off the Plan, It's That People Will Choose Not to Buy Something That They Don't Like or Want" As reported by RawStory on June 27, 2017,

During an interview that aired on Tuesday, Fox News host Brian Kilmeade asked Ryan to respond to a recent Congressional Budget Office (CBO) report that said there would be 22 million more people without health insurance by 2026 if the Senate’s version of the health care bill is signed into law. 'What they are basically saying at the Congressional Budget Office, if you’re not going to force people to buy Obamacare, if you’re not going to force people to buy something they don’t want, then they won’t buy it,' the Speaker opined. 'So, it’s not that people are getting pushed off a plan, it’s that people will choose not to buy something that they don’t like or want.' 'And that’s the difference here,' he added. 'By repealing the individual and employer mandate, which mandates people buy this health insurance that they can’t afford, that they don’t like — if you don’t mandate that they’re going to do this then that many people won’t do it.'

Please note that the mandate to which he refers is a relatively small tax under "Obamacare" paid by people who do not have health insurance. Further note that under the proposed Senate bill, many poorer people would lose substantial subsidies of their health insurance. So Mr Ryan seems to be using linguistic sleight of hand.  He accepts the term "mandate" as literally true, allowing him to claim that the negative financial incentive which the "mandate" imposes while the negative financial incentive caused by losses of subsidies and increases in insurance prices is not.  A rose is not a rose when it's called something else? This is the logical fallacy of ambiguity, using double meanings or ambiguity of meaning in language to disguise the truth.  Summary Whether to maintain our current - admittedly Rube Goldberg-esque - system of financing health care, or to radically change it is a serious question.  The answer will affect the wellbeing, health, and even lifespan of many people.  The question should not be taken lightly. So what to make of so many politicans and political appointees making pronouncements on whether to keep, or "repeal and replace Obamacare" that are based on major factual errors and logical fallacies?  The last time I took this on, I speculated whether health care policy has sunk into a swamp of postmodernism generated by years of exposure to the post-modernist stance of many in academia.  That may have been fanciful. On the other hand, another speculation is that this is the result of "managerialism."  We have discussed the doctrine promoted in business schools that people trained in management should lead every type of human organization and endeavor.  Management by people from the disciplines most relevant to the mission and nature of particular organizations should be eschewed.  So managers, not physicians or other health care professionals, should lead health care organizations.  Following that theme, managers, or those like them, rather than health care professionals and health policy experts should lead health policy.  However, managers who run health care organizations, or make policy, have an unfortunate tendency to be ill-informed (as well as unsympathetic if not hostile to health care professionals' value and the health care mission, and subject to perverse incentives that often put short-term revenue ahead of the health of patients and the population.)  And in the latest health care reform debate, some of the politicians and political appointees who are the de facto managers of health policy have disdained the advice of health care professionals and health policy experts.   The causes of this trend are certainly open to debate.  However, I believe we should all be really worried about continued health care policy making by people who are driven by factual errors and non-evidence rather than evidence, and logical fallacies rather than sound reasoning.  We need health policy leadership that is well-informed, understands the health care mission, avoids self-interest and conflicts of interest, and is accountable, ethical and honest.   (Of course, we have often said we need leadership of health care organizations with these characteristics.)  Right now, we are not coming close.  Woe is us. Article source:Health Care Renewal