Tuesday, September 18, 2007
Over at Concurring Opinions, Professor Daniel Solove looks into whether the infamous TB patient may sue the CDC for release of his name. Professor Solove thinks that he may have a case and provides this overview of Mr. Speaker's life and potential lawsuit,
The WSJ blog points to this interesting update about the TB patient who was quarantined for having a highly-resistant strain of TB. I blogged about the case here and here. According to the news story, times aren't very good from Andrew Speaker, the TB patient:
Speaker was released from National Jewish on July 26, his treatment successfully completed. He takes 11 pills every morning at 8 a.m., supervised by public health officials who drop by on their way to work -- a standard regimen he will follow for the next two years to make sure the TB has been fully eradicated. He's in excellent health and has gone back to his previous routines, unmasked and unquarantined.
But his personal injury law practice is floundering, and his life is far from normal. His existing clients have stuck with him, but there have been no new clients since the ordeal began. The perception that he's a selfish jerk who thought nothing of exposing others to a deadly disease lingers.
"The CDC told everyone that I only care about myself," he said. "They made statements they knew were wrong. They intentionally went after my family and our character." . . . .
Speaker is also being sued in Canada for $1.3 million by eight passengers on his flight from Prague to Montreal for potentially exposing them to TB plus pain and suffering. The brother of one passenger is also suing.
At the end of the article is this interesting tidbit:
Does Speaker have any plans to sue the CDC?
"They're a federal agency. They have immunity," he said in resignation. "It's easier to think this guy is a jerk than that a government agency got together to intentionally misinform the public. That's much harder to believe."
According to the news reports, Speaker's name was disclosed by government medical officials (probably CDC officials trying to cover their behinds for screwing up so badly). Medical officials have legal and ethical duties to maintain confidentiality. There's also a potential Bivens action for a violation of the constitutional right to information privacy. See Whalen v. Roe, 429 U.S. 589 (1977). Most circuits recognize the constitutional right to information privacy, and it is violated by unjustified disclosures of personal information, especially medical data. For example, in Doe v. Borough of Barrington, 729 F. Supp. 376 (D.N.J. 1990), the court held that the police could be liable for disclosing to a person's neighbor that the person was HIV positive. There are many other cases on point.
The short of it is that Speaker does have a case against the CDC if he can prove that CDC officials leaked his name and/or other medical information. It is clearly established that government officials have a duty of confidentiality of medical data under the constitutional right to information privacy in most circuits, so any qualified immunity claims would not bar liability (qualified immunity applies if the constitutional violation is not clearly established). . . .
Senator Hillary Clinton announced her proposal for health care reform today. Her website states,
Building on her proposals to rein in costs and to insist on value and quality, her American Health Choices Plan will secure, simplify and ensure choice in health coverage for all Americans. This Plan covers every American - finally addressing the needs of the 47 million uninsured and the tens of millions of workers with coverage who fear they could be one pink slip away from losing their health coverage - with no overall increase in health spending or taxes. For those with health insurance, the plan builds on the current system to give businesses and their employees greater choice of health plans - including keeping the one they have - while lowering cost and improving quality.
Here's the thumbnail: Clinton's plan is of the "individual mandate" variety, in which universal coverage is achieved by mandating that every American purchase health care. In order to ensure that that's both possible and affordable, the Clinton plan creates a few new coverage options, reform the insurance industry, limits coverage costs to a percentage of income, and washes your car.
Okay, it doesn't wash your car. It does open the Federal Employee Health Benefits Program to everybody, ensuring that anyone can access the same menu of regulated private options that federal employees get. FEHBP is the program that already insures millions of current government employees, including the members of Congress, by offering a variety of regulated private options to choose from. Throwing the doors to that program wide open is the most basic and ubiquitous of coverage solutions.
More importantly, the plan also creates a new public insurance option, modeled off, but distinct from, Medicare. That's a big deal: The public insurer offers full coverage and is open to all Americans without restriction. Public insurance is what I feared her plan would avoid, and instead, she embraced it wholeheartedly. The concern with a plan like this (as with the Edwards plan), is that insurers will market coverage to the young and healthy and subtly tilt the public plan's risk pool towards the old and sick (the check is that governmental plans are, for reasons related to administration costs and care incentives, cheaper). At the end of the day, there's not much that can be done about that, unless you want to tax insurers with overly healthy pools, as they do in Germany. Come to think of it, that's exactly what they should do -- it was even in the 1994 bill.
And if you don't go through the newly expanded FEHBP or the public option, preferring to keep your current insurance, you'll still be dealing with a heavily-regulated and reformed insurance industry, which can no longer price discriminate based on preexisting conditions or demographic characteristics, refuse you coverage, or deny renewal of your policy -- including if you change your job. So if you like your current insurance but quit your cubicled existence at MegaCorp, your insurer can't drop you. All this matters because it keeps the private programs from having too much capacity to undercut the risk pools of the other options. It also destroys the elements of the insurance industry's business model that rely too explicitly on screwing you over. . . .
He has some further thoughts here as well. There is more to the plan so continue reading at Senator Clinton's website or Ezra Klein's. Firedoglake also reviews Senator Clinton's plan here - not as positive a review (putting it mildly). The Diane Rehm show has a brief overview of the various candidate proposals for health reform here. Senator Edwards' also has a health care plan and he provides more details on how he plans to ensure that his plan becomes the law - remove coverage from those in Congress.
The New York Times ran a front page cover story concerning a young woman's decision about whether to have a mastectomy based on her family's history of breast cancer and the results of a genetic test. It was a rather revealing story and revealed quite dramatically the changes that genetic information holds not just for medical decision making but also for our relationships with family members. The article discusses the young woman's options on learning about her increased risk for breast cancer and the advice she receives from her relatives about whether to pursue surgery:
Parents who have fought cancer typically have no experience with the choices that confront their children, and guilt over being the biological source of the problem can color their advice. Siblings and cousins who carry the risk gene evangelize their own approach to managing it, while those who dodged its inheritance seem unqualified to judge.
Even as she searched for her own answer in the year after her DNA test, Deborah Lindner, medical resident, found herself navigating her family’s strong and divergent opinions on the imperfect options that lay before her.
Her father, who once feared he would lose his wife to cancer, encouraged the surgery. Her sister reminded her that cancer might be cured in a few years if she could wait. Her aunt said she hated to see her niece embrace a course of action akin to “leechings of the Dark Ages.” A cousin declined even to take the DNA test.
But it was her mother’s blessing that Deborah most eagerly sought. Mrs. Lindner, who had passed her defective gene to her daughter, wanted to will her more time. When she had her own breasts removed she had been married for 27 years and had raised two daughters. Now Mrs. Lindner couldn’t shake the fear that her daughter might trade too much in her quest for a cancer-free future. What if taking such a radical step made it harder for Deborah to find someone special and become a mother herself?
The Next Hurrah has a great post on the article and states,
The story is a sign of our changing relationship with our genetic inheritance -- not only the substance of the story, but the very fact that an entire family's genetic pedigree and relevant medical data, with their photos, was published as a front-page story in a major newspaper. Maybe it's the exhibitionism of the reality TV age dovetailing with the post-genome era: only one member of the pedigree declined to have his name and photo published. (Why didn't the NYT respect his wish for privacy and just leave him off the tree?) Not only do we know more than ever about our genetic makeup, we are sharing it.
Importantly, our ability to read (and publish) our genes is outpacing our philosophy of when to do so. Ultimately, the answer is simple: it's up to the individual. But those individuals will want to make an informed choice, and (as I've written many times) in a setting where about 3/4 of us believe in angels but only 1/4 believe in evolution, the infrastructure is not in place for people to be savvy consumers of genetic information. Add into the mix the self-interest of counseling companies, pharmaceutical companies, and insurance companies and you get a recipe for confusion and frustration. . . .
And who gets to read your DNA? Your employer? Your insurance company? The government? New York Gov. Eliot Spitzer has been trying to expand DNA databasing to anyone convicted of a misdemeanor, and some states apparently collect DNA from anyone arrested (whether or not they are convicted). Will your DNA become a bit of personal information like your social security number -- putatively private, but in reality requested every time you fill out a form, apply for credit, visit your dentist?
Below these pragmatic concerns there exists a deeper question about humanity and free will. How "proactively" do we want to try to control our future, and to what degree should we realize that we may be able to lightly weight the dice, but in the end we can only really control our own attitudes toward what may come? Arlo Guthrie decided not to be tested for the copy of the gene that led to his father, Woody, dying of Huntington's disease, for which there is still no treatment. He recently passed the age at which his father died, and is still going strong without any sign of illness -- he said, "I spent the day talking to my dad about it, as it were [...] I said, 'All right, there's progress. And if my kids live a day older than I get to be, we're moving in the right direction, anyway.' "
According to the The New York Times, companies are anxious to inform the public about the availability of such tests and have started rather aggressive advertising campaigns. The Times published an article last week discussing the concerns that some have over the manner in which companies advertise the availability of genetic tests. The Times reports,
Breast cancer runs in my family,” one woman says. She is followed in quick succession by other young and middle-aged women, who say in turn: “My mother.” “My grandmother.” “My dad’s sisters.”
So opens a television commercial that is starting to run this week in New York and elsewhere in the Northeast. It urges women to consider being tested for certain genetic mutations that can sharply increase the risk of developing breast or ovarian cancer. But the commercial, sponsored by Myriad Genetics, which sells the test, is stirring protests from some cancer and genetics specialists, and it has brought on an inquiry by Connecticut’s attorney general. Critics say that advertising such a complex screening test to the general population might create unnecessary anxiety among women and lead to overuse of the test, which costs $3,120. “It really preys on the fears of our society, and one of those fears is getting breast cancer,” said Ellen T. Matloff, director of cancer genetic counseling at the Yale Cancer Center. . . . .
Myriad, which said it would cooperate with Mr. Blumenthal’s (Connecticut Attorney General)request, defends the commercial and other elements of what it calls a public awareness campaign. The company says that while its test has been given to about 200,000 women since 1996, only 3 percent of the women believed to harbor the harmful mutations that can be detected by the test have been identified so far. Therefore, the company says, there is a need for much more extensive testing.
Monday, September 17, 2007
Sunday, September 16, 2007
I don't know if any of you have been following (ok, how could you not be) the whole saga of the University of California-Irvine and its dean selection process that ended up in the press because they hired and then fired (or something close to fired) Professor Chemerinsky for reasons apparently related to his "controversial" political beliefs. Now the LA Times reports that the law school may want to un-fire him. Professor Paul Caron has a post detailing what both sides have said and some of the commentary and debate on the process. The AP Reports on the influence of politics in the decision and quotes a member of the county Board of Supervisors,
Making Chemerinsky the head of the law school "would be like appointing al-Qaida in charge of homeland security," Michael Antonovich, a longtime Republican member of the county Board of Supervisors, said in a voicemail left with The Associated Press.
Yikes - what an open-minded tolerant individual! The Next Hurrah explains further some of the backgrounds of indiividuals involved in the Chemerinsky decision and provides some details on California politics.
Saturday, September 8, 2007
Blue Cross of California has decided to spend millions on dollars to lobby against health reform in California. In response, a group called "It's OUR Healthcare" has set up a website, which contains personal stories, a blog and some utube videos. The group states,
The state legislature is down to its final days of the session and Blue Cross alerted their list of insurance agent supporters that current reforms on the table are "unhealthy." (And the status quo isn't?)
If you're sick of groups like Blue Cross standing in the way of healthcare reform, then you'll love our new animated video released today at www.SickOfBlueCross.com/BrightSide. We're asking Californians to watch the video and sign our petition and tell Blue Cross: "Don't stand in the way of reform!"
Very creative! In care you were not aware of what types of health care reform that are under consideration in California, if you visit the It's OUR Healthcare website, the right side of the page has a listing of recent articles detailing the California legislature's attempt at health care reform.
TalkLeft has a brief story on the acquittal of the Manganos, the New Orleans nursing home owners who had been charged with negligent homicide in the deaths of patients at their nursing home. The Washington Post provides some further background:
On Friday night, after four hours of deliberations, a jury acquitted the Manganos of negligent homicide, charges that could have put them in prison for life. The case raised broader questions about who, if anyone, deserves to be punished for the deaths in Katrina's deadly flooding.
Though numerous government agencies have been faulted for the disaster, the Manganos were the first and only people to be tried in a criminal court for any of the countless mistakes of planning that led to 1,800 deaths in the flooding that followed the storm late in the summer of 2005. . . . .
"I went back and forth for sure, but when it came down to it, the Manganos were not criminals," the juror, Kim Maxwell, 46, a secretary at a power plant, said later. "I just wanted to hug them." . . .
By all accounts, the Manganos' nursing home offered good care to its residents before the storm.
Mabel, the administrator, sometimes helped bathe and dress the residents; Sal, in charge of maintenance, stopped to spoon-feed those who could not feed themselves. Their son and daughter-in-law helped out.
Having been through Hurricane Betsy in 1965, the Manganos also believed that their nursing home had been built on a high spot and was less vulnerable to flooding.
The Manganos' fears for residents' safety during an evacuation were well-founded, too, according to expert witnesses who testified that nursing homes often suffer fatalities when evacuated.
The trial has been fraught with tears and bitterness, and the relatives of the dead and the Manganos have relived the tragedy.
"They killed 35 people," Joy Lewis, whose mother died in the flooding, said after closing arguments. She added that while she does not necessarily think the Manganos should go to jail, "they should pay" and the specific form would be up to God. "When they put their heads on their pillow at night," she said, "they'll pay."
Friday, September 7, 2007
The Washington Post reported on the Centers for Disease Control and Prevention completed some interesting research on myths surrounding the flu vaccine and how pervasive they are. The Post states,
The federal Centers for Disease Control and Prevention recently issued a flier to combat myths about the flu vaccine. It recited various commonly held views and labeled them either "true" or "false." Among those identified as false were statements such as "The side effects are worse than the flu" and "Only older people need flu vaccine."
When University of Michigan social psychologist Norbert Schwarz had volunteers read the CDC flier, however, he found that within 30 minutes, older people misremembered 28 percent of the false statements as true. Three days later, they remembered 40 percent of the myths as factual.
Younger people did better at first, but three days later they made as many errors as older people did after 30 minutes. Most troubling was that people of all ages now felt that the source of their false beliefs was the respected CDC.
The psychological insights yielded by the research, which has been confirmed in a number of peer-reviewed laboratory experiments, have broad implications for public policy. The conventional response to myths and urban legends is to counter bad information with accurate information. But the new psychological studies show that denials and clarifications, for all their intuitive appeal, can paradoxically contribute to the resiliency of popular myths. . . .
Research on the difficulty of debunking myths has not been specifically tested on beliefs about Sept. 11 conspiracies or the Iraq war. But because the experiments illuminate basic properties of the human mind, psychologists such as Schwarz say the same phenomenon is probably implicated in the spread and persistence of a variety of political and social myths.
The research does not absolve those who are responsible for promoting myths in the first place. What the psychological studies highlight, however, is the potential paradox in trying to fight bad information with good information.
Schwarz's study was published this year in the journal Advances in Experimental Social Psychology, but the roots of the research go back decades. As early as 1945, psychologists Floyd Allport and Milton Lepkin found that the more often people heard false wartime rumors, the more likely they were to believe them. The research is painting a broad new understanding of how the mind works. Contrary to the conventional notion that people absorb information in a deliberate manner, the studies show that the brain uses subconscious "rules of thumb" that can bias it into thinking that false information is true. Clever manipulators can take advantage of this tendency.
The experiments also highlight the difference between asking people whether they still believe a falsehood immediately after giving them the correct information, and asking them a few days later. Long-term memories matter most in public health campaigns or political ones, and they are the most susceptible to the bias of thinking that well-recalled false information is true.
The experiments do not show that denials are completely useless; if that were true, everyone would believe the myths. But the mind's bias does affect many people, especially those who want to believe the myth for their own reasons, or those who are only peripherally interested and are less likely to invest the time and effort needed to firmly grasp the facts.
The research also highlights the disturbing reality that once an idea has been implanted in people's minds, it can be difficult to dislodge. Denials inherently require repeating the bad information, which may be one reason they can paradoxically reinforce it.
Indeed, repetition seems to be a key culprit. Things that are repeated often become more accessible in memory, and one of the brain's subconscious rules of thumb is that easily recalled things are true.
Many easily remembered things, in fact, such as one's birthday or a pet's name, are indeed true. But someone trying to manipulate public opinion can take advantage of this aspect of brain functioning. In politics and elsewhere, this means that whoever makes the first assertion about something has a large advantage over everyone who denies it later. . . .
Shannon Brownlee writing at the Washington Monthly discusses the recent studies published in the Seprember 5th edition of Journal of the American Medical Association (JAMA) on reducing hospital errors. She writes,
HOSPITAL ERROR....Two large studies, published today in the Journal of the American Medical Association, found that cutting the grueling work hours of doctors-in-training had little effect on reducing hospital errors and patient deaths. Surprised? So were the researchers who did the studies.
There are three possible explanations. One, most errors aren't caused by groggy, sleep-deprived, over-worked residents, so giving them more time off won't make any difference in the error rate. Two, the new regulations, which cut residents' typical workweek from 100 hours to 80, didn't reduce their hours enough to make a difference. I mean c'mon, 80 hours a week still doesn't leave much time for eating and sleeping and all those romantic couplings we see on television shows like "ER" and "Gray's Anatomy." Or, three, the number of mistakes made in hospitals is so large, any drop in the errors committed by residents was too small to be measured.
My vote goes to . . . well, let me just offer a couple of statistics. In its seminal 1999 report on the subject, To Err is Human, the Institute of Medicine estimated that as many as 98,000 American patients are killed each year by medical error. Hospitals are such complicated places, the ways that care givers can screw up are almost too numerous to count. A doctor can accidentally perforate a patient's colon during a colonoscopy, leading to infection. Surgeons leave devices or sponges inside wounds and stitch patients up. One intensive care unit that tracked near misses reported 1.7 errors per day per patient, about 30 percent of which could have been serious or fatal. . . . .
The two studies published today suggest why that might be the case. The studies included 318,000 veterans who were cared for at Veterans Administration Hospitals and another 8.5 million Medicare recipients. It turns out, error rates did go down at VA hospitals, but not at the other hospitals in the study.
When it comes to reducing medical error, the VA health system has three things going for it that most other hospitals don't have. Numero uno, every VA hospital has a fully-functioning electronic medical records system.
This system not only helps physicians and nurses avoid many kinds of errors, like giving a patient the wrong drug, it also allows each hospital to track the treatment of every patient. Hospital safety officers can easily give physicians and nurses feedback on how they're doing when they implement any sort of error-reduction program. Other hospitals are left flailing along, hoping that they are making a dent when they initiate some new plan. VA doctors know -- and in real time.
And finally, VA hospitals do a better job of coordinating all the different people who have a hand in a patient's care. Veterans don't tend to fall through the cracks during hand-offs between one shift and the next, for instance. That's why my colleague Phil Longman's book about the Veterans Health Administration is titled Best Care Anywhere. It's also why a Democratic presidential candidate will probably be pointing to the VA in a speech later this month as one model for improving American health care.
Tuesday, September 4, 2007
Science News Online reports on great news about the future development of a multiple sclerosis vaccine,
An experimental vaccine for people who have multiple sclerosis has proved safe, clearing a necessary first hurdle toward regulatory approval. The results of this initial trial also suggest that the vaccine can indeed quell the self-destructive immune reaction that many scientists believe causes the disease.
Despite this early promise, the researchers caution that the findings are based on data gathered from a small group over a limited time. The researchers used a technique called DNA vaccination, which introduces a gene into the body to elicit an immune response. But rather than rile the immune system against a foreign foe, the new multiple sclerosis (MS) vaccine seeks to induce immune tolerance of myelin basic protein, a component of myelin. A fatty material that protects nerves, myelin is degraded in MS, robbing patients of muscle control.
For the vaccine, researchers at Stanford University and Bayhill Therapeutics in Palo Alto, Calif., designed a DNA ring that encodes a slightly altered version of myelin basic protein. The changes replaced immune-stimulating parts of the protein with immune-suppressing ones. Scientists gave 30 MS patients four injections over 9 weeks and then tracked their progress for a year. The study was made public this week and will appear in the October Archives of Neurology. Periodic magnetic resonance imaging of the patients' brains showed that inflammation associated with the nerve damage of MS didn't worsen as a result of the vaccine. . . . .
"This is an important development in the field of MS therapy," says immunologist Gérald J. Prud'homme of the University of Toronto, who wasn't part of the study team. "This is the first demonstration of a beneficial effect of DNA vaccination in a clinical trial of autoimmune disease." The vaccine may inhibit myelin damage in several ways, Bar-Or says. For example, the vaccine's DNA apparently enters the nuclei of dendritic cells and other traffic cops that orchestrate immune reactions, he says. Because of the DNA's tweaked structure, the myelin basic protein that these cells then produce isn't seen as an enemy, and other immune cells decrease their responses against it. . . .
Meanwhile, the findings have cleared the way for a larger trial designed to assess whether the therapeutic vaccine can limit the nerve damage that marks MS. In that study, researchers have already given 290 patients a longer course of the vaccine than the safety study entailed. The team expects to release the results of the current study within the next year.
McClatchy News reports on the latest and very exciting, developments resulting from the Human Genome Project
Four years ago, scientists triumphantly announced that they’d finished reading the entire human genome — the 3 billion "letters" of DNA that are the instruction manual for making a person. Trouble was, they didn’t know how to make sense of the bewildering clutter of A's, C’s, G’s and T’s in the so-called "book of life." Now the genome project is beginning to bear fruit. A bumper crop of fresh discoveries connects specific bits of DNA to numerous diseases, including cancer, diabetes, blindness and AIDS.
New findings are being published almost weekly in scientific journals. Scientists say they're important steps toward future treatments or cures. "A whole series of studies is coming down the pike," Teri Manolio, a geneticist at the National Human Genome Research Institute in Bethesda, Md., told a genome conference in Boston this summer. "This is an unprecedented opportunity to apply genetics to disease."
The latest discovery is a report published in the journal Nature on Sunday declaring that two tiny changes in human DNA may add more than an inch to an individual’s height. An Aug. 2 paper in The New England Journal of Medicine identified other DNA variants that may predispose a person to a heart attack. Armed with such knowledge, doctors can recommend changes in lifestyle, such as losing weight and stopping smoking, that could save a patient’s life. . . .
The detection of a DNA variant related to a disease doesn’t mean that a cure is just around the corner. Some variants raise the risk of disease only slightly, and multiple genes are usually involved in complex diseases. The variant itself may not be to blame, but it shows the location along a strand of DNA where the trouble lies, helping researchers find the culprit. . . .
Saturday, September 1, 2007
Meghan McCardle, a columnist for the Atlantic Monthly wrote a piece on her blog about health care and the morality of health care finance that has attracted a bit of attention. She writes,
Moreover, as a class, the old and sick have some culpability in their ill health. They didn't eat right or excercise; they smoked; they didn't go to the doctor as often as they ought; they drank to much, or took drugs, or sped, or engaged in dangerous sports. Again, in individual cases this will not be true; but as a class, the old and sick bear some of the responsibility for their own ill health, while younger, healthier people have almost no causal role in the ill-health of others.
Perhaps they deserve it by virtue of suffering? But again, most of them are suffering because they have gotten old, often in high style. The young of today have two possible outcomes:
1) They will be old and sick too, in which case they are no less deserving of our concern than today's old and sick
2) They won't ever get to be old and sick, which is even worse than being old and sick.
As a class, the old and sick are already luckier than the young and healthy. Again, for individuals within that class--those with desperate congenital conditions, for example--this is not the case. But I'm not sure it's terribly compelling to argue that we should massively disadvantage a large group of people in order to massively advantage another, equally large group of people, all to help out the few who are needy, or deserving, or unlucky.
What lovely sentiments. . . . She writes further in her column in Atlantic.com that she was surprised by all the feedback she received. Ezra Klein has kindly decided to set her straight on why she might want to ree-think some of her positions here and here. He writes,
"I would like to hear from a large number of single-payer advocates," writes McMegan, "who will say that if the American system could be proven to provide higher quality care per dollar on average than other industrialised system, then they would be content to leave 40 million people uninsured." And I would like to hear from a large number of auto enthusiasts who will say that if the car I'm selling them can be proven to go really fast, then they won't care that it's missing two seats, a mufflers, half a door, and three cylinders.
The 45 million are not some puppies-and-rainbows issue we're talking about because they make us feel sad and draw frownie faces in the margins of our notebooks. It's not efficient to have 45 million people going without preventive care. I could name about 45 million reasons why this is so -- ranging from enhanced productivity to the cost-effectiveness of statin drugs to the young uninsured who should be in the risk pool -- but that's the fact of it. The reason policy reformers are so intent on pulling them into the system isn't because policy reformers are Really Great People, it's because their absence is mucking everything up, and causing gross inefficiencies for hospitals, clinics, Medicare, Medicaid, taxpayers, and themselves. . . .
But at least this straw reform movement which believes dogmatically in single payer for incomprehensible reasons and laughs at efficiency claims isn't around to menace us any longer. We can thank Megan for that.