On Tuesday, July 29, Kansas Senator Sam Brownback issued the following public statement regarding the Beijing Olympics:

The Chinese government has put in place a system to spy on and gather information about every guest at hotels where Olympic visitors are staying. This means journalists, athletes' families and other visitors will be subjected to invasive intelligence gathering by the Chinese Public Security Bureau.

On CNN the next day, the earnest senator elaborated his concerns:

Your internet communications can all be monitored in a real time basis by the public security bureau of the Chinese government. I think they’re clearly intent upon spying. They’re going to be spying.

Really. This is the same Republican Senator who voted for the FISA law last month, effectively giving the President unrestricted authority for warrantless wiretapping of U.S. citizens.

Without a trace of irony intended, I would like know what Brownback is accusing the Chinese government of doing that the U.S. government is not doing to its own citizens this very moment. FISA allows the U.S. government to monitor all communications going in and out of the United States and to listen in on them without a warrant. Since "journalists, athletes' families, and other visitors" will also be sending emails, faxes, and making phone calls from China back to home, what the Chinese are doing, by our own standards, is perfectly legal and moral.

Brownback has responded to the question. He maintains that what the U.S. does and what China will do are different.

 

We don't put the hardware and software on hotels. If there is a targeted individual that seems to be a likely prospect of terrorists, they must go through the FISA court and ask for a court to determine that there is probable cause to be able to listen in on that information.

What a joke. If the President used FISA warrants, I would have no problem with with the FISA law. The problem with FISA is that it excuses the president from obtaining a warrant in the case on international calls -- a huge loophole that can be, and doubtlessly is, widely abused.

Besides, what is the use in arguing fine points of the law with the Chinese? We authorize warrantless wiretapping and so do they. Does anyone with a brain think China, or any other government in the world, really cares how Sam Brownback and the Republicans interpret U.S. law? I know I don't, and I'm an American.

FISA, after all, is intended to combat terrorism. The Olympics would certainly qualify as an attractive terrorist target. China not only can, but should suspend civil rights during a time of terrorist threats, if we are to believe the Wall Street Journal, who said this on July 25, 2008 in its infamous "Batman" editorial:

[George W. Bush] sometimes has to push the boundaries of civil rights to deal with an emergency, certain that he will re-establish those boundaries when the emergency is past.

We have been through this ad nausem concerning U.S. torture policy. When you maintain that your own situation excuses you from accepted ethics, you should not be surprised when an enemy makes the same argument.

Guiding China to a more democratic government is one of the most important diplomatic missions of our time. FISA, and the thinking that goes with it, takes the moral high ground away from the U.S. in this quest. If we use FISA to nab a few terrorists, but at the same time miss a golden opportunity to goad China in the right direction, we are aiming to win a few battles at the expense of losing a very important war.

When Ronald Reagan said, "Mr. Gorbachev, tear down this wall," he could say that because the United States did not have an analogous wall. With FISA on the books, what can we realistically say to the Chinese?

Note to readers: The following contains irony. I am told that irony is dead but I cannot resist picking at the corpse.

If you have to die, you might as well die at a time convenient for your doctor.

I was at home in my usual state when I am on call -- in my ottoman in front of the TV, my cell phone on the right armrest, beeper on the left. Since neither one had gone off in about an hour, I was contemplating resting my eyes, which in this case meant accomplishing the feat even as I was thinking about it. The last thing I remember was the sunlight cast through my living room window lengthening and reddening, the motes of dust drifting senselessly in its shaft, and then, tragically, the beeper going off. I recognized the number as the intensive care unit.

"We're coding Mr. Brown," the nurse said.

Mr. Brown was my partner's patient, someone I didn't know. The first thing I would ever know about him was this: He was dying.

"His heart rate suddenly dropped to zero," the nurse said. "There was no warning. The ER doctor is in the room and they are doing chest compressions."

"I'll be right in," I said.

I didn't waste any time, but truthfully there was no hurry. Once his heart had stopped, Mr. Brown had 20 minutes at the most. By the time I got there, it would all be decided.

Over the years, I have grown rather fatalistic about cardiac arrest, also known as code blue in hospital lingo, or sudden death in the medical literature. Perhaps it should come as no surprise that a condition known as sudden death would carry a poor prognosis, but that is the medical fact. All the CPR and Advanced Cardiac Life Support (ACLS) training medical personnel get is of little avail. If a person keels over and stops breathing in a mall, under ideal conditions (collapse witnessed, collapse cardiac-related, defibrillator applied within 3 minutes), his chance of surviving until hospital admission is anywhere between 30 to 50%, depending on which study you believe. But in the hospital, where patients already have underlying medical problems (or they wouldn't be in the hospital in the first place), witnessed sudden death ends with the patient discharged alive less than 15% of the time. Not great odds.

It looks good on TV, the pumping, the shocking, the wild effort to push in IV fluids and medications, but in the real world it doesn't usually work. When I get paged for a patient who is deteriorating but not in cardiac arrest, that is when my heart starts thumping. Those patients can be saved. But when a nurse calls me about a code in progress, my visit is usually perfunctory.

At it was in this case. I slipped into the hospital through the back door and threaded my way to the ICU. The ER doc was already headed out. "I called it about a minute ago," he said.

Now, as the attending doctor on call, it was my turn. Mostly paperwork. I went into the room to make certain the patient was dead. Not that I have ever encountered a mistake in this area, but I might as well check. The staff was busy cleaning up the room, making it presentable for the family. I went out and filled out the death certificate.

The nurse manager was waiting for me at the nurses' station. She told me the family had been moved to "the grief room." In other words, they didn't know yet, and it was my job to tell them.

One might think that telling a family a loved one has just died would be the most difficult job in medicine, but for me it has not been. Most of the time, hospital deaths occur at the end of a long illness and families are not all that surprised. Moreover, people of all walks of life seem to have a remarkable composure in moments like this, much more so than one might expect. This is not to say that patients accept the news with stoicism or aplomb, only that they usually understand that in the hour of death dignity is the best response. I think only medical personnel, clergy, and funeral home directors see this enough to really notice it, but it is remarkably true.

I looked over the chart. This was my partner's patient, and I had never seen him, ever. I would have to break the news after no more than a 5 minute crash review of Mr. Brown's entire medical life. I perused the daily notes, and asked his nurse a few questions about his reason for admission, why he was in the ICU, and how he had fared most of the day. Then, with the nurse manager, I went into the grief room.

There was only one person there, his sister. The death was sudden, and the rest of the family had gone home to dinner. I intended to employ the only strategy I know in such cases, the blunt approach. Sometime long ago during my medical training, a fool counseled me that the way to break bad news is to give the family a narrative, explaining everything that happened, how we responded to it, then ending with, "unfortunately, despite our best efforts, the patient died." This is supposed to "cushion the blow." I eventually decided it is idiocy to try to cushion news like this. The best approach, unfortunately, is to simply come out with it. Never in my life have I heard anyone say, "When John died it would have been such a shock, but the doctor explained to to me so skillfully and cushioned the blow so well that I wasn't all that upset at all."

If you end a 3,000 word essay with the words, "Your father died," the person listening to you hears a three word essay.

So I sat down at the end of the table and in an even voice simply said, "I don't know if the ER doctor has talked to you yet, but Mr. Brown died five minutes ago."

She took it with the calmness I had hoped for. She paused momentarily, and blinked back a few tears. "Well," she said, "he was been sick for a long time. I was expecting this." Then the nurse manager begin asking a few standard questions: Who did she want to notify, did she want a chaplain to come, what funeral home did they intend to use. The sister had no medical questions, at least not at the moment, and I saw that in less than 2 dozen words my job was over.

So I left the nurse manager to the details, went back to the nurses' station, and wrote an order to release the patient's body to the morgue. I told the nurse at the station to call me if the family had any further questions, and left for home. It was still daylight when I got back, and I checked my watch. Total time, 45 minutes. Hardly put a dent in my evening.

Shortly I was back in my chair, cell on the right armrest, beeper on the left, when my preschool son came up to me with a card game in his hands. I spent a good part of the next hour on the floor in the living room playing the game, which consisted of rolling dice and asking each other trivia questions about North American animals. He won; I let him.

I can't say I thought too much about the patient. At least not then. I hope he didn't mind that I observed the end of his life by going on with mine. One day my son will be burying me, and I expect him to do the same.

While America relaxed through the Independence Day weekend, the year's most important health care issue sat stalled in Congress, way past due. It is no longer five minutes to midnight, it is past midnight, and the contestto fix Medicare is now in overtime. The issue is an automatic budget cut that will reduce Medicare payments to doctors by 10.6%. If Congress doesn't fix the problem quickly, hundreds of thousands of patients could find themselves without physicians. Worse, as the ripples from this pay cut work their way through the system, the cuts will affect millions more not even insured by Medicare.

The root of the problem is something called the Sustainable Growth Rate, or SGR, a formula attached to Medicare law in 1997 to keep spending at or below certain growth targets. The formula controls costs by automatically slashing doctors' fees if spending limits are overrun in other areas. The SGR was originally intended as a carrot-and-stick measure that punished doctors with salary cuts if they overused services and rewarded them with modest increases if they ordered fewer tests and procedures. Unfortunately the SGR has never worked. Medicare costs continue to skyrocket, triggering the stick -- annual cuts in physician fees. Each year, outraged doctors lobby Congress to get the cuts reversed, and each year since 2002, Congress has complied. Thus, the SGR has proven useless -- not only does it fail to control costs, but Congress cancels its mandated penalties each fiscal year, eliminating any hope that it could change physician behavior.

But SGR is not simply an idea that has not been allowed to work. It is a badly flawed formula that cannot ever work. Congress has been doing half of a good thing by canceling its cuts, though it would be much better if it simply did away with the SGR entirely.

SGR fails for two reasons. First, it is a poorly thought out psychological tool, and secondly, it is technically obsolete. Disciplining doctors as a group is not an effective way to modify individual behavior. As a doctor, why would I reconsider ordering an expensive MRI on a patient simply because skipping the test would help satisfy the SGR? The Medicare budget is in the hundreds of billions. Any savings I might incur for the system could only translate into pennies in my pocket at the end of the year. Since there is no discernible connection between what I order and what I collect, there is no incentive for me to pay any attention to the SGR.  As I read once in a fortune cookie, in an avalanche no snowflake ever feels responsible.

Secondly, the formula is obsolete, since it represents the medical state of affairs in 1997, not in 2008. Since 1997 many new standard-of-practice guidelines have been adopted, and these guidelines have changed the way doctors think and practice. For example, the recommendation that all adults over the age of 50 have a screening colonoscopy has greatly increased the number of colonoscopies ordered for Medicare patients. This guideline alone adds hundreds of millions in expenses to the formula, and ultimately, the formula strips that money out of doctors' fees. So when doctors order colonoscopies as they are supposed to, the SGR punishes them by stripping the cost of the exams from physician fees. Updating the formula will not help -- as new practice guidelines emerge in the future, the revised SGR will again fall behind the times, placing the Medicare right back in the current dilemma.

Congress was supposed to enact a fix last December, but instead of correcting the problem it merely froze the current fee schedule until July 1. July 1 has, obviously, come and gone, and still no bill. In a last ditch effort, President Bush has ordered Medicare to cease processing any new claims until July 15, but at some point something has to be done. The calendar year is more than half over, and Congress has failed to properly budget one of its largest and most popular public programs.

Why doesn't Congress do the reasonable thing and do away with the SGR? This would eliminate the annual end-of-year scrum between doctors and politicians, and could place Medicare on more secure financial footing. The problem is that there is a political advantage hiding in the SGR. As long as the SGR is in place, the Medicare spending curve appears to rise slowly and affordably in all long term projections. Everyone in Washington knows Congress will never slash doctors' fees the 40% necessary to maintain that beautiful, gently upsloping curve -- everyone except voters, that is.  So SGR will stay, because it means the average Congressman can semi-truthfully tell his constituents that Medicare is not projected to not break the federal budget. An expedient budgetary lie.

On the other side of this issue are physicians, who are increasingly disgruntled over Medicare. With over 44 million enrollees, Medicare is America's largest health care carrier. Its physician re-imbursement rates are on the low side of the payment spectrum, but because there are so many Medicare patients doctors have trouble living without them. Some specialties that deal extensively with problems of the elderly, such as orthopedics, nephrology, and oncology, can't do without Medicare patients. For them, what the government decides to give out will heavily influence their bottom line. Making matters worse, in the health insurance business physicians' fees behave a lot like airline ticket prices: when one big carrier makes a price move, all the others quickly follow. Many insurers strictly tie their payments to Medicare, stipulating in their contracts that doctors are paid a flat percentage of Medicare, ranging from 80% for some HMOs to 130% for some of the better private plans. When Medicare fees move, most health plans move along with it.

Thus, the stakes in this 10.6% cut are enormous. According to AMA surveys, 60% of doctors plan to cut back on the new Medicare patients they will see if the cuts go through. If the SGR remains in place through 2015, that number increases to 77%. The New York Times has reported that this process has started already. Critics argue that this is just AMA bluster, that doctors make more than enough money to absorb a pay cut. But it is foolhardy to assume that such a large cut will not significantly alter doctors' behavior. Some experts opine that large numbers of physicians will retire early or move into other professions. I worry about a more insidious loss -- doctors refocusing their practices on treatments that yield cash, such as wrinkle removal, Lasik surgery, or so-called concierge medicine, where doctors limit their practices to a small number of patients in exchange for hefty membership fees. A quick look at the yellow pages for any major city will support this concern -- more and larger ads for plastic surgeons and beauty clinics, fewer and smaller ads for primary care physicians.

Given the popularity of Medicare, and the size and political clout of the over-65 voting bloc, the politics of fixing the cuts should be straightforward. Leave it to Congress to screw it up. To pay for the increased doctors' fees, the bill pending in Congress slashes the Medicare Advantage program, a branch of Medicare that allows private companies set up the equivalent of HMOs under the Medicare program. The Advantage programs make a profit, but some politicians think they make too much of a profit and want to cut them back. The insurance carriers are fighting hard to keep their own payments up.

President Bush supports the Medicare Advantage companies, and has threatened to veto any Medicare bill that cuts Advantage funding. This has stalled the bill in the Senate, where Republicans have initiated a filibuster to block its passage. Supporters of the payment fix only have 58 votes, 2 short of the 60 needed to override the filibuster. So here we sit.

I am sorry to say that both senators from my home state of Mississippi voted against the bill. At this very moment the AMA is running TV ads in Mississippi calling out the two senators, Thad Cochran and Roger Wicker, for voting to support the Advantage insurance lobby and against the retirees of Mississippi.

Though I do not often side with the AMA on political matters, I am with them here. Medicare patients are not particularly profitable patients to have, and a 10.6% cut will only make matters worse. Medicare patients are older and on average sicker than the general population, and making this vulnerable group less attractive than ever to physicians is reckless. The way to save money in health care is to help doctors treat patients more effectively, thus avoiding the expensive, catastrophic illnesses that are sucking the life out of Medicare. Drastic pay cuts will only make doctors angrier and less receptive to cost-saving change.

It is easy to fault the obstructionist methods of Republicans and the President for our current situation, but, even after slathering it on the GOP, there is more than enough blame left over for the Democrats. This bill would have passed a long time ago if the Democrats did not insist on slashing Medicare Advantage in the same legislation. Democrats seem to think the private companies under the Advantage program are making too much money, and they are using this popular and urgent bill as an opportunity to gut it. I am not saying Medicare Advantage is a good program or a bad one, but its merits can be considered at a later time. The fix is already way, way overdue. The Democrats couldn't get the Advantage cuts through in December, and they failed again in June. Enough is enough. There will be time to go after the Advantage program again after the November elections.

Congress continues to authorize billions for Iraq without cuts elsewhere in the Pentagon, so it is unclear why the Democrats, who have been pitifully complaint with the President's budget requests in every other area, have suddenly found religion with Medicare. Ordinarily I do not espouse increased government spending without proper financing, but Congress has had more than enough time to work this out. It is time to get this done, before patients get hurt.

One thing that bothers me about this stalemate is the Democrats' obvious mistrust of the Medicare Advantage program. Medicare Advantage is a miniature version of the huge public-private partnership that Barack Obama and other key Democratic leaders are alluding to when they talk about single-payer universal health care. Single-payer is intended to be a government entity that will contract with and coordinate hundreds of private health insurers to bring affordable health care to every American. This model is very similar to the arrangement Medicare has with its Advantage programs -- Medicare collects the money, or at least oversees its collection, and pays the private carriers to manage the medical care of its customers. If the Democrats can't stand it that Advantage companies are making a nice profit off Medicare, how do they ever expect to make peace with the private plans that service 58% of all Americans? Private companies are in the business of making profits, and they won't cooperate with government initiatives if they think Congress will prune away their profits at will. For single-payer to work, there has to be cooperation between the public and private sectors.  This attitude towards Advantage is not cooperation -- it is bullying, and it will destroy the goodwill necessary to make health care reform a reality.

Stupidly, Democrats think if they win control of Congress and the presidency, they can simply force large scale reform through. They have no idea how wrong they are. Private interests picked off the 1994 Clinton plan like target practice, and these same people will meet any reform plan that is not in their interest with a ferocious fight. Health care is a two trillion dollar business, and there is no way a trillion dollars goes quietly into the night.

Yes, we are in overtime. Sudden death overtime.

Rarely is the front page of a newspaper the place for laughs, but today's New York Times is a noteworthy exception. I laughed out loud when I read the headline, "U.S. To Take North Korea Off Terror List."

What's so funny, you may ask? North Korea, you may recall, is a member of George W. Bush's famous Axis of Evil, along with Iran and Iraq. Bush coined the term in a 2002 State of the Union address to emphasize to the American public how dangerous these nations are and how important it is that we be tough with them (read: go to war).  Now, suddenly the Axis is one member smaller, and not because we crushed them with nukes, but because we negotiated an agreement with them.

That's right, negotiated. Negotiated. Let's all say it together: ne-GO-ti-ated.

As in, we talked to them for a long time, and they agreed to back off on their nuclear enrichment program. No less than Mr. Bush himself says that the verbal agreements in place could greatly improve tensions in East Asia: “This can be a moment of opportunity for North Korea. If it continues to make the right choices it can repair its relationship with the international community.”

Simply amazing what diplomacy can do when you give it a chance. 

The rest of this essay writes itself. If this approach worked with North Korean dictator Kim Jung-Il, widely regarded as one of the most unprincipled and brutal dictator in the world, why wouldn't it have worked with Saddam Hussein? Why won't it work with Iran? What excuse could anyone possibly give me for the war in Iraq now that would dissuade me from believing we did it (1) for oil, and (2) because the Bush administration thought it could win the 2004 election if we were at war.

The irony is galling. We had to invade Iraq over WMDs that didn't exist, and succeeded in cutting a deal with North Korea over WMDs that probably do. Almost 5,000 Americans dead, 30,000 wounded, hundreds of thousands of Iraqis dead, and over 2 million refugees now homeless because Bush said diplomacy was not an option.

We have all known somebody in our lives who always knows better, the hardheaded fool who has to do things his own way no matter what anybody says, and who, after everything else fails finally does what people told him to do from the start and he succeeds at last.

There is nothing to do but laugh at them. It beats crying.