The Oregon Dilemma

The realities of universal healthcare and euthanasia have recently been highlighted by the case in Oregon. But this is not the first of these cases and certainly won’t be the last.

A few of the articles are listed here: State denies cancer treatment, offers suicide instead
http://www.lifesitenews.com/ldn/2008/jun/08062501.html
Oregon Health Plan Refuses to Cover Cancer Treatments, Pays for Assisted Suicides Instead by Alf Gordon

This recent case highlights the limitations of Universal Healthcare. The bottom line is very clear. The government, whether it is State or Federal, cannot afford everything for everyone. Limits have to be set and individuals will be denied care.

In Oregon, Doctor Assisted Suicide (DAS) is legal and therefore the more cost effective option is to pay for DAS rather than expensive treatments which will only prolong life and not necessarily cure the problem.

Eventually, there will be age limits on certain procedures because the cost-benefit ratio created by the actuaries will show that terminating life is more cost effective than prolonging it.

Pandora's box has been opened!

Testosterone--its what's good for you

Some hormones get lots of publicity both good and bad. But testosterone may be the forgotten hormone when it comes to overall well-being.

In a recent population-based cohort study, there was a demonstrated link between low levels of testosterone and increased risk for mortality from all causes in adult men of all ages.

The study out of Germany showed the survival times of men with low testosterone levels to men with higher testosterone levels were significantly lower.

From the analysis the researchers concluded that men with testosterone levels lower than 8.7 nmol/L had a 2-fold increased risk of death.

During the follow-up period of the participants, 226 deaths occurred in the study population. After adjusting for age and other risk factors, the researchers determined that participants with low testosterone had a significantly higher risk for all-cause mortality than their normal-testosterone counterparts.

In a more specific breakdown of causes of mortality, the researchers found that men with low testosterone levels were at increased risk for death from cancer and cardiovascular disease but not respiratory disease.

The men in the low testosterone group tended to be older and had higher prevalence of diabetes, hypertension, and metabolic syndrome but it is still unclear whether low testosterone was a cause or effect of the cardiovascular risk factors.

This study underscores the importance of treating men with low testosterone levels even in the absence of symptoms, but in order to do this, we have to begin checking testosterone levels on a more routine basis and recognize the importance of replacement therapy.

Another problem that arises is many insurance companies do not pay for testosterone replacement therapy and the newest gels are very expensive preventing many patients from adequate therapy.

10 Year Road Plan for Indiana

The ten year plan for Indiana’s transportation system is shown in the diagram below.


As you can see, the bridges are still in the plan, but what are the odds of them being built in this time frame.

The I-69 corridor certainly looks as if it will add a more direct pathway to central Indiana from the southwest and this should help with economic development along this area.

Now, we just need to attract businesses and get people to embrace development.

Indiana's Economic Health

As the economy struggles in some areas, the question arises as to how we are doing in Indiana.

The chart above shows that overall; Indiana appears to be holding its own.

Personal Income in up 4.1%, unemployment rates are up from a year ago, but still below the national average and they did not rise as much as the national average.

Manufacturing jobs are down, but non-manufacturing jobs are up.

What is sad about this chart is that southern Indiana (the New Albany area) is no longer even listed as a major independent area of the state.

At the turn of the century, the New Albany area was the place to be.

Is it possible to regain our status or are we satisfied with the status-quo?

"Caturdays"

The animal lovers should love this idea.

Japan has decided to make every day “Caturday”.

A new business in Japan near Tokyo has developed some new cafés that allow patrons to eat and drink while they play with one of the cafés cats.

This is great for the cat lovers in the area who have always wanted a kitty but where many apartments didn't allow pets.

At Calico, a cat café in western Tokyo, customers pay $8 plus the cost of drinks to sit and play with their very own cat for an hour.

It gives customers the benefits of enjoying the feline companionship without the ongoing hassles of pet-ownership.

Maybe this is a new idea for downtown New Albany in conjunction with the animal shelter.

The Science of Medicine and Dr. Debakey

The field medicine recently lost a true pioneer in the healthcare field.

Dr. Michael E. DeBakey died at the age of 99 and was responsible for some of the most innovative procedures of our lifetime, including bypass surgery.

Sure he got some publicity, but compared to some celebrities and socialites who die, his passing went relatively unnoticed when you think of the impact he had on hundreds of thousands of lives.

When Dr. DeBakey began his career, most of us can’t imagine what practicing medicine was like.

Many of us cannot remember only having glass IV bottles, a handful of antibiotics and other medications and certainly cannot fathom a cardiac intensive care unit with no ventilators or an iron lung and no bypass surgery, angioplasties and stents.

With pioneers like Dr. DeBakey, the science of medicine moved at incredible speeds and with its progress, came great changes.

Nursing is much more technical and less hands-on than it used to be which has its pros and cons.
Machines now give us digital images and vital signs when before it was all manual and more labor intensive. Beds can now position patients automatically rather than manually turning patients.

All of the progress has helped with patient care and it has improved safety in some cases; more effective in others.

But have physicians and nurses lost something along the way?

Automating procedures, vitals, and other routines has eliminated those minutes that used to be spent at the bedside or in the room chatting with the patient and family.

Automation has eliminated the return visits that were required because the manual methods had to be constantly repeated.

Each of those visits gave doctors and nurses a chance to check the patient and make another quick assessment.

Although we have made tremendous strides and advances, I wonder if Dr. DeBakey ever felt like we were losing touch.

The science of medicine continues to advance, but the “art of medicine” may be a dying relic.

Dr. DeBakey and his fellow inventors and pioneers have given the world tremendous gifts, but we need to remember that sometimes, progress in one area may cause a decline in others.

There are times we need to sit down and see what parts of the past we should keep!

The risks of beauty

This is not the first study that has linked hair dye to various forms of lymphoma, but according to the newest report in June from the American Journal of Epidemiology, use of hair dye may increase the risk of certain types of non-Hodgkin lymphoma (NHL).

Up to this point, the epidemiological studies exploring the association with NHL have yielded inconsistent results.

This study out of Yale pooled data from four published case-control studies and covered 4461 patients with incident NHL and 5799 control subjects.

Among women, 75% of the cases and 70% of the controls had ever used hair dyes. Among men, 10% of both cases and controls had done so.

The pooled data results showed there was a 30% increased risk of NHL among women (but not men) who started using hair dye before 1980, compared with nonusers.

For those women who began using hair dye in 1980 or afterward, the risk appeared to be limited to users of dark-colored dyes.

Based on this pooled data, it appears that the longer one uses hair dyes, the larger the risk.

So ladies, consider your natural hair color a gift and forego adding more chemicals to your bodies.

Environmental change and disease

A wide range of events shape the behavior and social interactions of humans and diseases. We know that the spread of childhood communicable diseases mirrors school calendars and we also know that holidays spur travel and novel social "mixing patterns," which increases the spatial distribution of disease transmission.

We know that plane travel effects transmission of certain diseases and seasonal shifts in immunity and host susceptibility are exacerbated by increased exposure through crowds during the colder months.

There are also seasonal trends in infectious diseases that have been well studied. For instance, the peak transmission of the malaria parasites tracks rainy seasons and the survival of certain pathogens, such as the diarrheal disease cholera is enhanced by warmer temperatures. Rapid fall cooling promotes the seasonal viral transmission of tick-borne encephalitis and there are many more.

Therefore, "Agent" and "host" are united by the "environment" and any of the three can have an impact on the others.

Increased industrialization, booming population growth, widespread deforestation, certain farming methods and increased use of antimicrobials have led to emerging and changing behaviors of diseases and their transmission. No one would argue this point.

Climate change may have some effect on diseases but it is far too early to speculate that global warming is a major catastrophic event related to disease transmission and those who continually state this as fact are doing a dis-service.

In fact, 2007 actually showed a cooling but this piece of information has been left out of most mainstream media reports as well as others touting the catastrophic effects of global warming.

The earth is constantly changing and adapting just as we do and just as bacteria and viruses adapt to their surroundings.

Making broad speculative statements about the effects is in many regards irresponsible. We need to be cognizant about the effects but being reactionary may be far worse in its long term implications.

All life is affected by climate change as well as many other variables and their unremitting influences on an increasingly interconnected globe needs to always be appreciated.

Nature has a way of balancing changes in our environment and there is no reason to believe that this will not continue. Twenty years or so ago, the media was citing the next ice age was coming and now they are touting global warning.

We need to be cognizant of our impact and strive to be better stewards of our world, but fanatical rhetoric should be challenged in all disciplines.

Genetic Ban in Britain

Genetic testing has become a major topic for debate in the life insurance industry, as tests using samples of blood, saliva or tissue can now indicate whether a person has inherited a tendency to develop certain potentially fatal diseases.

There are dozens of genetic tests available and doctors can order them for various reasons, including looking for genetic illnesses before symptoms appear.

As a result, life insurers could and probably will eventually turn down coverage or raise premiums, based entirely on the genetic predisposition of even healthy customers.

But in London, British insurers have agreed to extend a freeze on genetic tests to 2014 and allow consumers to purchase coverage without disclosing the adverse results of tests to predict a predisposition to cancer or heart disease.

The original moratorium was established in 2001 and covered life insurance policies worth up to 500,000 pounds ($972,400) and critical illness coverage up to 300,000 pounds. Only 3 percent of policies were sold are above those limits. Policies above these limits can ask customers to disclose some genetic results.

There remains debate and some feel that genetic testing and providing an insurer with your family medical history is no different and therefore the genetic testing information should be allowed when writing insurance policies.

In the U.S., lawmakers earlier this year approved a bill barring discrimination based on one's genetic predisposition. It bars insurers from turning down coverage but also prohibits employers from using the information to hire and fire employees. The law does not specifically deny raising the premiums based on the information.

Age Makes a Difference

What is the difference between girls/women aged: 8, 18, 28, 38, 48, 58, 68, and 78?

At 8 -- You take her to bed and tell her a story.

At 18 -- You tell her a story and take her to bed.

At 28 -- You don't need to tell her a story to take her to bed.

At 38 -- She tells you a story and takes you to bed.

At 48 -- She tells you a story to avoid going to bed.

At 58 -- You stay in bed to avoid her story.

At 68 -- If you take her to bed, that'll be a story!

At 78 -- What story??? What bed??? Who the heck are you???

The Showdown

It's finally over; at least for another 18 months when we will go through this same ridiculous process because we cannot seem to get congress to actually fix the problem.

The Medicare reform bill effectively became law after the Senate voted 70-26 and the House voted 383-41 to override a presidential veto of the bill

Both chambers of Congress acted quickly to overturn President Bush's rejection of the bill so the 10.6% cut to physician payments will not take effect.

Many democrats are using the opportunity to posture over this issue when in actuality they are just as much to blame for the problem getting to this showdown.

The White House, on the other hand, said the legislation is “fiscally irresponsible,” because it would take choices away from American seniors by cutting the Medicare Advantage program.

Humana already is paid more per individual Medicare advantage recipient than the traditional Medicare patient and their stocks and CEO salaries certainly have not been adversely affected these past few years.

I would like to see all of the financial records from the congressman and president and see how many own Humana and other insurance and pharmaceutical stocks. How many lobbyists does Humana have?

Now all we have to do is wait for CMS to release payment for the past 2-3 weeks of work. Maybe by next month we will have our first check; but I’m not holding my breath.

Vitamin/AIDS controversy in South Africa

In Cape Town, South Africa, a court on issued an order banning unauthorized clinical trials of vitamin therapies for AIDS conducted by a team including a German physician Matthias Rath and U.S. doctor David Rasnick

The case was brought before the court by the lobby group Treatment Action Campaign (TAC) and the South African Medical Association (SAMA) and they accused Rath of conducting illegal clinical trials among poor blacks and profiteering by selling and distributing unregistered vitamin treatments among poor communities.

We see similar things here in the USA where there are many unsubstantiated claims and huge profits made on certain products being sold.

It was reported that Rath and his Rath Foundation promote vitamin pills and micronutrients, mainly minerals such as iron or iodine, that they say can reverse the course of HIV/AIDS, but critics say Rath's work has led to unnecessary deaths when HIV-positive people stopped using life-saving antiretroviral drugs.

In court papers, TAC and SAMA accused the South African government of not doing enough to stop Rath and failing in its constitutional and statutory duty of care to the public but the Health Minister Manto Tshabalala-Msimang, who has herself courted controversy by advocating garlic and beetroot instead of antiretroviral drugs, denied the allegations.

Just as in the USA, the argument before the court was that Rath's products were not really medicines but foodstuffs and therefore fell outside the Medicines Control Council's regulatory scope.

Newest CDC Data

The Centers for Disease Control and Prevention recently released their data in which they questioned 14,041 students in grades 9 through 12 in 39 states in spring 2007 on a range of risky behaviors. They have done this survey every two years since 1991

Some of the highlights are as follows:

• Overall, fewer U.S. high school students are having sex or using drugs and alcohol compared to the 1990s
• Latinos are not sharing in many areas of progress
• Overall, just under half of all students have had sex
• 75% have tried alcohol and 20% smoke
• In 1991, 54% of the high school students said they had ever had sexual intercourse, compared to 48% in 2007.
• In 1991, 19% said they had at least four sexual partners, compared to 15% last year
• Sixty-six percent of black high school students said they had ever had sex, the highest of any of the groups, although it was down from 82% in 1991
• 28% of blacks in 2007 said they had sex with four or more people during their lifetime, down from 43% in 1991.
• Forty-four percent of white students reported ever having sexual intercourse, down from 50% in 1991, and the number with at least four sex partners fell to 12% from 15% in 1991.
• Latinos made no such progress. In 1991, 53% reporting having sex at least once, compared to 52% in 2007, and the number of Latinos who had sex with four or more people during their life was 17% in 1991 and 2007.
• Compared to either blacks or whites, Latinos were more likely to have reported attempting suicide, using cocaine, heroin or the drug ecstasy or riding with a driver who had been drinking alcohol.
• The survey said 20% of the high school students had used marijuana at least once in the prior month -- up from the 15% in 1991 but down from a peak of 27% in 1999.
• 38% said they had ever used marijuana, more than in 1991 but down from 47% in 1999.
• Seven percent of the students said they had ever used cocaine, down from 10% in 1999, and 4% had used methamphetamine, down from 10% in 2001.
• Twenty percent reported being current cigarette smokers, down from 28% in 1991.
• 45% said they had least one drink of alcohol in the prior month, down from 51% in 1991.
• 75% said they tried alcohol at least once, down from 82% in 1991.
• The survey also found more and more teenagers are using a seat belt while in a car, fewer have carried a weapon, and the percentage who has attempted suicide has fallen from 9% in 2001 to 7% last year.

So there is some progress in certain groups, but with the Latino population growing faster than any other group, we need to focus more on how we can facilitate helping them help themselves.

Temporary Reprieve

U.S. senators returned from the holiday break and put a halt to the 10.6% physician Medicare rate cut, but the president has vowed to veto the bill.

The U.S. Senate’s vote of 69 to 30 along with the House vote of 355 in support should be veto-proof; but you never know how they ultimately will vote when the time comes.

If finalized, the new bill will maintain current reimbursement levels for physicians through 2008 and allow for a 1.1 percent increase in the pay rate for 2009. This is much better than what will happen if it fails.

The Department of Health and Human Services announced it would not process claims at the reduced rate until July 15, allowing Congress to return to the capitol and deal with the issue again. Read the statement from the secretary of Health and Human Services.

The AMA used the congressional recess period to air ads on ratio and TV, pressuring senators – including Indiana's Sen. Lugar – to change their nay vote to yea, in favor of the measure. "A group of U.S. senators voted to protect the powerful insurance companies' huge profits at the expense of Medicare patients' access to doctors," said AMA President Nancy Nielsen, M.D., in the media ads.

Over the month of June, patients and physicians made more than 41,000 calls to Congress urging action through the AMA's grassroots hotline alone.

The survey below was performed in 2005 by the ISMA. It asked physicians about future Medicare participation in light of planned reimbursement cuts. At that time, 42 percent of respondents said they were likely to stop seeing Medicare patients if projected cuts materialized.

Since 2005 we have certainly been more frustrated with the inability of congress to fix the problem and if these cuts go through, we along with many other local physicians will stop seeing new Medicare patients.

Book Signing

My very good friend Joyce Oglesby is continuing to promote her new book and she will be having a book signing at Booklore, Saturday from 10:00 to 4:00.

Booklore is located in New Albany on Charlestown Road by Great Escapes theatre.

The book has caused some controversy over its cover, but it is a very good and a fairly quick read. It gives lots of helpful insights and suggestions to support and maintain marriage relationships.

For further information about Joyce or her speaking engagemts, her website is http://www.joyceoglesby.com/index.html

Erectile Dysfunction may predict cardiac events

Erectile dysfunction (ED) was once thought of as a primarily psychological problem, but we now know there are a multitude of diseases that can cause the problem.

There are a substantial number of men, especially those over 40 who have vascular disease as the etiology of their problem.

If vascular disease is the cause, the risk factors for ED are similar and include smoking, hypertension, cholesterol problems, and diabetes. Obesity and lack of physical activity (decondtioning) also play a role.

In a recent study, ED is now being shown as a reliable indicator of heart disease.

In recent issues of the Journal of the American College of Cardiology, there were 2 complementary articles that demonstrated the potential link between ED and subsequent cardiovascular events.

This can be of benefit in the primary care setting as ED can now be used in conjunction with other indicators and can be a predictor of cardiovascular events in diabetic patients and others.

Treatment with statins and other meds might reduce the occurrence and should be used more readily to reduce the risk of future problems.

One take home message for physicians is that in men with type 2 diabetes without clinically overt cardiovascular disease, the presence of ED helps predict a new onset of CHD events.

Payments on Hold

Below is the latest notice from CMS about the Medicare claims.

There statement that it should have minimum impact on physician cash flow is preposterous.

How many businesses can completely lose 20-70% of its cash flow and not have a problem. It won’t be July 1-15th that is the cash flow problem because that money will be from the two weeks prior. It is going to be July16th to whenever they finally decide to start sending checks that is going to be a real issue.

How about physicians just not treating Medicare patients until July 15th when congress and CMS decides to fix this problem. Or maybe insist that all Medicare patients pay cash and let them get reimbursed later.

I’d bet that would get things done a little quicker!

Fortunately, physicians care more about our patients than to allow that to happen. But many of us will hold off on accepting any new Medicare patients.

Holding Claims Paid Under the Medicare Physician Fee Schedule (MPFS) Joint Signature Memorandum (JSM/TDL-08382) (06-30-08)

“To the extent possible, The Centers for Medicare & Medicaid Services (CMS) is working with Congress, health care providers, and the beneficiary community to avoid disruption in the delivery of health care services and payment of claims for physicians, non-physician practitioners, and other providers of services paid under the Medicare physician fee schedule, beginning July 1. In this regard, CMS has instructed its contractors to hold these claims for the first ten business days of July, for dates of service in July.

This should have minimum impact on provider cash flow because, under current law, electronic claims are not paid any sooner than 14 days (29 days for paper claims) after the date of receipt.

Meanwhile, all claims for services delivered on or before June 30 will be processed and paid under normal procedures. After ten business days, contractors will begin releasing claims into processing under the fee schedule which implements current law. This, of course, could result in claims being processed with the negative 10.6 percent update. If a new law is enacted which changes the negative 10.6 percent update, retroactive to July 1, CMS is prepared to automatically reprocess most of those claims which have already been processed.

Under the Medicare statute, Medicare pays the lower of submitted charges and the Medicare fee schedule amount. Claims with dates of service July 1 and later billed with a submitted charge at least at the level of the January 1-June 30, 2008, fee schedule will be automatically reprocessed, if Congress retroactively reinstates the update that was in effect for that time period. Any lesser amount will likely require providers to re-submit a revised claim.

To the extent possible, providers may hold claims in-house until it becomes clearer as to whether new legislation will be enacted or until cash flow becomes problematic. This will reduce the need for providers to reconcile two payments (i.e., the initial claim and the reprocessed claim), and it will simplify provider billings of beneficiary coinsurance and payment calculations for payers which are secondary to Medicare.

In addition, be on the alert for more information about other legislative provisions which may affect you.”

CPT codes, descriptions, and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.

Therapeutic Tests

There are many times physicians examine patients and really do not find any specific explanation for their symptoms.

Some patients find this hard to accept and will occasionally continually complain about their symptoms even though there is no clinical reason to explain it.

At times, simply ordering a test (any test) and then informing the patient of the results suddenly leads to marked improvement in symptoms.

Allaying a patients fears and easing their mind can at times be accomplished by the following things:

• Sometimes, just giving a diagnosis rather than trying to explain symptoms may help. Telling a patient they have myalgia rather than just stating their muscles may be sore for a week or more after an injury may help.

• Many patients would rather be told when to return for follow-up rather than telling them to come back if things don’t get better.

• Some patients will hear you say the symptoms may last 7-10 days and when they aren’t completely gone; they become upset, fearful or feel you were wrong. Don’t be too specific as it can sometimes be detrimental to patients getting better.

• Words can sometimes be misunderstood. For some patients, there's a difference between "better" and "improved" and even though symptoms may be heading in the right direction, the expectation of some patients is to have no symptoms at all. Being clearer in telling patients what to expect is helpful

• Trying to find out from patients and families how compliant they are with the specific instructions and limitations on their illness is also helpful as many patients try doing too much too soon and then don’t get better as quickly as we might expect.

• Many patients, particularly the elderly, are fiercely independent and to accept help is to admit defeat. They may have symptoms longer because they are not following the directions of rest and limited activities.

• Changing our minds about a treatment without a good explanation for the patient can cause trepidation among patients. If we tell a patient they don’t need an X-ray or lab test but then get one a few weeks later because they are hounding us can cause problems with some patients. We need to explain to patients why we are making the change.

• Sometimes just ordering the test is therapeutic and it validates what they have already been told even when it does not change anything else.

• Many patients believe we cannot know what is going on by just an exam. We have created a generation that believes this fallacy but we have to acknowledge it.

Part of this problem is patients have, for too long, not had to pay for services and therefore expect more than is often needed. I don’t see a significant change until patients actually have to be more financially responsible for the services they receive.

Some of these pointers may help patients improve faster from illnesses and may help physicians with the “art of medicine”

Happy 4th of July

A salute to our Soldiers, Sailors, Airmen, Marines, Coast Guard and all the others who serve to protect our freedoms.

I appreciate their sacrifice as well as their families sacrifices. They allow us to live in the greatest country on earth and they allow us to help more people worldwide than any other single nation.

We are the "Home of the Free, because of the Brave"

Pelosi the fake

The democrat’s fearless leader once again has demonstrated her ignorance as well as her stubbornness to acknowledge that she just makes things up to fit her skewed view of the world.

On more than one occasion while talking about the environment, Pelosi would add in a spiritual twist: "The Bible tells us in the Old Testament, 'To minister to the needs of God's creation is an act of worship. To ignore those needs is to dishonor the God who made us.'"

Although it's a nice sounding line, it’s not in the Bible.

Many news stories have been written and many have tried to get answers from Pelosi’s office, but not surprising, they fail to return calls.

Biblical Scholars Challenge Pelosi's 'Scripture' Quote -- 04/23/2008

Nancy Pelosi criticized for using false “environmentalist” Bible quotation

Why is it that democrats want to justify many of their views using the bible all while condemning everyone else when they hold Christian beliefs?

Jumping to Conclusions

Here is the story of how we assume things that are not necessarily accurate.

18 year old senior Dustin Zebro decided to prove a point that kids could have fun without alcohol.

He staged a party at his home with hordes of teens, drinking games, and a keg.

The police were called and on their arrival, they found dozens of high-schoolers drinking from red plastic cups.

Pictures of the event were plastered all over facebook and as soon as school administrators got wind of it, they handed down extracurricular suspensions.

The problem really arose for the school because without all of the facts, they jumped to a conclusion that was wrong.

Police made no arrests even after performing 90 breathalyzer tests and found the keg filled with 1919 Classic American Root Beer.

What we think we know is not always accurate.

HR 6331 fails to pass

Although the House passed H.R. 6331 (the Medicare funding bill), the Senate did not pass it and therefore as of July 1, 2008 the scheduled 10% cuts in reimbursement to physicians will take effect.

In addition, Medicare payments to physicians and other healthcare professionals will fall more than 5% more under the program’s proposed fee schedule for 2009.

The CMS projects it will pay $54 billion to 980,000 physicians and other healthcare professionals in calendar year 2009. This is down from an estimated $57 billion this year and is occurring as the population ages and nearly every other expense in life is increasing

This bill not only cuts reimbursement, but it increases the oversight burden to providers by adding 56 new measures to the Physician Quality Reporting Initiative, for a total of 175 in 2009.

Many physicians are going to stop accepting new Medicare and Tricare patients because of these cuts and this will lead to more emergency room visits and actual higher costs to the taxpayers.

This is extremely shortsighted by the congress.