For the sake of those of you who have not yet gotten to your op-ed page today, this is a heads-up to make sure you don’t miss the excellent piece from our own Paul DeMarco, M.D.
As usual, Dr. DeMarco sets out the issues fairly, intelligently and with impeccable intellectual honesty. Some who don’t know him would be surprised that he seems to find some fault within his own worthy profession. Not I, and not anyone who knows him.
Paul DeMarco will always tell it straight.
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I posted this on the “Questions for DeMint and Graham” post but it seems appropriate here:
I enjoyed Dr. Demarco’s editorial in today’s paper. Today I had to deal with our medical system. Although today’s incident was minor it seems like there is always something to deal with.
I took my child to the doctor for a bad sore throat. Since he’s prone to strep-throat we usually don’t wait. It wasn’t long before the lady at the desk asks if I have the latest BC/BS card. I didn’t because my son is on my wife’s insurance. So in order to get credited for the money we spent we have to fax or bring by the new card. Apparently the old cards are invalid because they use the SSN as the patient ID number and that is no longer allowable. So the new cards have assigned numbers. And that is what is needed in order to get credit for the money we spent (in order to meet the deductible).
Why can’t we come up with some national health care system that simply does away with all this mess? Private insurance, medicaid, medicare, age limits, income limits, uninsured children, doctors and hospitals go unpaid because people simply can’t pay, counties fund hospitals, states fund medicaid. And try reading those sheets explaining what is covered and what is isn’t. Some things are others aren’t. And on and on.
Can’t we just establish a single payer system that guarantees everyone has at least a minimal amount of coverage? Every other developed nation in the world does that and there are far fewer complications. I think this mess contributes to our lower life expectancy as compared to other developed nations. It has to. And this is what we rejected the Clinton plan for? Give me a break.
Two things:
Does anyone really believe the government can manage an effective health care “system”;
And where does it say that health care is a “right”.
I agree with Brad. An excellent piece.
I tend to relate these “big issues” to my personal experiences. For example, a very good friend of mine, an orthopedic surgeon, was involved in a high profile malpractice case in Lexington last summer. Even though he did nothing wrong, to protect himself, his family, and his practice, his insurance company worked out a deal to pay $1M to the plaintiff even if he was found innocent. Sitting in the courtroom and watching a supposed jury of ones peers try and comprehend all the medical jargon was disappointing. These types of cases should be heard by an independent board of experts, not Joe Plumber or Jane Housewife.
We also need some real tort reform/award limits/etc. to stop the lawyers from turning every unfortunate event (there’s a difference between incompetence and an honest mistake) into a cash cow.
In December, my father had surgery for an aneurysm and never woke up following it. He was in a coma in intensive care for twelve days before dying. I got to see far too much of the way hospitals work during that period. The nurses are fantastic. The doctors are stretched too thin to spend enough time with patients and family members to explain things. It seems to be a bad mix of supply and demand for surgical services combined with all the regulation and convoluted insurance payment schemes that force doctors to do more procedures than they should. What does Medicare pay — 30% of the typical cost? All that does is artificially inflate the costs for people who have better insurance.
Then we have the decision recently (supported by The State) to stop Lexington Medical from creating their own heart center. From my experience with my father’s medical condition, the demand for cardiac services exceeds the capacity. The three and four hour waiting room experiences were quite common. Let the hospitals decide what services they want to provide.
Then yesterday an ad in USA Today happened to catch my eye. A company called Zimmer was actually marketing a knee replacement geared toward women. The tagline was “the first and only knee replacement shaped to fit a woman’s anatomy”. Does that need to be marketed in USA Today? All that does is inflate the cost. The whole marketing aspect of healthcare, especially for the drug companies, impacts the system as well.
Just as with the teaching profession, our government restricts highly skilled people from doing what they are trained to do.
I don’t expect much to be done. There’s too much money involved and too much bureacracy to untangle.
“If you think health care’s expensive now, just wait till it’s free.”
If you think the emergency rooms are busy now, just wait until the Boomers old age problems kick in.
Brad,
Kind words. Thanks.
Trajan,
Whether health care is a right is certainly debatable, but I believe it is. If you don’t have decent health, than how can you enjoy your other basic rights to live freely and pursue happiness? If it’s not a right, then it seems possible to deny care capriciously, say on the basis of income (a policy which assumes that poor people, by some character defect, haven’t earned the right to care). Taken to the extreme, that allows the poor to die needless and painful deaths from preventable disease (as they often still do in many Third World countries). That’s much less common in the US, but the cost of care is so frightening to some of our neighbors without insurance that they sacrifice their health or even their lives trying to avoid financial ruin. I love my county men too much to treat them that way.
Health care, in my view should be a social contract with all of us committing to pay our share so that all have access to care.
You raise an interesting point about increased usage with universal health care (UHC). This does occur and can be factored into the new system.
But you are right to imply that we can’t offer everything to everybody in UHC. As we advocate for UHC, we must be careful not to over promise. UHC will entail some limits-restricted formularies for drug plans (the VA uses one now that works quite well), exclusion criteria for certain procedures (for example, we may decide to limit the placement of feeding tubes in profoundly demented patients or put an age limit on dialysis).
But I think most people would opt for a UHC program that provided decent health care for all (with some limitations that would be the subject of much debate, I’m sure) than the current system.
I’d rather debate the evidence supporting whether a new drug or procedure should be added to our UHC plan any day than continue the decades-old debate about why so many millions of our fellow citizens are still uninsured.
I think Paul is right. But I fear whether politicians will get it right, and not mortgage the whole future in order to make people happy. You do have to have everybody paying into it, or it doesn’t work.
At the same time, you can easily kill the goose that lays the golden egg, and its no secret in Europe that (or at least it used to be–but that is changing too, I think) if you need the latest and best in health care, you have to go to the U.S. for it. My health insurance in Germany would pay for seriously ill patients, under the right circumstances, to be sent to the U.S. for treatment. The reason is obvious–there was a lot of money here for research and new ideas. So if a child had a certain form of leukemia, it was not unusual for them to send them here, despite the high cost.
Whether this is still true, I’m not sure; if it isn’t, then it’s another indication that our system is broken and getting worse–we don’t even have that advantage any more. I know that we have never been ahead in ophthalmology–our eye doctor over there pleaded with us not to let an American surgeon operate on one of our kid’s eyes–they wanted to do it here at age 3 or 4, but we waited until 12, like the Germans asked. Couldn’t have afforded it here, anyway.
One interesting tidbit–not particularly relevant to this discussion–the FDA always seemed to wait until drugs were tested on the European market, before allowing them here. The Europeans were our guinea pigs for a long time; again, I don’t know if they still are, but doctors over there were well aware of it.
And just for Trajan–nobody, I don’t think, is arguing that health care should be free. We don’t need the British national health system. But there are other models; the German one being one of the better ones, but not when politicians start using it to promise everybody everything. It goes broke fast that way.
So many people miss the most important point in the health care debate. We already have a de-facto universal health care in this country. We long ago made the decision that people in need of medical attention will get it. Nobody with a life threatening condition is turned away from a hospital. Paul made that point in his article. There is no serious debate on that point. We currently have universal health care. That’s a fact.
The debate is how to best distribute that care. The current system allows indigent patients without “official” coverage (medicaid, medicare or private insurance) to have mostly free treatment for serious conditions. Paul’s cancer patient is an example. Someone paid for her treatments. But preventive care or minor ailments may go unattended. The result is 18,000 unnecessary deaths.
I propose that we officially recognize that we already have a clumsy form of universal health care. Then let’s put a plan in place that makes it less clumsy and more efficient. Perhaps more preventive care will bring down the cost. Ideally, I’d have a single payer system with the U.S. government footing the bill along with co-payments by the patients. If a person wishes to purchase additional insurance to fund the copays that would be fine.
A tough issue that’s much like the debate over public education; health care is something we all need, but can we trust the government to manage it? I have my doubts.
To me the essence of government provided services is the economic economy of scale allowing us to “purchase” with our taxes those things which are necessary for life but otherwise too costly to provide for ourselves.
However, with health care, private industry, motivated by profit, does in fact meet the health care needs of the overwhelming majority of US citizens. It’s the profit motive which drives the innovation and advancement in medical science and the profit motive which builds and expands hospitals and private practices. This continuous improvement (new drugs, new procedures, new devices, etc) and expansion is, I would argue, just as essential to our continued collective health as the basic care is.
Would anyone here seriously trade the potential for increased life spans, improved geriatric quality of life, new cancer drugs, improved natal and neonatal care, etc. in order to have the government manage our health care? How about turning back the clock to a time when you could get a house call by the local GP, and pay for it with a chicken, but average life expectancy was just over 40 years?
To a large extent, Herb made this same point in his comments about the lack of innovation and cutting edge care available in Europe. I submit that far from being our “guinea pigs,” the Europeans and, for that matter, the rest of the world have been largely subsidized in their “universal health care systems” by US health care consumers. We are the ones paying for the global health care industry’s innovation and advancement which allows other countries to provide care for much lower costs than here. (But I digress.)
However, as bud says above, the precedent has been long established here in the US that health care, while maybe not a “Constitutional Right,” is certainly an expected entitlement (Medicare, Medicaid, laws against hospitals turning away patients, etc). Surely, as the wealthiest nation on the planet, we can afford to provide a “universal” minimum amount of care to everyone.
So I agree there’s really not much to debate over whether universal health care is a “right” or not; it’s already here, just very poorly executed. The real debate is just how do we make it happen without losing the best that we get from free-market incentives and not create another cumbersome and inefficient bureaucracy like we’ve managed to make out of our public education system?
Maybe we could start with the prescription drug and medical device industries and pass a law that required them to sell their products here in the US for the same lowest price (to include negotiated government purchases) that they sell them anywhere else overseas. That would immediately start to balance and spread the costs of research and development to all markets equally. The companies could still make as much profit as the market would bear, retaining the incentives to innovate, but US consumer costs should come down as foreign costs go up.
Can anyone point me to a HUGE, COMPLICATED, RLEATIVLY NEW government program that is not a total mess?
My problem is not the philosophical…but the logistical. I think if the US government was to become involved in a wholesale fashion our health care would be crushed under the weight of special interest, expense, unions, and ineptitude.
Whatever the merits of the policy…we just can not do it.
Chris
chris plays the “incompetent federal government” card. But I’ll bite. I think social security has worked very well for the last 70 years.
But chris misses (or didn’t read the above) the relevant. We already have universal health care with heavy government involvment. That’s already been established. It would be like someone arguing for an increase in the Pentagon budget and someone who opposes it says … “Can anyone point me to a HUGE, COMPLICATED, RLEATIVLY NEW government program that is not a total mess?” If we want a laissez-faire health care system then we’re going to have to allow people without money to go untreated and die. Otherwise we just need to acknowledge that we already have socialized medicine and try to make it better.
I did not mean to imply the incompetence is a federal issue. I have been studying state and local government mechanisms for the last 8 months, and let me just say that my findings are shocking. I was completely unaware of the breakdown of our governmental abilities.
Bud, you missed my point. I did not make a stand about whether or not changing the system was good thing. What I said was that we could not effectively administer a far reaching and comprehensive medical program…and that is a far different point.
My contention is that government is broken, and that the hyper-political atmosphere of the last 30 years has destroyed the very essence of our contract with the government. And as we see the failures of government (Katrina, Iraq, immigration…) we often confuse them with philosophical problems or differences, but in reality…our government is just plain inept.
Chris,
We already have government-run health care. It’s called Medicare and its serves those over 65 fairly well. My experience is that patients and physicians are just as satisfied with Medicare as private insurance. The big difference is that the overhead for Medicare is in the low single-digits (3-5%) while the overhead for private insurance is in the high teens (15-20%).
Like you, I favor the private sector providing a service rather than the government when possible. But in health care the government is providing the service more efficiently than the private sector and has being doing so for decades.
SGM,
It’s an open question as to whether innovation would suffer much under a government run program. A significant portion (I think I’ve read about one-third) of research funding in the medical field is already provided by the government (NIH, etc.).
Of that other two-thirds, which is provided by private industry, much is poorly spent. Private companies research for drugs/devices that will make a profit, not necessarily what’s best for patient care. The proliferation of “Me-too” drugs demonstrates this well. Company #1 comes out with a new drug (i.e., Pfizer discovers Viagra). That drug is really all the world needs. But it’s so lucrative that companies then spend millions to develop very similar drugs simply to capture part of the market share-witness Levitra and Cialis and the massive marketing campaigns that followed. Meanwhile, less lucrative drugs that would be much more beneficial for patients, such as new antibiotics, are neglected because they will never generate huge profits for the company.
Well, Paul, I don’t have any philosophical objections to a government provided universal health insurance type program.
As you pointed out, Medicare has been working pretty successfully for a long time. I personally have Tricare which is another federally administered program and am generally well served and satisfied. I do, however, have to pay premiums and co-pays just like any other insurance program. (For those who’ve never heard of it, it’s the DoD health insurance program used by military retirees and dependents of Active Duty Service Members.)
Of course, Tricare is actually managed by a private corporation that has a contract with the government, so as a practical matter there is a relatively low amount of direct gov. involvement. Again, it seems to me that the profit motive goes a long way towards the efficiency of the administration.
Your points about the funding of medical research are good ones. I didn’t actually realize that so much money was directly provided by the federal gov. I would have guessed maybe low double digits for a percentage, certainly not as much as 30%. But again, it seems to me that the profit motive is what drives most of the innovation, even for incremental improvements of existing things.
I would also suspect that the federal gov. directs how and on what most of its research money goes towards, and would further suspect that much of it is spent on those less lucrative projects that you mention (for that exact reason).
I suppose my concerns are really more in the area of bureaucratic inertia and waste that seems to grow exponentially as government programs expand. Your 3-5% overhead figure for Medicare is really astonishing, but I’ll take your word for it.
My question would be if the program was expanded (or another created) to serve 300 million health care consumers, would its overhead remain any where close to that? (And where would all those out of work private health care insurance company employees go, anyway?)
“Health care, in my view should be a social contract with all of us committing to pay our share so that all have access to care.”
And this, Paul, I imagine, is the root of a lot of disagreements we would have.
As a doctor with a six-figure income, it’s much easier to dictate to others what their positions ‘should” be, rather than what is actually right. Who determines “our share?” That sounds eerily Marxist.
The only reason I and my wife and kids have great insurance is because I have worked hard to provide for it through working. My health insurance through my firm costs me over $700 per month. With two small kids, and a 38 year old wife, and as a 45 year old male, I need insurance.
What I don’t want to do is have dictated to me, as a US citizen, what type of coverage I have, am entitled to, or if I can see a doctor at all, which is what happens when more and more government control is exerted.
I have no problem with providing care for those in need. We undoubtedly disagree, however, with whom those “needy” are, and why they’re needy.
Remove the illegal aliens from the free health care and government schools, then come back and tell us the real cost to real Americans.
Most of “the uninsured” are not the same “41 million” that are bandied about as if it were a real fact. Most real Americans without health insurance are just temporarily changing their insurance plans, or choose not to buy the insurance they can easily afford.
The rest are illegal aliens, who don’t count in serious analysis of this alleged problem.
Dr. DeMarco forgets to mention that those who pay cash for medical services are charged a much lower rate than those promising payment from Medicare, Medicaid, or some insurance company, because the doctor knows all of those plans plan to cheat the doctor.
Lee, could you direct me to those medical services that charge much less for cash customers? My experience has been the opposite. My family has a Health Savings Account (more later on why HSAs are NOT the answer) and a policy with a $5500 deductible that we’ve never hit, so we essentially pay all of our medical expenses in cash. Every time we get a medical bill, we’re charged “full retail,” and my wife or I has to call our insurer, give them the codes for the procedures, find out what the insurer would pay, then negotiate that rate with the provider. And I’m pretty sure that rate is not as low as the Medicare rate, because my family doctor has stopped taking on new Medicare patients.
I don’t doubt your claim that illegals contribute to rising health care costs, but at only 3-4% of the total population, their expense doesn’t explain why Americans 50% more for health care than other developed nations.
Incidentally, a single-payer system, in which health care “premiums” are collected like taxes, would eliminate a lot of the deadbeat problem you mentioned.
Economist Paul Krugman wrote an interesting article on health care cost in the Friday (2/17) New York Times. He cited a >report by the McKinsey Global Institute that examined the components of the $477 billion annual premium that Americans pay compared to our economic peer countries. The report attributed $98 billion to excess administrative fees, half of which came from insurers advertising and efforts to deny claims and weed out the people who might actually need health care. A single-payer system would eliminate most of that expense.
The report also found that Americans pay $66 billion more annually for drugs (adjusted for population and wealth differences) than our peers. This is hardly surprising, when we grant drug companies monopolies (patents) and don’t regulate prices (as we do with other state-granted monopolies, such as electric and gas utilities).
McKinsey estimated a cost of $77 billion annually to provide full coverage for the country’s uninsured. The cost savings from switching to a single-payer system and negotiating drug prices the way our peers do would more than cover the cost of extending insurance to all Americans.
I don’t know that I would consider health care a “right” any more than a full belly is a “right,” but, thankfully, most Americans still have the heart not to stand by while those less fortunate than us die of hunger or disease.
From a purely economic standpoint, health care for everyone is a good investment. Everybody loses when adults are too sick to work and kids are too sick to learn. Why do you think businesses started paying for worker health care in the first place?
The incentives and mechanics of the private insurance model are just too twisted to be functional. It’s time we adopt a single-payer system of universal coverage.
Why Health Savings Accounts are NOT the answer.
President Bush and a lot of folks trying desperately to preserve profiteering in the health care industry have been selling the idea of Health Savings Accounts as a way to use individual consumer pressure to drive down health care cost. I can tell you from my family’s personal experience that HSAs are NOT the answer to America’s health care crisis.
My family has had an HSA (or predecessor MSA) and high-deductible major medical insurance for over 10 years. In a good year (no major health issues or accidents in the family) the HSA saves us a little (hundreds, not thousands) off the standard coverage that my employer offers. On average we’re probably saving a bit, and we gain the flexibility of not worrying if our doctor of choice is on the “preferred provider” list.
But my family is young and healthy. We have never in those 10+ years exceeded our $5500 family deductible (so we have never gotten a penny of reimbursement from our insurer). We have had a string of years in which obscenely-priced prescription drugs and mind-boggling emergency room visit bills (kids will be kids!) have wiped out our HSA balance. So there’s no medical “nest egg.”
I suspect that many Americans, specially with our aging population, would fare far worse under the HSA than we have, hitting their deductible (plus 80/20!) every year and watching independent policy premiums skyrocket.
The HSA option does nothing to address the absurdity that insurers, who are paid presumably to pool risk, can maximize their profit by excluding the people most likely to need care, thereby transferring risk to providers and taxpayers.
As for HSAs encouraging price reductions through “smart shopping”, I suppose that paying all of our medical expenses out of pocket does make us think twice about minor things. But when your loved one is in pain or in danger of growing complications, you don’t take time to price shop.
I’ve seen several studies showing that Americans don’t voluntarily over-use health care, compared to other countries. Our hospital stays and doctor visits are shorter than in peer countries. I do believe our fee-for-service pay structure encourages providers to over-prescribe services, and we’ll need to address that regardless of how we restructure the payer side of the equation.
The bottom line on Health Savings Accounts is that they are useless for people too poor to pay for coverage now, they don’t offer any investment benefit to people serious health issues, and they won’t drive down costs significantly, even for the healthiest Americans.
“Single payer system” is a deceptive euphemism for a system when a minority of millions of productive citizens pays all the bills for many more millions who have no incentive to control their doctor visits or their appetites for unhealthy living.
“Negotiating drug prices” is a deceptive euphemism for government dictating to drug companies to hand over their intellectual property for much less than it is worth.
Such stupid, destructive and greedy desires, when converted into public policy, are disincentives for those who create innovative treatments and the wealth to deliver them the sick.
The only way socialist medical care can reduce costs is by cheating the caregivers, stealing from those who pay their own way, and denying care to those in critical need.
Medicare is currently 200 times the cost that it was originally projected to be on this date.
It is a miserable, corrupt failure.
Only those who are milking the system would dare to defend it.
Lee writes:
”
The only way socialist medical care can reduce costs is by cheating the caregivers, stealing from those who pay their own way, and denying care to those in critical need.
”
Again we have a conservative writer that fails to understand something very important — We have already agreed as a nation that we want socialized medicine. That is a fact. Free market health care is something we have long ago rejected as a nation. The only question for debate is how to best manage our American brand of socialized medicine.
As for medicare, it certainly has it’s share of corruption and inefficiency. But the same thing can be said for the United States military. It’s a red herring to continue to point out the fact that socialized health care has inefficiencies. I accept that it does. What I would like to see is a system that keeps these to a minimum while ensuring everyone has access to a reasonable level of health care.
McDoogle,
Your comments are appreciated and right on point. HSAs are a smoke screen. Most of uninsured are low wage workers who don’t pay enough taxes to benefit from an HSA. It’s a non-solution. It strikes me as a cynical attempt to appear to be addressing health care (i.e. to give Republicans something to talk about) while making almost no dent in the problem.
Lee,
Most of my patients who lack insurance are similar to the woman I describe in the article, people who have lost jobs as the textile economy has crumbled or who have lost coverage when their employer raised their premium out of reach.
You have a very distorted view of how medicine is actually practiced. I would invite you to come to my practice for a day to understand the inescapable hole some of my uninsured patients find themselves in.
Do I have some deadbeat uninsured patients-alcoholics, drug addicts, people who have made a mess of their lives? Sure, but that’s the minority.
And I share your anger and resentment of them not pulling their weight. I believe strongly in personal autonomy and free will. I believe even in a distressed county like Marion, anyone who really applies himself can have a decent life.
But whether I approve of the alcoholic or not is beside the point. Someone must pay for his care. Unless you advocate stepping over alcoholics as they bleed to death in the streets, someone is going to have to pay.
And that someone would be you and me. One way or another, through higher Blue Cross premiums, higher taxes to support Medicaid, higher Medicare premiums, etc. all the rest of us who can will be forced to pay the bill.
Since we must pay the bill anyway, why not streamline the healthcare system so that there is only one payer and all that unnecessary paperwork, all the insurance company denials and appeals, all the outrageous CEO pay go away. Imagine visiting a hospital or an ER and not receiving a bill. Hospitals would receive an annual budget allocation from the government and would be forced to live within that.
That would provide the kind of incentive you appreciate-to deliver care in the most efficient way. I imagine that as soon as this occurred, hospitals would take a hard look at their most expensive procedures and establish guidelines to ensure they were only offered to those who had evidence-based indications. So you might not get that MRI of the brain for your headache, which is often done just to placate a patient.
If you and Trajan didn’t want to be subject to these limitations, I’m sure you could count on the private sector to provide supplementary insurance fro you.
I think this fact is telling. According a 2003 Families USA report on CEO compensation,
the top administrator of Medicare earns about $130,000 a year. The average compensation for the top 20 insurance executives that year was over $11 million dollars, not to mention tens of millions more in stock options. Still think the private sector is leaner than government run health care?
Yes, Paul, thank you! Your input wise, thoughtful, and obviously factual, right out of every day practice. It deserves a front-line heading in every major newspaper and news magazine in this country. And speaking from an evangelical Christian perspective, I sincerely hope that many of my Christian brothers and sisters who tend to espouse right-wing politics will re-think this issue, and begin to see the need for what it is. In times past, Christians were on the cutting edge of social reform. Now we have too often been suckered by the false prophets of greed (no pun intended!).
One thing I really appreciated about my German insurance: every year, after age 45 (for me; age 30 for my wife) I got a “coupon” from the insurance for a yearly medical exam, including occult blood in stool, electrocardiogram, etc. (don’t know all the right terms, but you get the idea). What I can’t understand is that insurance companies here seem to have little interest in preventative medicine. Even the group we belong to (which is not a fraud, as some think, though there are fraudulent schemes out there–but it is simply Christians wanting to put NT Christianity into practice, doesn’t emphasize preventative medicine. Why do insurance companies, and even sharing programs like CCM, prefer to treat people after they get sick, instead of trying to prevent illness in the first place?
P. S. I nominate Paul DeMarco for Surgeon General–though maybe that really isn’t the best “bully pulpit” for him–but hopefully he will be heard!
Herb, if I’m not mistaken, the Germans are also the ones with cars which are 80% recycleable.
As a country, we are conservative and reactive in many ways.
1. Medicare is not an insurance program.
2. Medicare has never come close to controlling its costs, so I don’t know that any administrator is worth what they are being paid. On the other hand, if they hired a slightly more expensive person from the private sector, all the problems would probably be fixed in a year.
3. As a consultant to various medical device and pharmaceutical firms, and as the architect of computer systems for a major hospital here in SC, a medical school, a national medical insurance system for 2,500,000 employees and beneficiaries, and other national telemedicine initiatives, I think I know a low more about the big picture than a small town doctor who just feels sorry for his patients.
Folks, let’s not get Lee stirred up. Already, he’s up to his usual tricks of putting down anyone who disagrees with him as stupid or certainly not as smart as he is.
Brother Herb,
I appreciate your comments. Your perspective from Germany is a very valuable addition to the discussion. I would welcome more input about what you found good and bad about their system.
BTW, I am a fellow Christian (of the United Methodist variety. This weekend I led our youth group on a retreat to Springmaid Beach. It was great fun for me but not so much for my 13 year-old daughter, who is a member of the group. Her one instruction to me before we left: “Personal space (sweeping circumferential hand gesture). Three-foot radius.”).
And you’re right. Christians could be much more active on social justice and poverty issues. I’m disappointed that much of the focus is on emotional issues while issues that are fertile ground for quiet but productive Christian elbow grease are largely ignored.
Brother Lee,
You want a wider perspective. OK. Let’s go international.
1) Of the developed nations, the US is the only one without universal health care (UHC).
2) Americans pay twice as much per capita for health care than any other developed nation
3) Despite that lavish spending, our health outcomes as a nation are mediocre. Our infant mortality rate is near the bottom of the list of the top 33 developed nations, just above Latvia.
For more info visit the Physicians for a National Health Plan Website.
I respect your experience in the health care field, but there is no substitute for sitting at the bedside with another human being.
And although I love my patients, I’m not as myopic as you suggest. The big picture is always part of my decision making. For example, today I had a difficult discussion with the daughter of a frail elderly patient, telling her that his prognosis was so poor I didn’t feel comfortable transfusing any more blood into him (he has become reliant on occasional transfusions recently) because of the chronic blood shortage and my feeling that the blood could be better applied. She understood and agreed but it was still a heart-wrenching discussion; we were essentially cutting him adrift, giving up on his life in recognition of the scarcity of a precious resource and the greater need of younger, healthier patients more likely to benefit from the blood.
This kind of real life risk-benefit analysis is part of the job and give me what I hope is a broad perspective on not only the needs of my patients but the needs of our society as a whole. I’m not arguing for UHC for my patients alone. My patients know that they will be seen regardless of their ability to pay (although the thought of incurring a bill is still a significant disincentive). I’m arguing for UHC precisely because I have a broad perspective that comes from reading and talking to colleagues and knowing that too many patients in our country are not being well served .
Paul, your arguments are so convincing. They are filled with actual examples along with a fundemental understanding of the broader issues involved. I agree with everything you’ve said. I dread the day when I disagree with you on an important issue. You’ll be very difficult to score debating points against.
1. Many of the industrial nations, like Germany, are moving away from government programs. They have already made medical insurance and retirement totally portable and not tied to employment.
2. Americans pay more because they get better care, have more choices, and do not have to suffer the rationing, denial of care and killing of patients used by socialism to cut its costs.
3. Infant mortality is not a problem among Americans of European ancestry. Most of the pity statistics thrown out by socialists refer to the results of their other failed policies. Infant mortality and premature births are concentrated among blacks, young teenagers, drug addicts and illegal immigrants rushing here to get free ER delivery of an anchor baby that will enlist them on the welfare gravy train.
Using results of your broken social experiments as justification for a medical experiment is not a good argument among those of us who really care about cleaning up the entire socialist mess.
Lee,
Keep pitching me softballs. Responding to your points as you numbered them:
1) The US is the only developed country with an employer-based system. With universal health care (UHC), insurance is portable, so the millions of folks who are unable to change jobs because they will lose their coverage, or unable to make the leap from employment to starting their own business, or unable to decide to stay at home because their children need them more than they need the income will now be able.
2) Americans do get good medical care, and I wouldn’t argue that for those with insurance, it is the best in the world. The rub is that the WHO health outcome statistics include both insured and uninsured, so when the latter are factored in, we fall down the list. It is true that there will likely be some rationing in a UHC system as I’ve mentioned above, in the form of restricted formularies and decisions to limit procedures like dialysis. But I prefer those decisions than the current system which the Institute for Healthcare Improvement estimates causes 18,000 excess deaths in the uninsured every year.
3) Wow. That one speaks for itself. I’ll only say that roughly 70% of the uninsured are working and about 50% of them are non-Hispanic whites. I’m not interested in the “us versus them” arguments that you invoke.
It is true that illegal immigrants have very high non-insurance rates (I had a hard time finding a reliable estimate. A Kaiser Family Foundation report estimated the percentage of non-insurance for non-citizens who have lived less than 6 years in the US to be 51%, but this includes legal immigrants. For illegal immigrants I would guess it is in the 75% range).
My hope is that the drive for UHC will also put some momentum back into immigration reform as people realize that a UHC system without immigration reform would be subject to significant instability from waves of undocumented workers. But the bottom line is people are people (and sick people are sick people) no matter where they come from, what color they are, or what level of income they make, and somebody is going to have to pay for their care. A UHC system would be a much more rational way to do so and would be no skin off your nose, Lee, because unless you make $150,000 plus you would likely pay the same or less for your health care as you do now.
Lee, I began the process of leaving your compatriots years ago, because I realized that with the Goldwater crowd (as it was back then, which dates me, of course), the basic sin was not dealt with–greed. It lies at the basis of so much that this ideology believes in (because it wants to believe it), for example, that global warming is a figment of liberals’ imagination (so I can burn as much fossil fuel as I want). It is an ideology that looks down on others as inferior to self–the evil is out there, and if we can get rid of all those people out there, well, then, we will do just fine.
This is naive and dangerous, just as dangerous as thinking, on the other hand, that expanding an entitlement mentality will make people better.
I think our country is slowly but surely polarizing between these two, and somehow, some people have to lead in a way that challenges both extremes. That is what I find Paul, and Brad, in different avenues, and on different levels, basically arguing for, even though I wouldn’t always agree with them on all the specifics, but that is part of finding a consensus.
It is admittedly dangerous to try and lead this way. Some will try to pull it all one way, and create a socialist state, and that is naive. It stifles creativity and encourages the attitude that somebody else will take care of it. People don’t grow up; don’t take on challenges.
Others will try and pull it the other way–naively thinking, again, that human nature is basically good, and will do good things, if we just let it be good. It won’t. It will take advantage of the weak, and the gulf between the haves and have-nots will increase, until our society comes apart at the seams.
Somehow, we have to find a way between, on the one hand, an exorbitant, rabid, me-first have-it-all capitalism that awards a few lucky people, and, on the other, an entitlement attitude.
Paul, there is a lot of info on the German health system out there, some of it misleading. This article I just linked to uses the words “state health insurance plans,” which is not an accurate translation of the German word “Krankenkasse.” Here is a better description, of which I quote a portion:
Although the federal government has an important role in specifying national health care policies and although the Länder [provinces] control the hospital sector, the country’s health care system is not government run. Instead, it is administered by national and regional self-governing associations of payers and providers. These associations play key roles in specifying the details of national health policy and negotiate with one another about financing and providing health care. In addition, instead of being paid for by taxes, the system is financed mostly by health care insurance premiums, both compulsory and voluntary.
This safeguards somewhat the system from becoming what it is in England, and to a lesser extent perhaps, Canada.
Still, Germany has its problems, as any reading of the facts will have to admit. The problem has come through politicians using the system to make too many promises, so that people feel good and want to keep the powers that be in office. Nobody wants to bite the bullet, and roll back the benefits once they get too costly. After all, we like being able to go to a health spa when we feel achy, and let somebody else foot the bill (sorry for the sarcasm; I’m pretty healthy right now, talk is cheap for me).
But that’s human nature, isn’t it? We don’t want to bite the bullet here in this country, either.
Bottom line: find a way to provide the basics in health care for everybody, but don’t go beyond the basics. Children, yes. But over 18—make them get out and earn their keep. Keep profit incentives, let doctors earn good salaries, yes. There needs to be a balance, somehow. I’ll stop, time to go to bed.
Paul, what makes you think that Lee would object to stepping over dead and dying people in the street?
Poor and sick people just get what they deserve.
Right, Lee?
RTH, the most efficient health care system would accept that we will, on occassion, step over dying people in the streets. The costs would be lowest, the lines shortest. Health care would be distributed in the same way as other commodities, say, for example, plasma TVs. You just can’t have a pure, free-market system of health care distribution without accepting the pre-mature deaths of thousands of people. But, we as a people, have rejected that type of system. Lee may be a holdout for that, but he’s in the minority.
What is frustrating to me is that conservatives simply will not recognize what has occurred. They continue to harp about free-market solutions and the failures of socialized medicine in Canada/Europe. From now on I’m to refer to health care in the U.S. as Socio-US-Medicine or SUM for short. That way we can officially recognize that we have socialized medicine and move the debate toward how best to manage it.
Socialism is the only modern system which leaves dead and dying people in the street, and untreated in the hospital wards.
Socialist politicians deal with greed by catering to it, by pandering to the greed of people who who don’t want to take responsibility for their own health.
Socialist lie to these people, telling them that it is okay to fatten up on a Food Stamp Diet, drink cheap booze, shoot dope, and then expect a minority of productive individuals to pay for expensive medical experiments to correct years of misbehavior.
When these products of the Welfare Lifestyle become too expensive to treat in Europe, they are denied treatment, or injected with fatal doses of narcotics.
In America, they continue to receive expensive, futile intensive care, grossly inflating the overall cost of taxes and insurance to the responsible minority. Then the liars tell us that we need more socialism because “we have the most expensive healthcare in the world.”
Today’s headline from The State:
“Providence Northeast seeks to add beds”
– Hospital files with state to increase capacity, services
Can someone explain the rationale behind a hospital having to ask permission from the state government to expand the services they want to provide? How is the public interest served by such a requirement? And how much overhead do we end up paying for as consumers of medical services because of this regulation?
Lee, who knew that Dickensian England was a “socialist paradise?”
Please explain how unrestrained capitalism would prevent dead and dying in the streets?
When people get too old and infirm to keep up with work, the corporation fires them. Since their labor was a commodity bought for the lowest price, the workers won’t have saved much. If a younger individual was unlucky or unwise, he might have contracted a disease– especially since basic health-care, including breathing filters and clean water, was only available to those who could afford it.
Oh, well! There’s always charity of the rich to depend on.
Maybe you’re envisioning the streets of privately owned and operated, walled communities where the tiny number deserving rich would live. Naturally, these enclaves would have bubbles over them to prevent air pollution intrusion, also.
Lee writes:
”
Socialist politicians deal with greed by catering to it, by pandering to the greed of people who who don’t want to take responsibility for their own health.
”
Are you referring to Rush Limbaugh or Britany Spears, both of whom are conservative stalwarts?
Lee,
You’re mighty quick to brand any system with a government component as evil “socialism,” but I bet you don’t have a problem with the government taxing you to provide national defense. Why not eliminate that evil socialist program and hire your own army? Every man for himself. Hoo Ahh!
Contrary to your assessment, I am a strong believer in the capitalist system. No better way to deliver bushels of corn and iPods to the masses and let the power of individualized decision making do its magic. But a pure market model wouldn’t work for national defense, and it’s not working for private health care insurance. The incentives are all wrong.
To address a couple of your comments directly:
Are you suggesting that the private insurance system is controlling costs? Is that why my private insurance premiums go up 15-25% every year, though they’ve never paid me a penny in 11 years? Boy, I feel so much better paying the private insurance CEO 84 times more that of a government functionary, since he’s doing such a good job of keeping my premiums down.
Wrong. We could cut over $50 billion annually from by-passing the private insurance industry, (read the McKinsey report) who have totally dropped the ball by transferring much of the risk that they are paid to carry back to patients, providers, and taxpayers. UHC would eliminate the private bureaucracy for claims denial and weeding out of people likely to need care, among other private-specific costs, like advertising, campaign contributions, and plush lobbying junkets.
I’m not opposed to drug patents or other intellectual property rights, but you fail to explain how it makes any sense to grant monopoly rights to life saving drugs on the one hand and not exercise some restraint on monopoly prices on the other. I can live without a copyrighted book or a patent-protected iPod, but I might not be able to live without a patent-protected drug. When you’re dealing with life and death, the whole cost/benefit judgement breaks down because your life is basically worth every penny you’ve got. Therefore, it makes no sense to allow unrestrained monopoly drug pricing.
My local government granted Duke Energy monopoly control over the electrical grid. But they weren’t so naive as to let Duke charge whatever they feel like or believe the market can bear. Prices are regulated and every increase must be justified and approved. Under the arrangement, Duke manages to provide pretty good service and provide private shareholders with a reasonable return on their investment. The arrangement would seem to fit your definition of “socialist”, but most folks around here are pretty happy with the private-public system as is.
The whole patent/copyright system is a legal construct entirely of our own making. What law of nature or markets divined that designs or formulas should be protected for 17 years? Why not 2 years or 10,000 years? Interested parties got together and decided that 17 years struck a good balance between rewarding the inventors’ individual effort and allowing society to benefit from the new technologies (which build upon previous public-domain technology). Imagine if innovations like the boat hull or the wheel or the antibiotic were patent-protected in perpetuity. Such a social/legal construct would radically distort the progress of innovation and direct vast wealth towards people or companies who had little or nothing to do with the original innovation. So, we pick a number – 17 years. Who’s to say that that number shouldn’t be shorter for cancer drugs and longer for iPods? Society decides. I’m sorry if the S-word scares you.
Lee, if the private health insurance system worked in the open market the way iPods and bushels of corn do, we wouldn’t be having this discussion. Come to think of it, bushels of corn are subsidized, ostensibly to protect producers from the rigors of the free market. Go figure.
Brad, you should commend the writers on this post. Very little in the way of nasty bickering or personal attacks, just good ole fashion debating. I do think the pro-UHC folks are winning the debate. But perhaps I’m just biased.
Doug,
South Carolina is one of 36 states which have a certificate of need (CON) program. The CON program requires permission from DHEC for hospital expansions of a certain type or size.
I favor them. I think it makes sense for a disinterested party to look at the state as a whole and decide what services make sense. For-profit hospitals want to provide the services that make the most money, not necessarily the most needed.
One disturbing trend has been the proliferation of specialty hospitals (cardiovascular, orthopedic, women’s). These are attractive to investors because they are not required to have an emergency room so they can insulate themselves from undesirable (read: uninsured) patients.
I believe this is a perversion of a hospital’s obligation to the community. First and foremost, hospitals must safeguard the health of all the citizens in their catchment area. It is wrong for private hospitals to look for ways to skim off the cream while public or non-profit hospitals serve as the provider of last resort.
I have the same complaint about my colleagues who require hundreds of dollars in cash up front before they will see a patient. Unless your practice is in financial jeopardy, I believe it is unethical to refuse to see a patient who can’t pay.
Lee,
The above describes the way health care works when market forces predominate. Money trumps patient care. I’m a red-blooded American capitalist and find the private sector preferable in many areas. There’s no reason for the government to sell me a car or a refrigerator. But health care is a different animal. As a matter of policy, we have decided in the US that everyone is eligible for emergency care. If I owned a grocery store, my own sense of compassion would govern whether to gave a hungry person food. But as a doctor, I am legally (and morally) bound to provide care in an emergency.
That skews the private sector incentives in health care, making young, healthy people attractive to insurers. The sick, whom the system should be built to serve, become hot potatoes because the insurance companies don’t make money on them.
Think of how the auto industry would be different if dealerships were required to sell a car to any person who walked onto the lot, and that person paid only what they were able. Dealerships would strive to keep poor people off the lot. That’s what’s happening in today’s health care market. Just as car dealers would jack up prices to affluent people to cover the losses when a poor person sneaked on to the lot, taxpayers, businesses and employees are being asked to pay more and more to cover the uninsured. The situation has become untenable.
Automobile dealerships are better run than our hospitals. Illegal aliens and other deadbeats should not be counted in the statistics of those who “need” more medical care. They are criminals who have no right to be in the country.
Speaking of rights, no one has a right to material goods unless they EARNED with work, TRADED some other asset for it, or ACQUIRED it as a gift. What did those who don’t want to pay for their own medical care DO to EARN the right to make me work for them, and pay their doctor bills? Nothing.
Once you honestly admit they have no right to medical care, any more than they have right to a new car or ski boat, we can start discussing the moral methods of taking care of the very few CITIZENS in this country who really need some help.
Your patients have no right to a new car.
Nor to used car.
Nor to medicine or treatment.
So let’s discuss charity.
Paul, don’t try to confuse Lee with facts. What the hey does a doctor know about medicine?
Lee,
I understand your position entirely. I just disagree completely. Our philosophies are antithetical and I’m not really interested in trying to disabuse you of yours. Your philosophy is based solely on the individual; “every man for himself” seems to be your motto. While I recognize the importance of individual rights and the primacy of free will, I understand that sometimes factors beyond a person’s control affect his life and his health. My motto would be closer to MLK’s “We must learn to live together as brothers or perish together as fools.”
You may feel that you can step over the bleeding bum with a clear conscience-more power to you. Compassion will not allow me to do that. If that’s a failing, then I’ll freely admit it.
Read the biblical stories of Jesus’ healings. He doesn’t just heal the worthy. His is an example that I think all of us should follow.
Lee writes:
“Automobile dealerships are better run than our hospitals.”
Have you had to have your car serviced at a dealer lately? Try it and you might change your mind.
Dr. DeMarco,
Most of your patients are operating on the philosphy of getting as much medical care as they can at someone else’s expense. That is immoral.
If you want to donate what you own, out of your time and pockets, that is fine. If you donate too much, you will go broke, close your practice and stop treating anyone.
On a larger scale, the same thing will happen if the moochers are able to control the system. They will milk it dry and shut it down. That’s why America has to let those who pay their own way and those who produce wealth to establish the details of all distribution of all goods and services. The free riders are still better off as low-level consumers or charity cases, than if they had control and looted the system dry.
Socialism and other primitive economic systems simply don’t produce enough wealth to be able to afford charity care for the needy and clean environments.
In fact, Paul, you don’t disagree with my analysis at all. You simply walked away because you were unable to dispute my description of the circumstances.
The fact remains that those wanting the freebies want them because most of them are irresponsible people who did nothing to EARN a right to medical care by purchasing it.
Lee thinks Dr. DeMarco’s cancer patient was looking for a freebie. Given that this poor woman could not ever pay for her care regardless of how responsible she was shows just how delusional some folks can get on this issue.
Contrary to your feeble straw man, bud, no one claims that there are a FEW people in need of charity, for medical care, housing, clothing and food. But most of the people demanding that other people finance their lives are simply lazy and greedy, and made poor choices in remaining illiterate and abusing drugs.
Picking out one or two legitimate charity cases is no argument for supporting the vast numbers of deadbeats.
But you, like Dr. DeMarco, already knew you could not make an honest and direct argument for using armed force to funnel money to those who have CHOSEN an unhealthy lifestyle without medical insurance. That’s why both of you use bogus emotional devices. Dr. DeMarco is just more sincere and sophisticated about it, because he actually wants to help others, instead of trying to help himself to the earning of Other People.
Lee,
I’m in the process of writing a resolution on universal health care (UHC) for presentation and debate before the South Carolina Medical Association’s House of Delegates in May. I have been researching other similar resolutions and found one I like on the Physicians for a National Health Plan website. I’ve included it to give you some of the arguments for UHC, as listed in the WHEREAS clauses.
WHEREAS, the number of Americans uninsured is in excess of 46.6 million and tens of millions more Americans are underinsured and growing1;
WHEREAS, physicians have a moral imperative to advocate for a healthcare system in which all Americans have guaranteed access to high quality and affordable healthcare;
WHEREAS, business is increasingly withdrawing coverage from employees1;
Whereas, the quality of practice for physicians is declining and the lack of control over the practice of medicine (e.g. reimbursements, procedures and formularies) is growing;
WHEREAS, the healthcare infrastructure is inadequate and deteriorating (e.g. reduction in number of emergency rooms2, decrease in hospital beds3 and a decline in the ability to fulfill projected physician workforce requirements4);
WHEREAS, in the new global economy, American companies are at a competitive disadvantage, in part due to health care costs;
WHEREAS, our hodgepodge healthcare system is inadequate to meet homeland security threats (e.g. natural disasters, possible flu epidemics5 and terrorist attacks);
WHEREAS, universal health insurance would guarantee payment for all patients treated;
WHEREAS, the U.S. spends twice as much per capita in healthcare costs compared to other western democracies, yet fails to include all its citizens and fails to achieve equivalent healthcare statistics (e.g. life expectancy, infant mortality and vaccination rate)3;
WHEREAS, a single source government health insurance, i.e. Medicare, would reduce the vast sums of money spent on administrative costs that could more appropriately go to direct patient care6;
WHEREAS, medical malpractice premiums would decrease because settlements would not have to cover future medical expenses of the plaintiff;
WHEREAS, universal Medicare would increase choice of doctors and portability and eliminate job lock;
NOW, THEREFORE BE IT Resolved: that the (Name of Organization) does hereby endorse and will support HR 676, United States National Health Insurance Act.
****************************************
I thought it might be fun to create a counter resolution using some of your arguments (in your own words) on this thread, so here goes:
WHEREAS, Most of “the uninsured” are not the same “41 million” that are bandied about as if it were a real fact. Most real Americans without health insurance are just temporarily changing their insurance plans, or choose not to buy the insurance they can easily afford;
WHEREAS, The rest are illegal aliens, who don’t count in serious analysis of this alleged problem;
WHEREAS, “Single payer system” is a deceptive euphemism for a system when a minority of millions of productive citizens pays all the bills for many more millions who have no incentive to control their doctor visits or their appetites for unhealthy living;
WHEREAS, stupid, destructive and greedy desires, when converted into public policy, are disincentives for those who create innovative treatments and the wealth to deliver them the sick;
WHEREAS, (Medicare) is a miserable, corrupt failure (and)
Only those who are milking the system would dare to defend it;
WHEREAS, Infant mortality is not a problem among Americans of European ancestry. Most of the pity statistics thrown out by socialists refer to the results of their other failed policies. Infant mortality and premature births are concentrated among blacks, young teenagers, drug addicts and illegal immigrants rushing here to get free ER delivery of an another baby that will enlist them on the welfare gravy train;
WHEREAS, The free riders are still better off as low-level consumers or charity cases, than if they had control and looted the system dry;
NOW, THEREFORE BE IT Resolved:
1) (That) Americans pay more because they get better care, have more choices, and do not have to suffer the rationing, denial of care and killing of patients used by socialism to cut its costs; and
2) (That) once you honestly admit they have no right to medical care, any more than they have right to a new car or ski boat, we can start discussing the moral methods of taking care of the very few CITIZENS in this country who really need some help.
******************************************
Quite a contrast. It appears our positions are irreconcilable, although we seem to understand each other. Sometimes that’s the best you can do.
*******************************************
One parting shot: you feel very strongly about only having a right to what you have earned.
But not every good thing in life can be earned by one’s own effort. What did you do to earn your freedom? You can’t possibly repay all the money and lives spent over the past 230 years to preserve it.
What did you do to earn the right to drive on the road that took you to work today, or the Interstate?. All the taxes that you have personally ever paid in your life for roads probably wouldn’t build one long enough to get you out of your neighborhood.
But our road system works (as does our public school system, our armed forces, our national parks system, etc.) because we pool our resources to do what none of us could do alone. Our health care system should be based on the same model.
WHEREAS all of the assertions made by advocates of nationalizing medical care are bogus fabrications, socialist proposals can be ignored as dishonest greed and ignorance.
I earned the right to drive on public roads by
* Producing wealth for my employers and clients.
* Buying my own vehicles.
* Paying fuel taxes which are excessive for the amounts actually needed to pay for my use of the roads.
No one does anything to earn charity or government welfare handouts. The Supreme Court has ruled that no one has a right to Social Security, Medicare or Medicaid, because these are welfare programs.