The Health Care Debate

by publius starbursts

I’m ecstatic that McCain’s health care plan has taken center stage on the campaign trail. It’s a debate worth having. Unlike the juvenile nonsense we’ve endured for most of the campaign, it’s a truly substantive political debate — one that illustrates the deeper philosophical differences between the candidates and their parties. It also illustrates — to me, anyway — an important theoretical flaw with conservative economic ideology.

For fellow non-health wonks, I heartily recommend Ezra Klein’s accessible post summarizing the central problems with McCain’s health benefits tax. The nickel version is that the problem isn’t the tax itself, but the tax’s structural effects upon the health care market. McCain’s plan would essentially create a world where individuals are tossed out on their own, with little bargaining power and even less information.

In other words, the tax is bad even we assume it’s completely revenue neutral. Let’s pretend, for instance, that McCain’s tax doesn’t really cost you anything. Let's pretend the proposed tax increase on employer benefits is completely offset by tax credits and higher wages. Let’s even pretend that the tax credit is pegged to inflation medical costs (McCain’s is not, so the credit becomes worth less and less each year).

Even under these assumptions, the plan is still flawed at its core because of the way it restructures the market. As Klein explains, the effect of the tax increase is to cause employers to drop benefits, thus forcing employees into the individual market. The tax credit has the same effect — even individuals without employer coverage will start buying individual plans. In short, the vision of the McCain plan is a system consciously premised upon an “individual” market that is subsidized by taxes and tax credits. Klein, however, explains the problems with elevating individual markets to be the foundation of our health care system:

The individual insurance market is not the same as the employer-based insurance market. It sacrifices the bargaining powers of numbers for the cost-effectiveness of comparison shopping. It is fractured. It has higher administrative costs. Insurers can discriminate on the basis of preexisting conditions, geography, age, gender, and even simple whim. The risk pools are smaller. The deductibles are higher, as are the co-pays, and the spending caps are lower. And the individual insurance market is much more expensive[.]

Sounds lovely. That’s all bad obviously, but I want to focus more specifically on the bargaining power issue. One of my biggest gripes with conservative economic policy is its tendency to ignore disparities in bargaining power.

The romantic myth of individualism is powerful, but it ultimately just doesn’t work in many contexts. Health care is one of them. Look, it would be great to have a world where individuals had the time and expertise to shop around and negotiate for better policies. But they don’t. However rhetorically compelling “individualism” may be, the reality of an individual market is quite different — as Klein notes.

But it’s more than health care policy. The failure to give much weight to bargaining power disparities is at the heart of many a conservative/liberal economic disputes. Take unions for instance, or federal labor protections more generally. The standard conservative argument is that if employers act bad, employees can leave. Or, if they don’t pay enough, employees can just bargain. After all, everyone loves bargaining! (“Bargain” was a semi-erotic word for my old law and econ professors). These romantic visions, however, assume that individual employees have a lot more information, resources, and bargaining power than they actually have.

More broadly, the debate helps reaffirm the larger theme that government can be good. Indeed, government regulation is the end-all, be-all in correcting asymmetries in bargaining power and information. It's like a giant union in that respect. Even the employer-based system — for all its flaws — at least tries to address these problems. A real national health care reform would go even further.

A Republican administration, however, isn’t going to address these types of problems. That's because, in their world, markets don’t generally create these sorts of problems.

One last point — remember that the argument here isn’t so much about whether markets are good or not. There is no true “Left” in America — everyone believes in markets, including yours truly. The argument, then, is over what types of markets work best in what contexts. McCain thinks health care is a context where individual markets work best. Obama doesn’t. These differences are profound — on both a practical and theoretical level.

Comments

[iocaste]

One thing that did occur to me, though - and I haven't studied it, but isn't it true that if McCain's plan goes through, all those individuals are no longer covered by ERISA? Which ... well, I can't even guess what the full effects would be but at least to some extent it would mean that ERISA would no longer preempt claims against insurance companies for denial of benefits.

[magistra]

The fairness argument against individual health-care insurance is a very simple one. The poor are more likely to get sick (poor housing and diet, extra stress etc) and the sick are more likely to be poor (extra expenses and problems of holding down a well-paid job). So any individual based scheme is always going to mean higher insurance payments for those least able to afford it. The only way to justify such unfairness is to blame poor people for being poor and sick people for being sick in the first place, which is a common right-wing tactic.

[John Spragge]

I usually point out one fact and ask one question in these discussions.

Fact: neither the United States nor, as far as I know, any other industrialized nation has a "market" in health care. We have health systems, whether "socialized" or "private", dominated by "self-governing professions", aka medieval craft guilds. Maybe that works better than any alternative, but let's not kid ourselves that we have a free market. Don't take my word for it, look at Milton Friedman's writings on the subject.

Question (for conservatives): what would it take for you to abandon one American community to an invader? Imagine a small, isolated, and dysfunctional American community on the Florida Keys occupied by someone (say Cuba). How poor, how dysfunctional, how much of a net recipient of social spending would that community have to get before you would tell the US military not to bother and just let Raul Castro have 'em? Because, given what I read from conservatives in the blogsphere, no level of dysfunction would suffice. Not one inch of American soil, and not one American citizen would they leave to an invader. So why would you surrender to disease what you will never cede to a human conqueror? After all, you can tell Raul Castro "this far and no further", but you can't negotiate with an HI virus or a tuberculosis bacilli.

[Suzii]

Anyone else old enough to remember the joy that greeted the breakup of Ma Bell? The increased productivity that came to the economy when *Every* *Single* *Household* suddenly got to have one or more members divert hours and energy to reading page after page of small type about long-distance plans?

Anybody know one single person who experienced that change as an opportunity to get better service at lower prices? Heck, for all I know, some people *did* get better service at lower prices -- but they didn't enjoy it much, after the ordeal of shopping for it. It was horrible. Grandparents wept, and Johnny Carson cracked bitter jokes.

Now imagine shopping for something infinitely more complex than long-distance service, and knowing that if you screw up there's infinitely more on the line than an excessive phone bill.

I'm not sure it's possible for anybody but a sociopath to have lived through those days and think the American people want the freedom to shop for a better deal on their health care. Well ... a sociopath or somebody wealthy enough to have assigned the first choice to an executive assistant.

[Feddie]

I actually agree with many of your points in this post. The disparity of bargaining power in the health-care market cannot be ignored. What needs to happen is for small businesses to be able to pool together into associations to level the playing field. As a lawyer who always worked for smaller firms, I've never understood why a group liie the ABA should not be able to offer its members group coverage. It's just ridiculous.

If something isn't done soon, we'll be adopting some crappy Canadian system of health care, and who in his/her right mind wants that?

[BrianERogers]

As an HR professional for a multi-billion dollar national company, I'll second the concerns in this post. Our company has a national department of roughly 30 well compensated people whose job it is to read the various plans, analyze them, compare them to each other and then bargain with the providers for better deals. They face questions like "is switching to this less expensive provider better than the costs of displacing our associates coverage?" and "is the plan really less expesnive when we factor in the quality of service?" The idea that every single American family will have the time and expertise to do the same thing on an occasional basis is, quite simply, insanity.

[Jesurgislac]

So any individual based scheme is always going to mean higher insurance payments for those least able to afford it.

*nods* I was looking at the WHO health care survey data again, and noticed something interesting: on fairness of financial contribution, the US is ranked 54-55 (equally with Fiji). (WHO measures this by reckoning a system is absolutely fair if the burden of total health payment for each household is the same. So the measurement requires (a) how much the household spends for health services and (b) how much is the household’s effective income above subsistence.)

Fiji, by the way, has a DALE health level (Disability Adjusted Life Expectancy - “the expected number of years to be lived in what might be termed the equivalent of ‘full health’.”) of 106 and ranks at 71 in distribution: it ranks 87 in health expenditure per capita in international dollars, and it is ranked at 96 in overall health care system performance.

By contrast:

The UK is ranked 8-11, equal with Japan and Norway on fairness. Our DALE rank is 14, and we are 26th in the world on health expenditure per capita in international dollars. And we are 18th in the world on health care performance over all. Oh, and WHO reckons us as best in the world on health care distribution.

Norway is about the same as the UK on DALE (15) and almost as good as the UK on distribution (4). They do better than the UK overall (Norway’s WHO rank is 11, ours is 18). Norway is 16th in the world on health expenditure per capita in international dollars.

Japan is best in the world on DALE, between the UK and Norway on distribution (3) and slightly better than Norway on overall performance (10). Japan is 13th in the world on health expenditure per capita in international dollars.

The US ranks 32 on distribution of health care, and famously, of course, is the most expensive per capita health care system in the world.

What I found was: Every country in the world that does better than the US on DALE and better than the US on distribution, also manages to provide health care more cheaply, and distributes the cost of paying for it more fairly.

I don't think these are unrelated data.

[Michael Cain]

Anyone else old enough to remember the joy that greeted the breakup of Ma Bell.... Anybody know one single person who experienced that change as an opportunity to get better service at lower prices?

Lived through it on the inside. Large businesses loved the breakup. One person talking to a few of the new providers could save a large firm at least hundreds of thousands of dollars per year. My job at the time was to build and use custom test equipment to measure quality of service, and I can assure you that during the first few years, all other providers' service was worse than AT&T's. But a lot cheaper.

[Gary Farber]

"starbursts"

?

"If something isn't done soon, we'll be adopting some crappy Canadian system of health care, and who in his/her right mind wants that?"

Me, me! The Canadian system is fantastic! I'd have endless health care I don't have now. And I don't know a single Canadian -- and I know a whole lot of Canadians, a couple of hundred -- who don't love their health care system!

[cw]

Jes, WHO reckons us as best in the world on health care distribution.

For those not familiar with Jes, the "us" is the UK.

Feddie, some crappy Canadian system of health care, and who in his/her right mind wants that?

I'm not sure if you're kidding or not. In case you're not, the Canadian system beats the U.S. one in almost every important measure. I live part-time there and know many Canadians. Although they complain about their system too (who doesn't?) I don't know anyone up there who would trade.

DRAT - as always, Gary beat me to it.

[Gary Farber]

"DRAT - as always, Gary beat me to it."

Not always, but I should have written "who doesn't love," in any case.

[Jesurgislac]

cw: For those not familiar with Jes, the "us" is the UK.

Thank you. The post was a subset of one on my journal, and had more context there.

[Pithlord]

I'm a Canadian. I have been fortunate to have relatively good health, but my father died in a Canadian hospital last year, and I have family members with serious chronic illnesses. And I have serious problems with the Canadian system. I doubt very much that Americans with access to an HMO or to Medicare or Medicaid would prefer it. "The Barbarian Invasions" gives you an idea. People are left to die in hospital rooms stuffed to the gills that are like the corridors of the Motor Vehicle branch. Emergency room times are unbelievable and would shock Americans. And if you want surgery for a non-life-threatening-but-painful-and-debilitating condition, you buy a ticket to the United States.

And it looks like the Canadian system will (a) collapse under the weight of increased costs, and (b) be supplemented by a market system within the next twenty years.

Canadian supporters of the status quo do what Republican supporters of Guantanomo Bay do -- they just question your patriotism. Even though more than half of Canadians would like to see a change.

It's true that almost no one wants to go to the American system. But in this big world, there are more alternatives than that.

On McCain's plan, there is considerable sense in detaching health benefits from employment -- indeed, that is one of the advantages of the Canadian system. The difficulty is to make sure there are adequate pools for insurance. For big employers, the pool of employees is good because it avoids adverse selection problems and provides for bargaining power. But there is no need to put the thumb of the tax system on the scales.

[Jesurgislac]

People are left to die in hospital rooms stuffed to the gills that are like the corridors of the Motor Vehicle branch.

Hm. Got any stats to back this up? Because it is a standard right-wing meme that in socialist health care systems "people are left to die". (It tends to ignore the slightly obvious, that in any hospital at any time, some of the patients are going to die.)

Emergency room times are unbelievable and would shock Americans.

In the US:

25% of heart attack patients have to wait at least 50 minutes before they are seen by a doctor in American emergency rooms (ERs), says a report by the Harvard Medical School. The average wait for a heart attack patient in an ER in 2004 was 20 minutes compared to 8 minutes in 1997 - an increase of 150%. In general, Americans in 2004 had 36% longer ER waits in 2004 compared to 1997. A patient who was seen by a triage nurse and had been classed as one who needed immediate attention had a 40% longer wait in 2004 compared to 1997 (from 10 minutes to 14 minutes).Medical News Today, January 2008

In Canada: CTVnews, November 2005:

The guidelines Schull refers to are in the Canadian Triage and Acuity Scale (CTAS), recognized by doctors and emergency rooms across Canada as the standard on how long all patients should wait.

For example, Category 2 patients, those with severe chest pain, trouble breathing, or other serious symptoms, are supposed to be seen by a doctor within 15 minutes. In Ontario last year, those patients waited twice that long, on average. Some very ill people waited as long as two hours.

"This picture is basically the same across the country," said Dr. Schull.

So it looks like your "shocking ER wait times in Canada" were, three years ago... about the same as the ER wait times in the US today. Except that because the wait times in Canadian emergency rooms were shocking, the Canadian government then instituted a program to improve them.

Have you got any stats to show that the Canadian emergency room wait times have got worse over the past three years? Better? The same?

And if you want surgery for a non-life-threatening-but-painful-and-debilitating condition, you buy a ticket to the United States.

Got stats to prove this?

[The Conservative Deflator]

As I have said so many times before, the problem with these conservatives (one of many) is that they are at heart, starry eyed utopians. They believe, despite mountains of evidence to the contrary, that the free market is such a glorious thing that left to operate, it will solve all of our problems. This just ain't true, and McCain's idiotic health care "plan" is a sterling example of that.

Millions of Americans would end up uninsured or grossly underinsured under McCain's plans. Ask yourself - do you have time to drive around your city or town, shopping for health insurance, not knowing what questions to ask or what many insurance terms mean? It is a fucking absurd idea. Period.

[liberal japonicus]

Emergency room times are unbelievable and would shock Americans.

Ha. Two times in the past 5 years, I've had to deal with emergency room waits, one in LA and one in Mississippi. I assure you, if I had even been in rock throwing distance of the hour mark, I would have been dancing a jig. One of these was an unknown disease that was growing more serious by the minute, and the other was a broken arm. As a Canadian, I don't think you have any idea how badly the US health system is broken.

[Cyllan]

Emergency room times are unbelievable and would shock Americans.

We have wait times in some emergency rooms that average over 12 hours. Go ahead. Shock me.

[Dan Miller]

Publius, there's an error in your post. McCain's tax break is indexed to inflation--the CPI, specifically. Medical costs typically grow much faster than CPI, so it doesn't affect your larger point, but you might want to correct that for the sake of technical accuracy. From the NY Times blog The Caucus:

"According to [McCain adviser] Mr. Holtz-Eakin, the McCain health care tax credits would be indexed to “regular inflation,” presumably the Consumer Price Index, which is typically lower than annual increases in health care costs. Unless costs can be substantially reined in, the credits would therefore enable fewer people to afford coverage each year, leading to an eventual rise in the number of uninsured."

[publius]

yep - got it. thanks

[Gary Farber]

"We have wait times in some emergency rooms that average over 12 hours."

It's useful to provide a credible cite, so we can see exact figures. Thanks!

[Nell]

Thanks for this post, publius.

The first thing that came to mind when I read your explanation of the McCain 'plan' was of the frightening imagery of being left on one's own, up against the insurance companies.

That's already the situation for the millions of us without employer coverage, but it's probably an even more frightening prospect for the many more people with employer coverage now. People hate and fear insurance companies. So it ought to be simple to do a very effective ad.

In contrast, Obama's current ad, one whose goal is a positive view of his plan rather than attacking McCain's, is infuriating and insulting to those of us without health insurance coverage. It's aimed, apparently, at the -- admittedly far more numerous -- voters with employer-tied health insurance, to fend off McCain's "socialized medicine" attacks. It makes me want very much to move to Canada.

[liberal japonicus]

I'm thinking that Cyllan is talking about 'boarding', where patients are kept in emergency rooms because there are no regular beds available.

[Feddie]

Geez, people. I agree with one of Publius's post, and all y'all do is criticize my obligatory shot at the Canadian health-care system.

Can't a conservative catch a break around here? :)

[Lewis Carroll]

On the subject of relative bargaining power, this seems relevant:

"We rarely hear, it has been said, of the combinations of masters, though frequently of those of workmen. But whoever imagines, upon this account, that masters rarely combine, is as ignorant of the world as of the subject. Masters are always and everywhere in a sort of tacit, but constant and uniform combination, not to raise the wages of labour above their actual rate. To violate this combination is everywhere a most unpopular action, and a sort of reproach to a master among his neighbours and equals. We seldom, indeed, hear of this combination, because it is the usual, and one may say, the natural state of things, which nobody ever hears of. Masters, too, sometimes enter into particular combinations to sink the wages of labour even below this rate. These are always conducted with the utmost silence and secrecy, till the moment of execution, and when the workmen yield, as they sometimes do, without resistance, though severely felt by them, they are never heard of by other people."

-- From well-known central planning advocate Adam Smith, Wealth of Nations, Book 1, Chapter 8

[liberal japonicus]

Can't a conservative catch a break around here? :)

With the current Republican ticket? No...

8^)

[Cyllan]

I'm thinking that Cyllan is talking about 'boarding', where patients are kept in emergency rooms because there are no regular beds available.

In some part. Boarding is a problem, but it's not the only factor in the emergency room waiting. Wait times are particularly poor for patients seeking non emergency care in an emergency room. Wait times at Grady Hospital regularly reach eight hours and can sometimes stretch to 12 hours or more.

Critical care patient wait time is up as well, but this cite has been brought up before.

[Mike Schilling]

Thanks, Publius. I've been making these exact points (expertise and bargaining power) for years, to anyone who would listen.

Cute wink too, but, well, I'm already seeing someone.

[OCSteve]

Can't a conservative catch a break around here? :)

Which bone do you prefer broken?

[Jesurgislac]

Feddie: my obligatory shot at the Canadian health-care system.

Just because it's an obligation of your employment by the Republican party doesn't mean you have to take their money. But thanks for admitting it's something you have to do, rather than something you actually mean.

[mightygodking]

I'm a Canadian. I have been fortunate to have relatively good health, but my father died in a Canadian hospital last year, and I have family members with serious chronic illnesses. And I have serious problems with the Canadian system.

I'm a Canadian too, and while I freely grant that our system has serious issues with wait times - particularly in smaller provinces and rural areas where universal coverage is far more difficult to efficiently manage - I know full well that these problems are well outweighed by the benefits the system provides.

I also know that the issues with wait times arose from conscious policy decisions in the 1990s, when the country was in severe economic straits. Turnaround time on these issues simply isn't rapid - especially when the government is a right-wing Tory one with little active interest in improving public healthcare.

[Gary Farber]

Feddie: my obligatory shot at the Canadian health-care system.

Just because it's an obligation of your employment by the Republican party doesn't mean you have to take their money. But thanks for admitting it's something you have to do, rather than something you actually mean.

It's possible that when someone is displaying good humor, by making a harmless and self-deprecating remark, that coming down on them like a dull lead weight, isn't the only, or even best, option.

[Feddie]

Yet another reason why I am conservative. You people need to lighten up.

Heaven forbid, Obama actually loses. Y'all will really lose it then, won't you?

[Feddie]

Thanks, Gary.

[J. Michael Neal]

The only time I've been to an emergency room and waited less than an hour was for a sprained ankle. They got to me almost immediately that time. Suicidal depression? About an hour and a half. Uncontrolled shaking of unknown cause? More than an hour. My (now ex-)wife's deep vein thrombosis, complete with pulminary embolism? About two hours.

Recently, I was suffering from a sinus infection. The first available appointment with my doctor was seven days later.

[cleek]

Wait times are particularly poor for patients seeking non emergency care in an emergency room.

um ... ? why should it be otherwise ?

the only time i can even get to see my G.P. without having to wait a week is if i have something serious, like a killer ear infection. maybe i can get in that same day, if i call early in the AM. it takes literally months for me to see a dermatologist or allergist. if i show up at the emergency room with a rash or a bit of ennui, why should i expect to get seen before any serious cases are dealt with?

and, it's trivially easy to find reports of people dying in American ER waiting rooms because they sat 10 or 12 or 18 hours before a doctor got to them.

[Cyllan]

um ... ? why should it be otherwise ?

Generally, I'd like to envision a health care system in which non emergency care isn't provided for by an emergency room. It's simply one more symptom of the mess our current system offers us.

Curiously, I have never had problems getting in to see a dermatologist. The longest I've had to wait was 3 or 4 days.

[Jesurgislac]

Feddie: Yet another reason why I am conservative. You people need to lighten up.

Sheesh, Feddie. I wouldn't have made a joke about your being in the pay of the Republican Party if I'd realised you'd take it so seriously. Got any reason to have no sense of humor when you're teased about being a paid shill for the Republicans? Or is this just the famous right-wing rage and self-pity causing you to complain?

[John Spragge]

As a Canadian who has spent about a sixth of my life in the US, and belonged to HMOs and PPOs and had health care from one of the most respected teaching and research medical centres in the US, I have this to say: the US system has a lot to recommend it, but this idea that if Americans get sick they don't have to wait just doesn't match the reality I know. Logic dictates that in a finite system, where demand sometimes outstrips capacity, people will sometimes have to wait. That happens in both the United States and in Canada.

You could do much worse than our single-payer system; indeed, in many respects and for many Americans, I fear that you already do. I have no doubt that, given the resources you already put into your medical system, you could do better.

[Jeff]

We have health systems, whether "socialized" or "private", dominated by "self-governing professions", aka medieval craft guilds.

I think this is a crack at the AMA, because Randians believe any idiot should be able to call themselves a "doctor", and the "market" will get rid of the quacks. The many people who will suffer or die in the meantime don't matter to Randians, because Rand was careful not to include them in her Holy Books.

[efgoldman]

Several quick hits:

- thanks publius for bringing up the more general point about bargaining. Ever since Reagan fired the air traffic controllers, the repubs have made it their sworn duty to do away with any semblance of collective bargaining. They've done a damn fine job of it, too, abetted by some stupid union leadership that acted as if it was still the 1930's.

- It is a myth that ERs see and handle acute patients quickly. My wife has chronic diseases that have acute episodes, often with unbearable pain. There are three ERs within easy distance of our home, that the 911 ambulance might use. We have multiple experiences with all three (and I've been to the ER mysef a few times). My wife has been left on a gurney in the corridor many times (it is a capacity issue) and our turnaround times have ranged from a best of 3-4 hours to as long as 14-16 hours.

- note that people are kept longer in the ER *precisely* because the insurance companies are so aggressive about forcing clinicians to justify an admission for anything other than well-defined acute conditions (heart attacks, burst appendix, etc.) When was the last time any of you, or anyone you know, was admitted solely because they couldn't tell what you had, and a day or two of diagnostic tests were required.

- a sub-comment on the previous: note that the incentive against using the ER is exclusive to insured patients. Our ER copay is $100. An uninsured, poor patient generally pays nothing. I don't resent that, I wouldn't want ever to be in the place of the uninsured poor, just pointing out a fact.

- There might in fact be a market solution to at least part of the ER problem: the "minute clinics" (under various names) which are being opened in large chain stores. CVS and other chains want to start clinics in Massachusetts. Guess who's fighting it the hardest? Why, its the hospitals, their lobbyists and their political lapdogs. What a surprise! (BTW, so called "urgent care" facilities are not the same thing. They are insurance-dependent and some won't see uninsured patients or patients who's insurance they don't take).

- Employers are becoming more cognizant of employee health issues, and what even a simple illness (strep throat, say, or a 24-hour virus) can cost in terms of absenteeism and productivity. Many large employers (mine and my daughter's included) have established on-site clinics with very low or no copays. Downside: privacy issues; if its a company clinic, on company property, can the clinic report to HR when employees have certain chronic diseases (diabetes) or perhaps a positive drug test (not otherwise required for employment) or an STD?

Sorry turned out not such a quick hit. And kind of lost the direction of the original thread, which is that McCain's so-called market-based solution is just so much idiocy.

[Jen]

And if you want surgery for a non-life-threatening-but-painful-and-debilitating condition, you buy a ticket to the United States.

Massive exaggeration there. Funding cutbacks, not structural problems, have led to some backlogs and some sensational cases of delayed care, true. But to imply that people can get surgery here only if their condition is life threatening is complete nonsense. You made the claim: you bring the data to back it up, OK?

Anecdote: 3 of the 5 children in my family, plus my mother, all required surgical correction of severe scoliosis. (The two other kids developed scoliosis early, but it either corrected itself or stabilized at a mild level early). We were struggling financially in the 60s and 70s when we all had our surgery, teetering into bankruptcy after the second surgery and were actually on welfare by the time my mother finally had her surgery done 2 years after I had mine. I cannot imagine how a family in our dire economic straits would have managed one Harrington procedure, let alone four, if we had been in similar straits in the States and uninsured. Yes, the Shriners and similar charities are known for helping children who need this surgery -- but three of them, plus an adult? Plus, we were all treated in local hospitals, receiving excellent care, rather than having to travel to a specific charitable hospital.

These days, elective surgery is still on the table (no pun intended) for the vast majority of Canadians. My Ontario insurance, paid through my taxes, covered the fibroid surgery I finally had in 2006. I told my gynecologist that I was finally ready to take the plunge in June, I saw the surgeon in July, and I had my surgery in early October. If I had been in massive distress, it could have been done earlier.

[russell]

Not mentioned so far, I think:

McCain's plan provides a tax credit of $2500 for an individual, and $5000 for families.

The average cost of employer-provided health care is $12,100 for a family of four, $4,400 for an individual.

So if you have a family, you need to come up with about $7,000 to get insurance, not quite $600/mo.

For individuals, it's only $1,600, about $130/mo.

All of this assumes that comparable coverage for dollar spent will be available at the retail level.

On the topic of long waits for health care services: I've been a patient of my primary care physician for something approaching 10 years.

If I call his office to say, frex, that blood is pouring from my ears and my feet are turning green, I can get in the same day. For routine stuff -- physicals, etc -- appointments have to be scheduled weeks to months out.

Routine tests and other, similar procedures are also scheduled weeks to months in advance.

I have very, very good health insurance.

Thanks -

[russell]

Yikes! Sorry, I forgot to preview.

Thanks -

[josefina]

You could do much worse than our single-payer system; indeed, in many respects and for many Americans, I fear that you already do. I have no doubt that, given the resources you already put into your medical system, you could do better.

Yes. This.

[Anarch]

Emergency room times are unbelievable and would shock Americans.

I concussed myself once -- unbelievably stupid accident, but there ya go -- and there was some suspicion that I might have done some real damage to myself. It took a grand total of about six hours to get seen, with the following results:

1) My HMO refused to cover an ER visit without first visiting their "Urgent Care".

2) This "Urgent Care", however, necessitated an appointment. Which wouldn't be for three hours.

3) After finally getting in to Urgent Care, the doctor confirmed that I had a concussion and needed to get an MRI (I think it was)... but they'd taken so long that my HMO's radiologists had all gone home. So I had to go to the ER anyway.

4) When I checked into the ER, the triage nurse said I was high priority and that I should be seen in around 15 minutes. Two and a half hours later, they finally got around to seeing me.

Now I got lucky, after a fashion: I had been waiting for so long that, by the mere fact I was both vertical and conscious, they knew there was no damage from the concussion. But still... I have no particular love for the ER systems here.

[And don't even get me started on the six month wait for testing I had to endure to determine whether I had an irreversible neurodegenerative disorder...]

[hilzoy]

Without getting into ERs: the delightful HMO that I was part of during the 90s did the following things to me:

(1) After I stepped on a rusty nail, and realized that I couldn't remember my last tetanus shot (but it was clearly over a decade before), they did not give me a tetanus shot. I ended up paying for one myself, outside the system.

(2) Before I went to Mozambique, I went to get shots, and they discovered that I had not had measles (I had always thought I had.) But they refused to vaccinate me for measles, even though measles is common there, and measles vaccines are recommended on every travel md website I checked. (I eventually got vaccinated, but not until after I went to Mozambique.)

Penny wise, pound foolish.

[John Spragge]

Please provide a cite for the claim that Ayn Rand ever advocated abolishing the medical profession. I can find cites for Milton Friedman's opinion on medical licensing, but no corresponding cites for Ayn Rand.

In any case, I should make myself clear: I do not oppose a licensed and self-governing medical profession per se; I only oppose the invocation of free market ideology to oppose socialized medicine, when no major country I know of has a free market in medicine.

Maybe, as many people claim, we need to have doctors as a self-governing profession. Maybe no other means of delivering medical service would work as well. Not having tried any alternatives, I can accept the possibility. But for all its virtues, you cannot call our current system a free market.

[DecidedFenceSitter]

My horror story - which isn't that horrorific. Back about 4 years ago, when I was 25, I cut myself severely. How severely, well I managed to call 911 and unlock the door before I decided that sitting was a good idea. The ambulance ER techs who came in without knocking said that they'd seen less messy crime scenes. I hit an artery on my finger with a box cutter. Yay nerve damage.

I spent 7 hours in the hospital holding a bandage to my hand waiting to get in for something like 8-12 stitches. There were no major emergencies as far as I can tell.

It cost me 50 bucks.

Thank god I had insurance. But yeah, if I hadn't had insurance I have no clue how much that screw-up would have cost me, and secondly, oh yeah, cause the US has no major waits in its emergency rooms.

[Gary Farber]

My recent ER visit story. The first bill and the second bill. What's $1296.00 to get a prescription for antibiotics and hydrocodone for a toothache?

And, yeah, they've billed me, and will turn it over to a collection agency if I don't pay by deadline.

[Gary Farber]

On wait times, I only had to wait five minutes to get logged in; about ten minutes to get triaged, then around 40 minutes to get seen by an aide, then another 20 minutes to see a Physician's assistant, but then when I had to come back because they hadn't given me the right prescription form I had to wait about an hour and a half again.

But all in all, not too bad. I had to wait vastly longer back in 1988 at Bellevue for treatment of the broken arm and head wound.

[freelunch]

Many years ago, my wife had to go to an ER in New Orleans for a problem with her eyes. We were next to the Quarter, but everyone recommended that we go past two or three major hospitals to a small hospital with a small ER. It worked. The doctor was competent and managed to see her within a very short time. We were assured that it would have been many hours had she stopped at one of the nearby hospitals. Different levels of emergency require different staffing. We really need to get people and the medical community to understand that and deliver and request emergency aid in a sensible fashion.

[wonkie]

I think that I have an advantage in ER services since i live n a small town. My mother-in-law used to have emergencies regularly before we realized that her problem was senile dementia. In every case we were greeted effusively at the ER by a bored staff that was very eager to have someting to do.

So far as I know Medicare paid for it.

[russell]

But for all its virtues, you cannot call our current system a free market.

It's hard for me to imagine how any useful health care system can be provided via a free market.

Medical care involves highly specialized knowledge, and has (correctly IMO) a high barrier of entry. The consumers of medical care are rarely in a position to walk away from a transaction if they can't find convenient terms.

It's not a service that is likely to be effectively provided by purely market dynamics.

Likewise health insurance.

Market dynamics applied to health insurance will result in sicker, or more at-risk, people either not being able to obtain health insurance at all, or having to pay a lot for it.

Of course, those are the folks who need it the most.

If you view the purpose of providing medical care to be primarily maximizing the return on whatever resources are devoted to it, then a deregulated environment will be your cup of tea.

If you view the purpose as being actually improving people's health, a deregulated environment is counterproductive.

Thanks -

[John Spragge]

Russell -- again, I have no brief for (or quite frankly, against) Milton Friedman's analysis of the medical system. I just object to people who thoughtlessly or dishonestly tell us we can't disrupt the "free market" in medical services some of them they seem to think the US now enjoys.

Speaking of ideas that strike me as weird: Ross Douthat defended the McCain health insurance plan:

So the typical family will get their $5,000 credit from the government, and something like the remaining $7,000 they need to buy health insurance will show up in their paycheck.

Can any Americans tell me if any law, regulation, or anything else requires a company that stops providing a health plan to give the equivalent in pay instead? Because it strikes me that at least some companies may simply drop the health plan, particularly during hard times of rising insecurity and rising unemployment.

[Gary Farber]

"So the typical family will get their $5,000 credit from the government, and something like the remaining $7,000 they need to buy health insurance will show up in their paycheck."

Good thing there aren't 7.6 million officially unemployed people in the U.S., and far more in their families, and far more who aren't counted in the official statistics.

They're not contributing, so they don't count. They can go to the emergency room!

[John Spragge]

Gary, I agree that the McCain plan leaves the unemployed in the cold. And that would matter even if the economic forecasts did not indicate that the ranks of the unemployed would soon increase. But as I understand it, the current system has that feature bug, as well.

I wanted to know if anything in American law says that, should an employer phase out or terminate a company health plan, the employees have the right to the difference in cash. Because what Ross Douthait wrote suggests that employees whose firms phase out their health plans will pretty automatically get the cash difference, and he uses that as the basis for claiming that Senator Biden did not tell the truth about the McCain plan. My own experience of employment in the US suggests otherwise; I had little idea how much of a contribution my employer made to my health plan, and I certainly didn't consider it a part of my wages. I just wonder how much of the money an employer no longer pays toward health care the average American worker could recover, particularly in times of economic stress and high unemployment. In other words, I suspect Mr. Douthait's accusation against Senator Biden rests on a romantic view of the mechanisms of employment economics. But then, I haven't worked in the US for some time now, so things may have changed.

None of that, of course, changes the other flaws in Senator McCain's health insurance proposals.

[rosie]

At my (worker friendly) company, if a person does not take the company-subsidized health insurance, we get $120 per year for our medical spending account. Not such a good trade-off in my view!

[Howard Green, MD, FACP, FAAD, FACMS]

Reprinted From: ‘On Call’ The Journal of the Palm Beach County Medical Society
Nov-Dec, 2007
On Line: http://www.pnhp.org/news/2008/february/what_government_does.php

What Government Does Better: Health Insurance
Howard A. Green, MD, FACP, FAAD, FACMS

You’ll listen to me because I’m your doctor. I only have your health interests in mind. I have written this article without ‘prior authorization’ from any insurance companies.

There are some intuitively obvious services that the government runs more productively and efficiently than private for-profit enterprises. For example, our armed forces and GI’s conquer and hold and protect territory more effectively and at a fraction of cost of private militias such as Blackwater USA and the Crescent Security Corporations. In addition, the government rules and regulations which our governments’ military adhere to insure an ethical cohesive fighting force compared to the unregulated for-profit corporate armies. Our GI soldiers assigned to kitchen duty prepare and cook meals at a fraction of the cost of identically prepared meals from the private for-profit logistics divisions of the Halliburton or Kellog Brown and Root Corporations. Government regulated public education in America such as the undergraduate and college systems of the City of New York and other large metropolises have for over a century produced more CEO's, doctors, lawyers, accountants, engineers, chemists, poets, philosophers and military officers than any private school system, and at a fraction of the cost compared to all the private schools in the country combined. Take away the government grants, government tax breaks, and government sponsored free overseas labor from Americas top private Colleges and their classrooms and graduate programs would most likely shut down, no matter how large their private endowments. The government run and regulated public school systems of Israel, India and China are churning out competent engineers, scientists and entrepreneurs at a quality and rate much greater than that of any collection of private schools in any country in the world. These non-American people, highly educated by their government run school systems, have formed a new collective worldwide labor arbitrage system which is fueling the productivity of intercontinental private business. The Marshall Plan, Interstate Highways, Space Program, Peace Corps, and the GI Bill all demonstrate successful government run bureaucracies of their time.

In a similar fashion, our mammoth government-run health insurance company (Medicare) operates at a fraction of the cost of private insurance corporations such as Aetna, Cigna, United, Blue Shield Blue Cross, Kaiser Permanente and Humana. Medicare, the government health insurance for the elderly uses only 1-2% of your dollar to achieve rates of morbidity (sickness) and mortality (death) among their patients which are identical to those of the private health insurance corporations. However, private insurance corporate bureaucracies inefficiently siphon $350 billion per year, or 20-25% of your hard earned dollars away from doctors, hospitals and patient care into the pockets of their executives, administrative employees, shareholders and politicians. The recent stock option fraud perpetrated by the CEO of United Health Care demonstrates the negligent disdain the private insurance corporations have for physicians, hospitals, health care workers and patients. Since their founding 40 years ago, private health maintenance insurance corporations have failed to deliver what their business plans always promise; lower rates of morbidity and mortality associated with low costs to the patients. These insurance companies are financially profitable for their shareholders and executives, but medically bankrupt for their patients. Without their own massive government subsidies, government protection from malpractice lawsuits, and a government ban on collective bargaining by physicians the private health insurance corporate bureaucracies of Aetna, Cigna, United and Humana, and hundreds of other smaller health insurance companies of the health insurance industry would undoubted fail to exist. Most elderly people who call themselves Republicans, and conservative physicians in this Country have recognized the efficacy of our government regulated Medicare health insurance corporation and have enrolled themselves and utilized this Government run health insurance company for their own medical needs (despite the shrill cries of socialized medicine from their leaders). 40 years ago we heard these same shrill cries from organized medicine and Republicans concerning the establishment of Medicare. After accepting hundreds of billions of dollars in Medicare Insurance payments over the ensuing 4 decades, one can only wonder why conservative physicians still rally like Quixote against this government run insurance product.

The following 9 steps will simply suggest how, without the inefficiencies and burden to productivity of private insurance corporations, we can deliver efficient and effective comprehensive health care with great savings and no sacrifice of jobs. In fact, we may be able to decrease morbidity and mortality in this Country with one coordinated system which cares for all Americans, and concurrently analyzes optimal diagnoses and treatment modalities through its integrated computerized billing system. The savings incurred insuring all Americans through the more efficient Medicare system will benefit all citizens of our Country.

9 Steps to Comprehensive Quality Health Care in America

1) Shut down the private health insurance corporations.

2) Enroll all Americans (including Veterans) and the 40 million uninsured citizens into the Medicare Health Insurance Corporation. Since the current functioning Medicare Insurance Company is already accepted by almost all physicians, Hospitals and clinics in the Country, hardly any infrastructure investments on the health care delivery end will be necessary. Have all private businesses pay a Medicare premium for their employees instead of private health insurance premiums. Let employees as well as businesses contribute a fixed premium amount based on their age up until 65 for their Medicare services and drugs. Freeze current premiums for all Americans over 65 and adjust in the future according to the cost of living index. These premiums paid by businesses to Medicare for their employees should be less than that paid to current private insurance companies because of the lower overhead costs of the Medicare Corporation and improved risk distribution.

3) Hire the now unemployed former private health insurance corporate bureaucrats to actually deliver and not inhibit health care by working in hospitals, doctors’ offices, clinics and nursing homes around our Country. Demographically, the percentage of elderly Americans is rapidly increasing. With every American now insured through Universal Medicare Insurance, real health care workers will be in desperate need. For the first time in the brief but bloody history of managed care, these former private insurance corporation employees will actually touch and improve care for patients by working in physical therapy, nursing, home health care and other ancillary patient care capacities.

4) Obtain by eminent domain (for the public good) the best of the intellectual property protected computer codes which the closed private insurance businesses previously used to monitor patient care and doctors utilization and performance. Private health insurance companies have used these computer programs exclusively for the purpose of strong-arming their contracted health care providers into doing less for their patients and increasing the premium costs for sicker patients in order to achieve higher corporate profits. Medicare on the other hand can use these same computer programs for the common good; to monitor, collect data and eventually improve the efficacy of diagnoses and the treatment of diseases and medical outcomes every time a doctor submits a bill. For example, wouldn't it be nice to know as a medical consumer (patient) which oncology groups in Boston, New York or Houston have the highest cure rates for stage III breast cancer or Stage II prostate cancer? All those numbers currently exist in cancer registries nation wide and just need to be collected and honestly disseminated. Currently, instead of solid medical data which delineates morbidity and mortality and performance, the medical consumer when choosing an oncologist must rely on word of mouth, physician referrals or advertisements in the local papers which show photographs of smiling doctors in white coats who claim to be the ‘best’ doctors in town. In addition to garnering invaluable instantaneous epidemiologic data on diagnoses and treatment of diseases based on severity and other variables, a strong Medicare based utilization review computer code would also allow Medicare to monitor doctors and hospitals who abuse a fee-for-service billing system. Any physician, institution or service found to abuse the Medicare fee for service billing system after proper review and appeal should be dealt with severely through stiff penalties and loss of their Universal Medicare provider contract.

5) Freeze Medicare physician, hospital and ancillary services reimbursements at current 2007-2008 levels. Adjust reimbursements for future services yearly by Cost of Living increases, or in the event of a deflationary economy a decreases in doctor and hospital payments. Ask any physician and they'll tell you they would accept current reimbursement rates with COLA over the current mysterious illogical fee adjustment system of Medicare, or the physician population density reimbursement formula used by most private insurance corporations. Two tiered medical systems separating the “haves and have not’s” of society have and will always exist. Therefore, we must allow physicians to practice medicine without enrolling in or accepting the Universal Medicare reimbursement. With private medical insurance no longer available, and no performance based evidence for improved morbidity and mortality among their private for-pay patients, these extraordinarily expensive private ‘VIP’ practices will be limited.

6) Allow Medicare, much like the current Veterans Administration System and every private health insurance company and government health care system around the world, to bid on medications from pharmaceutical corporations for its Medicare drug formulary. Every physician recognizes that we don’t need a choice of a dozen redundant drugs in each pharmaceutical category. For example, we need only 2-3 statins for cholesterol, a handful of antibiotics for infections, 2 beta blockers for hypertension, and a few pain killers. Once the Government bids on pharmaceuticals for the Medicare Corporation formulary, macro economics will force prices to massively decrease to levels identical to that which all the other people of the world outside of America are paying for the same medicines. Since it has not effectively decreased morbidity or mortality in this Country, and only wastes money, we should also prohibit pharmaceutical companies and their workers from contributing to political campaigns or buying commercials on the public airways. We need to also prohibit the current practice whereby your local pharmacy and pharmacist sells your private medical diagnoses and your doctors private prescribing drug information to pharmaceutical companies so the pharmaceutical companies in-turn can directly pressure-market physicians. Prohibit pharmaceutical companies from contributing to organized medicine societies, colleges or associations because the doctors can’t rely on soft bribes or free lunches to prescribe what’s best for their patients. Prevent pharmaceutical representatives from visiting doctors’ offices or hospital pharmacies directly. Allow delivery of Medicare formulary approved sample medications for patients to physicians’ offices via post office mail only. Allow pharmaceutical companies to market products to physicians only via peer reviewed publications delivered by email or snail mail.

7) With the savings incurred from closing the private insurance corporations and paying less for drugs, have the American government fully fund the National Institutes of Health (NIH) and the National Cancer Institute (NCI) and Small Business Innovative Research (SBIR) programs. Emphasis should be placed on basic bench research carried out at not-for-profit American Institutions which employ or utilize a majority of American Citizens in their laboratories and clinics. Too often American Universities rely on free overseas labor to conduct bench research. Clinical trials should emphasize new drugs and devices which have promise to significantly decrease morbidity and mortality for any disease, including orphan diseases. Since a large percentage of private funding for drug and device studies will originate in the expanding financial liquidity and innovations and patients of the emerging developing world, we should allow the FDA to utilize research data obtained by reproduced laboratory and clinical studies performed overseas as well as in this Country.

Corruption of honest academics should be curtailed. Force all investigators to release reproduced publicly funded scientific data for all scientists to review on the internet via the Freedom of Information act (The Senator Shelby Amendment). Prohibit rights of first refusal on scientific data for private companies performing research in non-for profit institutions which receive public funding. Any rights to profits obtained from intellectual property and patents invented with combined funding from government and private sources should be split fairly among the contributing government institutions and any other private corporations funding the research, as well as with the individual inventor. Prevent organized medicine societies, associations or colleges from contributing to political campaigns since campaign donations have no relevance for physician performance or patient morbidity or mortality.

8) Offer physicians the same legal protection from malpractice lawsuits which have been established for commercial health insurance corporations during the last 3 decades.

9) The quality of current medical records software lags two decades behind business software. Therefore, we need to fund and challenge America’s best software corporations to finally develop standardized electronic medical records software for use in doctors’ offices and hospitals in order to increase the efficiency and productivity of physician charting, billing and prescribing. We should use the integrated medical records system to instantaneously and confidentially gather important epidemiologic data on physicians’ performance, patient diseases, and treatments. With new potent viruses and unsophisticated biomedical and nuclear warfare on the horizon, this system will be absolutely necessary for rapid National Security responses. Protect patient confidentiality at all costs to prevent the commercialization and abuse of patient data like that which the pharmacies trade today.

Lastly, some argue that Universal Government run health care in America will result in delays in diagnosis and treatment similar to those experienced in Britain and Canada. One can not simply compare the massive extremely functional Medicare insurance corporation based infrastructure which seamlessly delivers health care to tens of millions of people yearly in the USA to the government run westernized health care systems of Canada and Britain, France, Switzerland, Netherlands, Scandinavia, and Israel. America, for the last 40 years, thanks to the government run health insurance corporation-Medicare, has built an incredibly dense and fluid public insurance system involving almost all doctors’ offices, hospitals, clinics and ancillary services. The Medicare system dwarfs in breadth and actual practitioners and efficacy the lesser insurance systems established in all other countries. The billing and reimbursement bureaucracy for health care providers contracted with Medicare Insurance is already relatively streamlined and efficiently centralized in America thanks to 40 years of physician, hospitals and government cooperation.

We all know that the medically bankrupt private health insurance corporations and medical malpractice lawsuit threats have caused many disheartened physicians to quit practicing or downsize their practices in America. A continuation and technological upgrading of our most fair Universal Medicare based health insurance Corporation based on the concepts outlined above would undoubtedly motivate those disenfranchised physicians to return to the profession and bright younger physicians to invigorate the field. If patients, physicians and the Medicare Corporation continue to work together, without the deleterious interference of private for-profit health insurance corporations, malpractice threats and overt pharmaceutical marketing, the future for American health care will be healthy indeed.. A continuation of the status-quo mixture of a government subsidized private health maintenance insurance industry operating parallel to and within Medicare is wasteful, and will continue to provide no potential future health improvements for America.

[Howard Green, MD, FACP, FAAD, FACMS]

Reprinted From: ‘On Call’ The Journal of the Palm Beach County Medical Society
Nov-Dec, 2007
On Line: http://www.pnhp.org/news/2008/february/what_government_does.php

What Government Does Better: Health Insurance
Howard A. Green, MD, FACP, FAAD, FACMS

You’ll listen to me because I’m your doctor. I only have your health interests in mind. I have written this article without ‘prior authorization’ from any insurance companies.

There are some intuitively obvious services that the government runs more productively and efficiently than private for-profit enterprises. For example, our armed forces and GI’s conquer and hold and protect territory more effectively and at a fraction of cost of private militias such as Blackwater USA and the Crescent Security Corporations. In addition, the government rules and regulations which our governments’ military adhere to insure an ethical cohesive fighting force compared to the unregulated for-profit corporate armies. Our GI soldiers assigned to kitchen duty prepare and cook meals at a fraction of the cost of identically prepared meals from the private for-profit logistics divisions of the Halliburton or Kellog Brown and Root Corporations. Government regulated public education in America such as the undergraduate and college systems of the City of New York and other large metropolises have for over a century produced more CEO's, doctors, lawyers, accountants, engineers, chemists, poets, philosophers and military officers than any private school system, and at a fraction of the cost compared to all the private schools in the country combined. Take away the government grants, government tax breaks, and government sponsored free overseas labor from Americas top private Colleges and their classrooms and graduate programs would most likely shut down, no matter how large their private endowments. The government run and regulated public school systems of Israel, India and China are churning out competent engineers, scientists and entrepreneurs at a quality and rate much greater than that of any collection of private schools in any country in the world. These non-American people, highly educated by their government run school systems, have formed a new collective worldwide labor arbitrage system which is fueling the productivity of intercontinental private business. The Marshall Plan, Interstate Highways, Space Program, Peace Corps, and the GI Bill all demonstrate successful government run bureaucracies of their time.

In a similar fashion, our mammoth government-run health insurance company (Medicare) operates at a fraction of the cost of private insurance corporations such as Aetna, Cigna, United, Blue Shield Blue Cross, Kaiser Permanente and Humana. Medicare, the government health insurance for the elderly uses only 1-2% of your dollar to achieve rates of morbidity (sickness) and mortality (death) among their patients which are identical to those of the private health insurance corporations. However, private insurance corporate bureaucracies inefficiently siphon $350 billion per year, or 20-25% of your hard earned dollars away from doctors, hospitals and patient care into the pockets of their executives, administrative employees, shareholders and politicians. The recent stock option fraud perpetrated by the CEO of United Health Care demonstrates the negligent disdain the private insurance corporations have for physicians, hospitals, health care workers and patients. Since their founding 40 years ago, private health maintenance insurance corporations have failed to deliver what their business plans always promise; lower rates of morbidity and mortality associated with low costs to the patients. These insurance companies are financially profitable for their shareholders and executives, but medically bankrupt for their patients. Without their own massive government subsidies, government protection from malpractice lawsuits, and a government ban on collective bargaining by physicians the private health insurance corporate bureaucracies of Aetna, Cigna, United and Humana, and hundreds of other smaller health insurance companies of the health insurance industry would undoubted fail to exist. Most elderly people who call themselves Republicans, and conservative physicians in this Country have recognized the efficacy of our government regulated Medicare health insurance corporation and have enrolled themselves and utilized this Government run health insurance company for their own medical needs (despite the shrill cries of socialized medicine from their leaders). 40 years ago we heard these same shrill cries from organized medicine and Republicans concerning the establishment of Medicare. After accepting hundreds of billions of dollars in Medicare Insurance payments over the ensuing 4 decades, one can only wonder why conservative physicians still rally like Quixote against this government run insurance product.

The following 9 steps will simply suggest how, without the inefficiencies and burden to productivity of private insurance corporations, we can deliver efficient and effective comprehensive health care with great savings and no sacrifice of jobs. In fact, we may be able to decrease morbidity and mortality in this Country with one coordinated system which cares for all Americans, and concurrently analyzes optimal diagnoses and treatment modalities through its integrated computerized billing system. The savings incurred insuring all Americans through the more efficient Medicare system will benefit all citizens of our Country.

9 Steps to Comprehensive Quality Health Care in America

1) Shut down the private health insurance corporations.

2) Enroll all Americans (including Veterans) and the 40 million uninsured citizens into the Medicare Health Insurance Corporation. Since the current functioning Medicare Insurance Company is already accepted by almost all physicians, Hospitals and clinics in the Country, hardly any infrastructure investments on the health care delivery end will be necessary. Have all private businesses pay a Medicare premium for their employees instead of private health insurance premiums. Let employees as well as businesses contribute a fixed premium amount based on their age up until 65 for their Medicare services and drugs. Freeze current premiums for all Americans over 65 and adjust in the future according to the cost of living index. These premiums paid by businesses to Medicare for their employees should be less than that paid to current private insurance companies because of the lower overhead costs of the Medicare Corporation and improved risk distribution.

3) Hire the now unemployed former private health insurance corporate bureaucrats to actually deliver and not inhibit health care by working in hospitals, doctors’ offices, clinics and nursing homes around our Country. Demographically, the percentage of elderly Americans is rapidly increasing. With every American now insured through Universal Medicare Insurance, real health care workers will be in desperate need. For the first time in the brief but bloody history of managed care, these former private insurance corporation employees will actually touch and improve care for patients by working in physical therapy, nursing, home health care and other ancillary patient care capacities.

4) Obtain by eminent domain (for the public good) the best of the intellectual property protected computer codes which the closed private insurance businesses previously used to monitor patient care and doctors utilization and performance. Private health insurance companies have used these computer programs exclusively for the purpose of strong-arming their contracted health care providers into doing less for their patients and increasing the premium costs for sicker patients in order to achieve higher corporate profits. Medicare on the other hand can use these same computer programs for the common good; to monitor, collect data and eventually improve the efficacy of diagnoses and the treatment of diseases and medical outcomes every time a doctor submits a bill. For example, wouldn't it be nice to know as a medical consumer (patient) which oncology groups in Boston, New York or Houston have the highest cure rates for stage III breast cancer or Stage II prostate cancer? All those numbers currently exist in cancer registries nation wide and just need to be collected and honestly disseminated. Currently, instead of solid medical data which delineates morbidity and mortality and performance, the medical consumer when choosing an oncologist must rely on word of mouth, physician referrals or advertisements in the local papers which show photographs of smiling doctors in white coats who claim to be the ‘best’ doctors in town. In addition to garnering invaluable instantaneous epidemiologic data on diagnoses and treatment of diseases based on severity and other variables, a strong Medicare based utilization review computer code would also allow Medicare to monitor doctors and hospitals who abuse a fee-for-service billing system. Any physician, institution or service found to abuse the Medicare fee for service billing system after proper review and appeal should be dealt with severely through stiff penalties and loss of their Universal Medicare provider contract.

5) Freeze Medicare physician, hospital and ancillary services reimbursements at current 2007-2008 levels. Adjust reimbursements for future services yearly by Cost of Living increases, or in the event of a deflationary economy a decreases in doctor and hospital payments. Ask any physician and they'll tell you they would accept current reimbursement rates with COLA over the current mysterious illogical fee adjustment system of Medicare, or the physician population density reimbursement formula used by most private insurance corporations. Two tiered medical systems separating the “haves and have not’s” of society have and will always exist. Therefore, we must allow physicians to practice medicine without enrolling in or accepting the Universal Medicare reimbursement. With private medical insurance no longer available, and no performance based evidence for improved morbidity and mortality among their private for-pay patients, these extraordinarily expensive private ‘VIP’ practices will be limited.

6) Allow Medicare, much like the current Veterans Administration System and every private health insurance company and government health care system around the world, to bid on medications from pharmaceutical corporations for its Medicare drug formulary. Every physician recognizes that we don’t need a choice of a dozen redundant drugs in each pharmaceutical category. For example, we need only 2-3 statins for cholesterol, a handful of antibiotics for infections, 2 beta blockers for hypertension, and a few pain killers. Once the Government bids on pharmaceuticals for the Medicare Corporation formulary, macro economics will force prices to massively decrease to levels identical to that which all the other people of the world outside of America are paying for the same medicines. Since it has not effectively decreased morbidity or mortality in this Country, and only wastes money, we should also prohibit pharmaceutical companies and their workers from contributing to political campaigns or buying commercials on the public airways. We need to also prohibit the current practice whereby your local pharmacy and pharmacist sells your private medical diagnoses and your doctors private prescribing drug information to pharmaceutical companies so the pharmaceutical companies in-turn can directly pressure-market physicians. Prohibit pharmaceutical companies from contributing to organized medicine societies, colleges or associations because the doctors can’t rely on soft bribes or free lunches to prescribe what’s best for their patients. Prevent pharmaceutical representatives from visiting doctors’ offices or hospital pharmacies directly. Allow delivery of Medicare formulary approved sample medications for patients to physicians’ offices via post office mail only. Allow pharmaceutical companies to market products to physicians only via peer reviewed publications delivered by email or snail mail.

7) With the savings incurred from closing the private insurance corporations and paying less for drugs, have the American government fully fund the National Institutes of Health (NIH) and the National Cancer Institute (NCI) and Small Business Innovative Research (SBIR) programs. Emphasis should be placed on basic bench research carried out at not-for-profit American Institutions which employ or utilize a majority of American Citizens in their laboratories and clinics. Too often American Universities rely on free overseas labor to conduct bench research. Clinical trials should emphasize new drugs and devices which have promise to significantly decrease morbidity and mortality for any disease, including orphan diseases. Since a large percentage of private funding for drug and device studies will originate in the expanding financial liquidity and innovations and patients of the emerging developing world, we should allow the FDA to utilize research data obtained by reproduced laboratory and clinical studies performed overseas as well as in this Country.

Corruption of honest academics should be curtailed. Force all investigators to release reproduced publicly funded scientific data for all scientists to review on the internet via the Freedom of Information act (The Senator Shelby Amendment). Prohibit rights of first refusal on scientific data for private companies performing research in non-for profit institutions which receive public funding. Any rights to profits obtained from intellectual property and patents invented with combined funding from government and private sources should be split fairly among the contributing government institutions and any other private corporations funding the research, as well as with the individual inventor. Prevent organized medicine societies, associations or colleges from contributing to political campaigns since campaign donations have no relevance for physician performance or patient morbidity or mortality.

8) Offer physicians the same legal protection from malpractice lawsuits which have been established for commercial health insurance corporations during the last 3 decades.

9) The quality of current medical records software lags two decades behind business software. Therefore, we need to fund and challenge America’s best software corporations to finally develop standardized electronic medical records software for use in doctors’ offices and hospitals in order to increase the efficiency and productivity of physician charting, billing and prescribing. We should use the integrated medical records system to instantaneously and confidentially gather important epidemiologic data on physicians’ performance, patient diseases, and treatments. With new potent viruses and unsophisticated biomedical and nuclear warfare on the horizon, this system will be absolutely necessary for rapid National Security responses. Protect patient confidentiality at all costs to prevent the commercialization and abuse of patient data like that which the pharmacies trade today.

Lastly, some argue that Universal Government run health care in America will result in delays in diagnosis and treatment similar to those experienced in Britain and Canada. One can not simply compare the massive extremely functional Medicare insurance corporation based infrastructure which seamlessly delivers health care to tens of millions of people yearly in the USA to the government run westernized health care systems of Canada and Britain, France, Switzerland, Netherlands, Scandinavia, and Israel. America, for the last 40 years, thanks to the government run health insurance corporation-Medicare, has built an incredibly dense and fluid public insurance system involving almost all doctors’ offices, hospitals, clinics and ancillary services. The Medicare system dwarfs in breadth and actual practitioners and efficacy the lesser insurance systems established in all other countries. The billing and reimbursement bureaucracy for health care providers contracted with Medicare Insurance is already relatively streamlined and efficiently centralized in America thanks to 40 years of physician, hospitals and government cooperation.

We all know that the medically bankrupt private health insurance corporations and medical malpractice lawsuit threats have caused many disheartened physicians to quit practicing or downsize their practices in America. A continuation and technological upgrading of our most fair Universal Medicare based health insurance Corporation based on the concepts outlined above would undoubtedly motivate those disenfranchised physicians to return to the profession and bright younger physicians to invigorate the field. If patients, physicians and the Medicare Corporation continue to work together, without the deleterious interference of private for-profit health insurance corporations, malpractice threats and overt pharmaceutical marketing, the future for American health care will be healthy indeed.. A continuation of the status-quo mixture of a government subsidized private health maintenance insurance industry operating parallel to and within Medicare is wasteful, and will continue to provide no potential future health improvements for America.