There are also non-profits that hire physicians.  That does not guarantee better conditions for healthcare workers.

The AMA acts as an advocate for physicians and patients.  Nowadays, the AMA seems mostly to respond to special interests groups and push forward "progessive" agendas like SCHIP, Nationailzed Healthcare, and GLBT issues.  The hierarchy is populated by progessive types.  Think ABC Harvard trained socialist Doctor Tim Johnson, the patrician physician on ABC.  There are some good Conservative folks out there, but the chickecoop is full of socialists and special interest egg layers.  The yolk will be on us all one day.

The AMA does do very good things.  They are Medicine's chief PAC/lobbyists resisting reimbursement cuts and righting wrongs perpetrated by InsurCo.'s and the government itself.  They also release policy papers which define ethics, like abortion and euthanasia, both of which are A-Ok but participation in a Capital Crimes execution is verbotten.  And the AMA is trying to keep government out of policing the ranks, though I fail to see how they are not bargaining away the farm piece by piece.  It's like the lying manslaughterer Teddy Kennedy saying in the 1980's there would be no more amnesty and immigration laws would be enforced once his Amnesty Bill was enacted.  That worked out pretty well.  (/sarc)

So, the AMA is a mixed bag of policy and action.  I am not a member because I do not agree with the focus and direction they are taking, but I will give credit where I believe is due.  It is a love-hate sort of relationship because the AMA may be the only group standing up for the profession, yet they do things that, IMO, bring down the profession.

You are correct that 3rd party insurers are the 800 pound gorilla.  But they didn't get that way without help.  Several key things had to occur before it got this way, including:

• Loosening of Anti-Trust law which allowed insurance companies to begin and grow after WWII.  Even today, InsurCo's cannot be sued for certain monopolistic ways they contract and do business.  They are protected by our friendly gub'mint wiseguys.
• Physicians invested in InsurCos early on (Blue Cross / Blue Shield) since the return on investment looked good (and it was) and they were now guaranteed payment for work done (and the reimbursement was good).  (Was there as much a hue and cry about healthcare overutilization back in the 50's and 60's?)
• Businesses offering healthcare benefits for recruiting and retention of employees.  The price was reasonable and the healthier and happier workforce were productive without damaging businesses financials too much.
• Employees like healthcare benefits for obvious reasons including it was a cost that did not come directly out of there pockets.  They earned the same wage AND had "free" healthcare added. 

For many, having job related healthcare was the first time they ever were covered or felt unencumbered by worries over financial crisis if a health crisis occured.  That is a strong inducement to keep feeding the InsurCos. appetites, making them stronger and bigger, gobbling up the other fish to capture market share.  InsurCos have not been crazy about portability of health insurance - they don't want the insured changing to a different InsurCo.  Another reason is that InsurCos have denied coverage of "pre-existing" medical problems if you have not been covered before applying - one reason COBRA was implemented.  This is what happens when Medicine becomes a business/commodity separated from the physician-patient relationship. 

Bean Counters of the World UNITE!

A common misperception is that the patient/employee is the consumer.  The business that purchases the healthcare benefits is the InsurCos' consumer.  Plans are crafted to give businesses what they want.  The employee is the beneficiary, not the person who paid for the benefits... at least in the eyes of InsurCos. 

An analogy would be a life insurance policy where the InsurCo wants to keep the person paying for the policy happy, buying them lunch or meeting with them to massage the ego and enquire about additional coverage they should consider.  But the InsurCo cares little about the family member that ultimately recieves money after the policy holder dies.  The InsurCo wants the policy holder to live a long life, keep paying his premium, and hopefully outlive the beneficiary on the policy so the money isn't disbursed.  (cynical?) 

InsurCos do not want beneficiaries to utilize healthcare because it takes profit away.  They would rather you die, quickly and inexpensively, than receive costly chronic care.  They now push for preventative medicine, hospice, Medical Directives about end of life issues, etc. - all things I've believed in before the InsurCos did.   It isn't kindness from the InsurCos.  The Bean Counters figured there was more money to be made this way.  Why else would they require people to pay co-pays?  It's to make seeking healthcare a little bit more unappealing. 

In every other business, jacking up prices may lead to lower consumption of the product and the company will either fold or change their pricing structure.  The consumer may be inconvienced but is not incapacitated.  In healthcare, jacking up the prices usually leads to people avoiding healthcare (grandpa only takes his medicine every other day or doesn't buy it at all) and the subsequent worsening of their health, which then leads to even more resource usage.  It's a vicious circle because people can do without pricey vacations or a new car, but they can't do without their health.  Sick people use resources and are not as able to be productive and pay taxes. 

What a mess.

So, what could be done to lower cost and improve the delivery of healthcare?

1)  Like any other business, remove some of the layers of bureaucracy that are choking operations.  One thing that has happened is a move to a single Medicare claims form for all insurers.  Good luck on getting all the private InsurCos to agree on a single form - they have invested millions into their computer systems and personnel to use their form.  Plus, the idiosynchracies of each form and the methods of green lighting a claim are unique and provide an expected rate of refusal, including an expectation that a percentage of kickbacked claims will not be resubmitted.  Yippeee - more cash in the pockets of InsCos! 

Our olde tyme GP used index cards as medical records.  Mine was a 3.5"X5" card that had everything he really needed to know about me.  If I had Strept throat he would jot down "Strept Throat, PCN (penecillin given) and the date.  What else do you really need to know?  No medicine lot numbers recorded, no multiple billing codes for services rendered, no SOAP note.  For many people, that's all that is needed, even today.  But InsurCos require piles of documentation and the government requires it all be kept for years even after you retire.

Additional costs include the time and personel that must be dedicated to calling InsurCos about authorization, billing questions and other problems.  Not only are the waiting times often long, some up to an hour, but you might have to be transferred multiple times before getting an answer, if a helpful one at all.  A large group practice may have a person dedicated to just pulling charts and calling the InsurCos all day long.  Even if it is 2 hours a day, that adds up to 40 hours a month which could be dedicated to performing actual patient care.  That's a lot of money spent on both sides because of bureaucracy.  (Of course the InsurCos do this because the bean counters have determined that roadblocks keep more money in the InsurCos' pockets)

Even the well intentioned HIPAA compliance rules adds to the cost of operating a practice unnessarily because privacy was already in place for centuries.  So there are many layers of paperwork and regulations that could be lightened to provide for cost cutting measures. 

2)  Another positive thing would be a uniform computer application for the transmittal and retention of data to all healthcare businesses - hospitals, doctors offices, pharmacies, labs, etc..  While this sounds anti-competetive, and it is, there are dozens or hundreds of applications systems that cannot "talk" to one another.  It is frustrating when you can't do business because your computers can't "understand" the other's data.  Then it is snail mail, fax and telephone time, which adds cost to the business.

In general, computerizing does not save time on the front end, and oftentimes thereafter due to poor integration, ease of use, and ability to collate data needed.  It is extremely costly to purchase and maintain.   To date, I have only seen one system I found appealing and it required a lot of customization. 

What happens if the power goes out? 

Computerization standards must be implemented at some point.  My fear is that it will be the VHS vs Betamax overdrawn battle and the lessor will win out because some Barack the Bean Counter with no medical operations experience will make the decision.  On the bright side, human ingenuity will then rise up and create applications that can integrate into the Gub'mint's mess and provide solutions to individual physician's needs.  Until then, medical computerization is Hopey-Changey - you will like it or be forced to like it.

3)  TORT REFORM.  Some would also like to have a medico-legal panel of judges or arbitrators instead of jury of one's peers.  The reasoning is that an experienced medico-legal judge will be able to understand the complexities of medical issues and render fair verdicts and recompense as warranted.  I don't see that happening anytime soon.

4)  Motivate people who are not working or who are working and do not pay for healthcare to get a job and/or pay for heathcare, respectively speaking.  Maybe a "catastrophic only"-type insurance at a low rate, with the financial risk spread out over millions of subscribers.  This would not cover preventative medicine, minor acute, or chronic issue, but it would cover the most critical and most costly care that occurs during emergent crisis.  We are already paying for this with our taxes.  Why not offload some of the cost to taxpayers by having the non-payers start working and paying a share of their own care.  Then, as these people make money they can purchase more benefits.

5)  Return to true fee for service - no InsurCo's.  Probably not an option currently, but it would put a damper on healthcare usage.  It might result in less diagnostic testing and actual care performed.  We would then need fewer healthcare workers resulting in a drop in tax collections until new jobs were found.  A variety of diseases, both acute and chronic might spike and ultimately cause a decrease in worker productivity (and therefore taxes paid) and potentially endanger the health of even the ones who still utilize healthcare.  Think of the people that don't have their children immunized.  If a new strain of a disease crops up that hasn't been immunized for in the populace (herd immunity), then everyone may suffer.  For example rubella outbreaks caused by infected unimmunized people who go on to infect and injure/kill fetuses and children who haven't yet completed their MMR series.  Another example is pertussis, which I have seen in a nonimmigrant mother and her child at the same time, neither of which were immunized by choice.  They used a lot of medical resources before they were discharged from the hospital. 

Maybe some things, like immunizations, should be subsidized by insurance/government for the common good.  But do we "force" immunizations?  We do "force" people with tuberculosis to take their treatment if they refuse.  Remember the lawyer that returned from Italy to the USA via Canada who thought he had Multiple Drug Resistant - TB?  Several people that flew in close proximity sued him.  Don't know what happened but I have little patience for his reckless actions.  Where do we draw the line?  I'm still working on that thought!

6)  Use more physician extenders - physician assistants and nurse practitioners.  Theses folks can perform a variety of tasks like a physician and are reimbursed less.  The creep of physician extenders is growing, and it is aided by the physicians themselves who use them to increase their own profits.  The downsides are extenders do not have the training of physicians, will eventually cause a decrease in reimbursement for physicians (why pay more to an MD/DO for the same service?), and ultimately put physicians out of work.

Like investing in InsurCos 50 years ago, today's physicians use physician extenders to secure more profit now.  It will come back to bite us all in the arse again someday.

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7)  Institute laws that force people to eat healthier and exercise.  You could ease into this by using shame, intimidation and picking on snobby things like faux gras and taxing the heck out of alcohol and tobacco.  Don't forget to get rid of guns too.  Obama could use his new Civilian Forces (or whatever the fool said) to enforce the rules.  Conscientious objectors and repeat offenders will be sent to labor/indoctrination camps (run by Bill ayers and His Weathermen?) until made compliant. 

8)  If Obama or his successors turn America into a Socialist/Communist state, then everything will be cheap... when actually available, that is.  Unfortunately, few will have money.  And the Russian joke of "They pretend to pay us and we pretend to work" will be an axiom of living.

*OK.  Numbers seven and eight were red herrings.*

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9) Price Controls.  Already happening.  Medicare and Medicaide are the templates for private InsurCos in shaping fees and costs.  One thing I don't understand is why Bush did not negotiate pricing on pharmaceuticals for Medicare patients.  I understand that Medicare PArt D was an attempt to contain costs via the free market.  But for pete's sake, what company does not try to negotiate lower costs via their purchasing power?  Millions of seniors buying medical goods and services should have some juice to negotiate lower costs!

10)  Rationing medical care.  This is the big bad wolf in my opinion.  We have had rationing of sorts already - for instance, no coverage on experimental procedures/meds and generic or formulary medications required.  The scary stuff is what happens in Canada and Britain where care may be delayed or withheld in order to manage costs.  Bad stuff is what happens in Cuba and the former USSR.

Other questions you had:

• Cost of a medical education - just for the typical 4 years of medical school, usually over $100K.  See here for a 2005 study.  Then there is postgraduate training - Internship and residency - subsized by the government.  When I trained, the residency program received about $75K per resident physician.  It used to be you could go back and take another, different residency and the government would subsidize. Now the government says one time and that's it per doctor.  Sounds reasonable except the gub'mint wants to reduce or remove subsidies altogether.  A lot of programs won't survive, just like the banks nowadays when the Obama mad money spigot shuts off.  Would that be a bad thing?  Yes if it's an inner city or rural program whose community depends upon the residents to provide care to its constituents.  You can travel a few more miles to do your banking.  Good luck traveling with that heart attack.
• Time involved varies,  from four years medical school plus three years residency for primary care; four years medical school plus five years residency for general surgery plus 1-3 years for subspecialty fellowship like cardiothoracic surgeon.  Salaries reached as high as low $40K for first year residents in my time (I was paid substantially less).  The hours still sucked big time.  BTW, there are schools that meld undergraduate schooling with medical school into a total of six years instead of the traditional 8 years for both.  My med school initially was a 3 year program but added another year before I matriculated.
• Supply is lopsided depending where you live.  Rural areas may have great needs for all types of physicians.  City folks usually have plenty (or more than plenty) of docs to choose from.  Medical schools are putting out greater and greater number of newly minted physicians.  Still, plenty of them rely upon foreign medical grads to fill the roster and provide the cost cutting resident slave labor needed (at least that's how we felt our role).  With Obama promising Socialized Medicine, I'm going to guess and say that medical school applications will drop, at least from the really smart college kids.
• Continuing with supply issues, foreign physicians have had an important role in providing care to rural and inner city areas.  Following 9/11, these J-1 Visa foreign medical doctors found it more difficult to work in the USA and communities suffered for access to care.  I don't know the status of this program currently.
• Lastly about supply, there was a spike in the number of med students entering primary care in the 90's after BJ Clinton announced that primary care docs would be the "gatekeepers" to the specialists.  Primary care docs would get an increase in reimbursement to reflect the work they provided while the evil specialists would have reimbursement cut.  Viva Castro Medicine!  What a wonderful worker's paradise!  Now everyone is miserable compared to the good old days. (an exaggeration but not by a lot)  More med students are choosing subspecialtiy careers to pay off loans and live a better live.  The numbers choosing Primary Care is decreasing.  Don't get me wrong:  Even primary care docs make a decent living.  It's just that there are less frustrating and litigious ways of making money.  Get used to foreign Primary Care medical docs because America needs them to cover all the patients.

Would pumping more money into the system keep the brightest Americans persuing Medicine as a career?  Probably.  Physicians would also not have to see 30-40 patients a day to make the same amount of money, which might translate into longer visits with patients like it used to be.  Alas, I think the barn door is open and the horses have left - plenty of doctors used to rushing about will continue to rush about.  I know one doc that sees up to 60 patients in a day, and another that sees up to 80 patients.  Jumpin' Jehosaphat! That's a lot.  The old days of seeing 15-20 plus your hospitalized patients and still making good money is slipping away fast.

Sorry for the length and rambling nature.  I guess I needed to get that out of my system.  :-o

Medical care is not a civil right.

You had me at Basically, an insurance policy is just a legal bet, a wager.

At which point AIG & credit default swaps (another legal bet, a wager) popped into my brain like a million watt spotlight.  The same AIG to which we've thrown in excess of $100B, because it's "too big to fail".

So that is the fallacy of universal health care, at the core.  Obama and the democrats will push it as a basic civil right for all residents (note I didn't say citizens) of this country. 

I hope he fails, too.

Ooops! You're a prophet and didn't know it. Someone DID take over the auto industry so at least the UAW can still have decent jobs.

If I thought anyone would read this I would have spent more time trying to make it funnier, but you get the point.

Basic Question
March 7, 2009 - 23:42 ET by KC Mulville

Do you believe that medical treatment is a right?

I saw the following press release and thought I'd post it if anybody was interested in checking it out. I haven't looked at the site yet, so I can't comment on what to expect.

Right to Health Care Debated at New ProCon.org Website

SANTA MONICA, Calif., Sept. 23 /PRNewswire-USNewswire/ -- ProCon.org, a nonpartisan 501(c)3 nonprofit public charity dedicated to promoting critical thinking, created the new website healthcare.procon.org to explore the core question "Should all Americans have the right (be entitled) to health care?"

Health care is the largest industry in the United States, employing more than 14 million people nationwide. U.S. health expenditure totaled $2.2 trillion in 2007, comprising 16.2% of the U.S. economy.

77% of Americans say that they think health care should be a right. Others argue that it is not the government's responsibility to guarantee health coverage for its citizens. The U.S. Census Bureau reports that 46.3 million people in the U.S. were uninsured in 2008, although some groups contend that this figure is inflated and misleading due to flawed methodology and the number's inclusion of undocumented immigrants and people who choose not to obtain insurance.

Many Americans say our health care system works well and that reform is not needed; however, according to a 2009 peer-reviewed study in the American Journal of Medicine, 62.1% of all U.S. bankruptcies in 2007 were related to medical expenses and 78% of these bankruptcies were filed by people who had medical insurance.

Partisan views in Congress differ on the means through which universal coverage should be achieved, if at all, and a fundamental debate also remains on whether health care should be guaranteed to all Americans.

The site's purpose is to help people think critically so they can make better decisions about whether or not all Americans should have a right to health care. The site contains a "Did You Know?" section, an overview of the issue, over 20 pro and con arguments, an image and video gallery, a reader survey, and a listing of all sources used.

About Us

ProCon.org is a 501(c)3 nonprofit public charity whose mission is promoting critical thinking, education, and informed citizenship.

Information is presented on 23 different ProCon.org issue websites in subjects ranging from health care and medical marijuana to the Israeli-Palestinian conflict and illegal immigration.

ProCon.org websites are free of charge, require no registration, and contain no advertising. The websites have been referenced by over 130 media entities and used in over 600 schools in 48 states and 14 countries.

to reply Dr. Strat. 

I appreciate the information you have provided. 

However, I remain confused about some things.(If you could just point me in the right direction for information on these, I would appreciate it.)

1) Since doctors must pass national certification (thank you for that btw) why do they have to have licences to practice in individual states? Is this just some sort of antiquated system, or does it serve a viable purpose such as to "double-check" the applying Dr.'s certifications? 

Also, take our Dr. King for example, he was licenced in multiple states. Even though his licence was revoked in most of the states why is he able to continue to "practice" medicine in others? Indeed, given the number of states that have revoked his licence, why has his national certification not been revoked?  And if it was, would that immediately invalidate his ability to practice in the states that he still holds a licence in?

2) I am still unclear as to what regulations govern Dr.'s, with regard to criminal culpability? Obviously, malpractice lawsuits settle the civil side of things, but like in Dr. Kings case, how is it that Dr.'s are not charge with murder when a patient dies? Is there even an investigation? It seems to me that financial ruin is just not a strong enough punishment when someones(or many someones) life is lost as a result medical incompetence. 

Please don't misunderstand me, I am fully aware of the nature of medicine( i.e. a sucking chest wound can easily cause death, regardless of the best efforts of the Doctor) so I am not referring to "common" death while in a physicans care. But rather "uncommon" death, the type that results in a successful malpractice suit say.  It seems the different types of negligent homicide offer the perfect vehicle to prosecute such offenders.   

Oh, and Dr. King isn't just incompetent, he appears to be a rather sick SOB.

A whistleblower complaint accuses former osteopathic surgeon Dr. John A. King of experimenting on 26 of his patients.

The federal complaint says King used medical devices in ways that
hadn't been approved by the FDA and received illegal kickbacks for
doing it.

"King and David McNair [King's physician assistant] were conducting
clinical research and human patient experimentation when they performed
the anterior lumbar inter-body fusions" on eight patients, the "qui
tam," or whistleblower, complaint states.

"King and McNair took studies that failed in laboratory animals, and
then, without any reasonable basis to conclude that they would be
successful, began to experiment on humans," the complaint says. Con't

Once again, thank you for taking the time to respond to my inquiries. I know that they are "off topic" somewhat, so I appreciate the time you take to respond. 

If you make people think they're thinking, they'll love you; But if you really make them think, they'll hate you.

Don Marquis 1878-1937

Par:

Merritt Hawkins is an obscure place for a civilian to hang out at.  Are you in the medical field? 

If you've told me before then I'm blaming it on OldTimers.

Blonde:

Agree with first paragraph.  There is little hope of returning the geni to the bottle.  One thing the government has down is to formalize a Medicare format so that all InsurCos must use that form.

"the three groups of physicians that comprise "family practice" in a hospital"

Do you mean "Primary Care"?  There are three traditional groups comprising primary care - Internal Medicine, Family Medicine, and Pediatrics.  When BJ Clinton talked about primary care being the vaunted "gatekeepers" in medicine, OB/GYN wanted to be included.  Podiatrists and Chiropracters may also be considered "primary care" by insurance entities - they also thought the moneytrain was on the "Primary Care" tracks.  (Wrong!)  I agree with the balance of paragraph two.

Concerning the third paragraph, yes and it is already occuring.   The graph of US med student grads entering Family Medicine residency show a decresing trend along with a concommitant increase in reliance of Foreign Medical Grads to fill vacant slots.  US grads are choosing higher paying specialties/subspecialties.

I did not know that Halvorsen affiliated himself with Soros.  Figures. 

Probably as in any other work environment, the "in the trenches" working physicians cast a jaundiced eye towards administrative and academic physicians due to a belief that priorities and positions are altered depending upon the job one performs.  Halvorsen did little inthat article to dispel this line of thinking.

Your last paragraph opens up a big can of worms.  Except for charity work, any hospital, whether for profit or nonprofit, relies on payment for goods and services.  Given the nature of human expectation of pay for work performed, what else is there?  I like your thought about returning to private transactions between patient and physician without the middleman of InsurCo.  At this point, Society would need to be deprogrammed from the current reimbursement structure.  Good luck weaning physicians!

Socialism has never worked, including in the arena of healthcare.  I'll stick with free markets and capitalism, including private insurers with some government safety net.  Whatever the system, I want the least government involvement possible. 

What needs to be done is either convince Americans to pay more out of pocket for their care and/or recondition expectations on what goods and services they should receive (outside charity) for the money they are willing to spend.  Combine that with tort reform and redirecting our nation's emergency department's glut of non-emergent patients to outpatient clinics and there would be a significant savings to our citizens and healthcare industry.

Jer:

What are satisfaction ratings?  Opinion.

What drives opinion?  Environment including personal experience.

• Expectation is a huge driver of opinion.  Healthcare expectation, which is incredibly high in the American Public, has been driven by the medical community, activists from numerous strata and occupation, government, and the MSM.  IMO, the MSM has been the largest driver of negative public opinion over the years.  The current government is closing the disparaging gap rapidly.
• Most Americans have never experienced what healthcare is truly like in foreign countries.  If they have, then it is as a tourist in an emergent situation and are not vulnerable to the daily and lifelong issues faced in that country.  As humans are wont to be, especially in America, complaining is a national pasttime and healthcare is a favorite target - everyone has or knows someone who has a real or perceived poor experience.
• When those in your environment keep saying healthcare is bad or too expensive or unavailable, then you might start to believe it too, regardless of your experience.

What is a poor experience?  For some it is an outcome that was not desirable despite adequate/proper care.  For some it is not getting care they think they need but in reality do not, or, not received as timely as they believed it should have been.  For others it is an actual complication, including death, due to treatment.  Maybe it was an interpersonal relationship that rubbed them the wrong way. 

My sister recently had bilateral knee replacement.  She was upset that she was not discharged from the hospital until after 6PM despite medically cleared to leave at any time that day.  The physician was probably busy with patients requiring needed care, which meant she would wait until those more ill than her were treated before he completed her discharge.  It's triage - the sicker ones get seen sooner.  Unfortunately, the doctor forgot to discharge my sister and left the hospital, needing to be called back in.  My sister was fuming and refused to shake his hand on leaving.  Did this guy take care of her otherwise?  Yes.  Should she have been so impatient and rude?  Not in my opinion.  I fully understand her feelings, though.

The story is an example of the all too often impatience within our culture.  It is an example of EXPECTATIONS that are greater today than ever before in this country.  We want things, we want it all, and we want them now.

I have friends/associates that have done medical missions to various hellholes on the planet, like the people that live in the garbage dump of Mexico City or the shanty towns in an African country.  All of these patients are desparately poor and have essentially zero healthcare.  Given the limited supplies, a number of patients will not receive adequate or any useful treatment.  They will be informed of the presumptive diagnosis, told what may be done given the resources available, and then move on.  Yet, pretty much every patient seen is grateful for just being examined and spoken to as a human being, even knowing that there is little to nothing they can do because of their economic plight.  This is their expectations. 

Cultural expectations are quite different elsewhere in the world.  To compare healthcare satisfaction between different countries is like comparing apples to oranges.  Unless one really knows what it is like elsewhere, how do you know how good it is here? 

We have the best healthcare in the world.  Expectations and reality oftentimes do not match.  People in America need to lower their expectations or be prepared to pay for our current Cadillac of medical care model.  Leaving it up to the government will result in something a bit closer to a Pinto, complete with its lesser reliability and occassionally disasterous explosive consequences.  Just look at every other country in the world.

Are you resolved to less healthcare and taxed more because the MSM and government say it's egalitarian?

What happened to equality in opportunity, not equality in outcome?  Isn't this what Life, Liberty, and the Pursuit of Happiness means? 

If the MSM didn't vomit constantly about healthcare, would there be more satisfaction in the public?  What if people were instead told to have lower/moderate expectations or else be prepared to pay for their healthcare because that is the way transactions of ALL goods and services work. 

This is the way healthcare works everywhere.... everywhere.  The rest is a political heartstring shell game of wanting your cake and eat it too.

Lastly, what does "affordable" mean?  No one has answered this yet.  Can we then apply it to the fruits of your labor too?  How about everyone's labor product?  Why not?

What are your expectations, Jer?

Jer:Finally finished "Illness And Injury As Contributors To Bankruptcy", the article I believed you referenced in an earlier post.  What follows are my observations, comments and criticisms as a non-statistician physician.  Some is picky; some may be well off base.  I think point number #6 is critical to my belief in the lesser quality of the study’s results.

Just as I was going to post, I found a professional critique of the study – “Medical Bankruptcy: Myth Versus Fact.”  There is a chirpy rebuttal by Himmelstein and Co. to the critique called “Discounting The Debtors Will Not Make Medical Bankruptcy Disappear.”  The website that links all three articles, Health Affairs, appears to be duplicating our efforts in discussing our system of healthcare.  ;-)

It will be more worthwhile to read the professional’s critique than mine.  If you want to read what I thought, I have included my unvarnished stream of consciousness, for better or for worse.  You have been warned.

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1. The study claims 16% of families spend more than 1/20th of their income on healthcare.  How much goes towards housing, food, clothing, entertainment, etc?  Medical malpractice for my specialty runs about 10-12% of income for physicians in my area.  And the point is...?  You want goods and services then you must pay for it.  Better health and longer life sounds worth the 1/20th.  But it is your choice.
2. Not significant, but curious - the author says asset exception includes "Bibles".  What about Torahs, Korans, and other religious tomes?  Additionally, any author that quotes Ted Kennedy should give pause as to bias.  Maybe we should look at the authors to see if there is an ideology at work.  (Of course I did!)
3. The sampling strategy was by "Cluster Sampling" which is easier to do, is less costly BUT is less precise.  Total Bankruptcy Filings (N=1771) was comprised of
   • 1250 "Households" - No further definition is given so I presume this includes all comers - renters, owners, squatters, everyone.  All the data came from 5 Federal Judicial Districts, with 250 collected from each of the 5 Districts.  Where and why just these 5 Districts?  How do we know this is representative?
   • 521 Homeowners Only - was this random?  Why were these delineated from "Households"?
   • Responses were "weighted" to "maintain sample representativeness".  How done?  This is an unknown fudge factor that is very open to interpretation.  (Remember NASA's Hansen's Global Warming Hockey Stick debacle?)
   • The authors' state "To extrapolate our findings nationally, we assumed that our core sample was representative of the 1,457,572 households filing for bankruptcy during 2001" - How/Why?  Major area for bias.
   • What comprises a "Filing"?  Is it one filing per household no matter how many are included in the household?  In some of the calculations, do the authors use number of households or the number of people in a household to calculate values such as when they look at "Debtors"?  This brings into question the comparability of results. 
4. What were the questions?  Was there bias in the questions, in the person presenting the questions?  Did paying the interviewee $50 cause bias in the answers?  There were 931 follow up telephone interviews of 332 Debtor Households containing a total of 391 persons with "health problems".  (What are "health problems"?)  There must have been multiple conversations with the same person - this might increase accuracy of answers, but 931 F/U's may not increase the overall accuracy of the study.  It is a nice high number that looks nice.  This (332 Households) was the sole source of data on how many had health insurance at onset of illness and represented 18.7% of all questionnaire respondents - not exactly a high number to make national extrapolations.  Are calculations based on the 332 number or the 391 number?  Confusing.
5. On one hand the authors state that a lapse in insurance is a "strong predictor" of a "medical cause" of bankruptcy.  (more on "medical cause" in a bit)  Then the authors state "Surprisingly, medical debtors were no less likely than other debtors to have coverage at the time of filing."  The reason for this seeming contradiction is that the authors later say that even with insurance, one can become bankrupt.  Their goal is to have even more comprehensive insurance for all, including paid sick leave (for how long?).  No mention on where the money will come from or what will be rationed in order to provide this "all things to all people" insurance.  Just like guaranteeing no one will ever be struck by lightning would cause an undue burden freedoms, so does guaranteeing no bankruptcies due to medical causes to the population paying for universal medicine.
6. The most significant issue with this study is the collation of data into groups.  There are two groups that comprise medically related bankruptcies: 
   • Major Medical Bankruptcy
     • Cited illness or injury as a specific reason for bankruptcy - No problem from me on this definition.
     • Reported uncovered medical bills exceeding $1000 in the past two years - Way too little an amount of a potentially lengthy period of time.  What if they had $1K in med bills but much more in mortgage or other bills?  Why would that still account as a Major Medical Cause when the other bills are more a problem?
     • Lost at least two weeks of work-related income because of illness/injury - Another threshold set very low.
     • Mortgaged home to pay medical bills - Seems a reasonable index to measure.
   • Any Medical Bankruptcy
     • Any of the above, or,
     • Addiction - does that include cigarettes?
     • Uncontrolled gambling - Does the person spending $1K or more on lottery tickets qualify?  Why?
     • birth
     • death of a family member

The major issue I take with this study is the inclusion of issues either obliquely related to healthcare (addiction and gambling) or the bar set so very low ($1000 dollar medical bills or 2 weeks sick leave from work) so as to be included as either any cause of medical bankruptcy or as THE cause of bankruptcy, respectfully speaking.  This appears to be a great way of ginning-up the numbers.  I'd bet it was.

Curiously, foster children were not mentioned at this point, though they were discussed previously.  Doesn't the State take care of medical costs for foster children?  If so, then the inclusion of foster children in this paper was confusing and tangential at best.    

  7.  P-values range from very good (<.001) to very poor (>.05), representing the statistical significant to the relatively insignificant or higher probability of error.  This is a bit sloppy, but the authors must have felt it to be necessary to help dramaticize their conclusions (going without food, electricity, and/or phone, moved, or problems paying bills).  It's not that I disagree these things do not occur, because I'm sure they do, it's that I suspect that data/specific conclusions.

  8)  Exhibit 3 - Can someone tell me how the authors came up with greater %'s for the more specific Major Medical Cause (38.4%) of bankruptcy over the more general and inclusive Any Medical Cause (37.7%) of bankruptcy?  Since the more inclusive Any Medical Cause INCLUDES ALL the more specific Major Medical Cause totals, how can the numbers be seemingly reversed?  I have seen these numbers on several internet publications.  Maybe a correction is out there.

  9)  The authors state "59.9% of families bankrupted by medical problems (is this the Major or Any cause group?) Indicated that medical bills contributed to the bankruptcy."  How many would state housing costs, transportation costs, and food costs "contributed" to their bankruptcy?  You could obtain extremely high %'s depending on how the question was asked.  The cost of goods and services ALL contribute to the bankruptcy, from a $100 electric bill to a $5000 medical bill - if the electric bill was less, then more money could be spent elsewhere.  Is the answer, then, to make electricity an entitlement, too?  What is to be protected... everything?

  10)  In the section titled "The Human Face Of Bankruptcy" the authors state many debtors expressed fear that medical providers would refuse to continue care.  Jer, how long will you provide your labor when the customer continues to not pay?  I wonder if physicians, in the aggregate, provide more free services than attorneys.  How often are you forced by government to provide services that are reimbursed below your costs?  More importantly, how will these patient's medical care be paid for - increased taxes, rationing, both (a definite).  In the end, rationing of care will result in patients NOT receiving care they can and do receive currently.  Medical bankruptcies may be fewer under Socialized Medicine, but lives will still be lost, though for different reasons.  Socialized Medicine is just pushing the same peas around the same plate using a new knife.

  11)  The authors recognize that their sampling method makes inferences "perilous".  Yet they have extrapolated a 23X increase in medical bankruptcies since 1981.  This is an astounding increase!  And suspect.  They also stated that bankruptcy filings jumped an additional 11% since their data was collected.  How much of this was from the Dot.Com bubble burst, Enron, fear of upcoming bankruptcy law changes, etc?  Is this a new baseline or is it a blip?  I get the feeling that the authors care not either way as long as it supports their conclusion.

  12)  The authors point out that Canada has a low rate of Medical Bankruptcy.  That may be so, but they also has crappy outcomes compared to our healthcare system, care is either not available or is wait-listed, the people have less money at their disposal due to higher taxes, and the Canadian healthcare system remains hungry for new funds and runs in the red.

Now let's take a look at some of the authors of this study.

1. Dr. David Himmelstein
   • Harvard
   • Activist - See here, here (eg. 300K "refused" ER treatment?  Or $300K could wait till tomorrow to be seen at the clinic?) and many other googled sites.
   • Only a Single Payer insurer can save American Healthcare - See above
2. Dr. Steffie Woolhandler
   • Harvard
   • Activist - "After several years of working in the movement against the Vietnam War, I sought a career that would allow me to continue my work for social change."
   • Only a Single Payer insurer can save American Healthcare

Himmelstein and Wollhandler cofounded Physicians For A National Health Program, a political group whose sole purpose is to enact national healthcare.  No matter how they fib or stretch the truth or dance on the head of a pin, what they want is Socialized Medicine.  Going through the first five points in their FAQ:

1. A single Payer system WILL BE Socialized Medicine, with the government as the de facto arbiter.
2. Unless Americans are to be taxed more, the US system will be every bit as rationing as Canada's.  Ancillary services will be weeded out and services will be offered or not with applicable waitlists like every other Socialized Medicine system in the world.  It is impossible to expect same or more when paying for all.
3. The government will be running the show in a single payer system.  Period.  Farming out the day to day management, like is done with Medicare to a private insurer, is NOT a lack of government management.
4. Why would you spend hundreds of millions of private dollars to research a new medicine that, if it works, to have the government dictate your profit?  Is the government going to change the Patent system to incentivize R&D?  Tell me all the foreign companies developing new drugs that treat low sales yielding illnesses.  Compare all the advances in treatments/medicines by democracies (especially the USA and Israel) compared to socialist/communist countries - huge difference where capitalism is celebrated and government does not run everything.  What should be of more concern to everyone is that new antibiotics being developed are at perilously low rate.  This is not due to money or governmental intrusion, but to difficulties in designing new products that will kill bacteria.  While HIV is scary, a bacteria (or virus) resistant to treatment could wipe out millions in one pass in this country all without us having to touch anyone else.
5. Medicare claims of 3% overhead costs are creative accounting.  Medicare farms out daily management to private insurers who, of course, charge a fee in the double digit %'s, which is in addition to the 3% the government claims it only spends.  Do you really believe that government can more inexpensively provide the same services in the same timeframe as the private insurers do?

I could provide counterpoint to the rest of their points as well, but you get the idea.

Now let's contrast these folks and their policy group to some Canadians and their policy group - Fraser America.  In a study’s conclusions that Par For The Course posted earlier, the Canadian system is not the panacea to even Canadians themselves.  A pared down article (pun intended) can be found here. 

I still submit that the American Healthcare System is the best in the world in availability, quantity, accessibility, and outcomes.  I do not believe that a single payer system regulated by the government or anything that government controls incrementally more, will improve or even keep our healthcare where it is today… unless you want to pay more to support yourself and/or others that won’t support themselves. 

Another salient post by Par.  Where do you find them? 

 

"The coalition, Health Care for America Now (HCAN), which includes groups such as ACORN, the AFL-CIO, Campaign for America’s Future and MoveOn.org..."

"Specifically, liberal groups are waging a national grassroots campaign..."

When should we expect Pelosi and MSM decry this neo-Socialist movement as "Astroturfing"?  What a classic example of projection by the Left in how they criticized the tea party's.

Very little lately surprises me about Liberals and Leftists.  The bios of the staff involved with Campaign For America's Future read like rubberstamped propaganda pamphlets handed out at on street corners next to tie-dyed t-shirt headshops. 

One bio captured the essence of the activists and drones that staffed the site:

I switched careers to work at a non-profit political organization because I was disgusted with the conservative political climate in D.C. (in particular, the White House) and wanted to be part of an advocacy group for change. I grew up believing that America was always the good guy. Perhaps that was naïve, but I always wanted to believe it. I wanted to believe that America would stop the bully, that America would never start a fight, but would certainly end it. I wanted to believe that America stood for something, something that people around the world could look at and admire. That's gone but I'm proud that, here at CAF, we are trying to take our country back—to get others to realize that we are all in this together and together we can be free AND safe while following the principles of our beloved Constitution.

It is good to know the tactics and mindset of the opposition.  Thanks to your summary post, Par, I will not have to waste any further minutes of my life on that article.

Reading the first four pages and skimming most of the rest of the 27 page article you linked, my first impressions are:

• Word Shifting - You can try and call it “public plan choice” but it still is Socialized Medicine. 
• Cost Shifting - The author accuses private insurers of this yet fail to mention their public plan will also cost shift through the mechanisms of public subsidies via increased taxes and off loading administrative costs onto private corporations as Medicare currently does.
• Piggybacking the private plans onto the public plan - this is the sugar that makes the medicine go down easier.  I believe the goal is to remove all private insurers from the equation one day.  Give an inch and they'll take a mile.
• "... our crumbling framework of health financing..." - BULL!  It is crumbling only because people want the cadillac of plans while paying same or less in premiums.  We pay more in the USA because we GET MORE in the USA, and we get it faster as well.
• In the same paragraph, the author simultaneously chastizes opponents of Socialized Healthcare because they do not know details of a public plan AND then states the public supports Socialized Healthcare of that same illusionary plan.  If no one knows what a public plan will be in order to criticize it, how can the public be righteous in their support of a phantom plan?
• "...private health plans will have incentives to engage in practices—such as selecting healthier enrollees or shifting costs onto patients..."  And a public plan will not shift costs to all of us, regardless of our usage of healthcare?  How dare we charge someone more for utilizing more services.  No matter how you slice the bacon, it still is bacon.
• Corporations "evil" mantra repeated often.
• The author simultaneously promotes less choice of plans and more choice of plans... as long as they adopt the government's model.  Referencing popular psychology book The Paradox of Choice: Why More Is Less by Barry Schwartz does not impress me further.  These folks hide their actual agenda of a single payer healthcare system.
• While the author states that private and public plans could act as checks and balances on one another, the simple fact is that the public plan will always require funding even if people decide to return to private plans, and that the public plan will increase its spending in order to attract enough people and justify its existence.  After the public plan has an outright monopoly there will be reviews, revisions and cuts that will affect outcomes on morbidity and mortality eventually paralleling all other Socialized Healthcare systems.
• The author fallaciously states that countries with Socialized Healthcare have "better overall healthcare outcomes".  If you accept the Who's statistical skew, then he has a point.  Evidence has already been submitted in this forum about the greatly improved outcomes of American healthcare versus the Socialized healthcare of Canada and Britain.   This is explicitly due to Americans paying more for their healthcare and receiving more healthcare in return.

I understand that Obama may slam his Obamacare down our throats by fiat, but that doesn't mean they will not be called on their BS by me. 

Time to watch Meet The Press for my Sunday dose of inanity.

Another quality post, Par.

These cases may be news for government involvement, but there is plenty of precedence from similar cases against private insurers.  In other words, these cases will be resolved more often in favor of the defendent (government).

Even sadder is this is the beginning cannonfire of Statist Medicine.

Blond:

Thank you for the thought, but I don't recall anticipating a response from you.  Regardless, who wouldn't be happy to hear from you.  :-)

I do wonder, though, about not hearing from Jer.  He referenced medical bankruptcies in a post to which I finally responded.  I was anticipating some sort of response from him.  Oh, well.

Lastly, Par is a good contributor on this thread.  He motivates me to read and learn more.  Maybe he should consider changing his name to "Birdie" or "Eagle" because he's got game.

I appreciate your informative and insightful posts. 

Par    

I need to get my head back in this game.

I hope he fails, too.

Your article was the first thing I read today....and cheers me.

I wonder how long this will take to wind its way through the court system, further, will we hear about it in the news?

I hope he fails, too.

My apologies, I have been lazy, lazy, lazy when it comes to this thread, which I started, after all....and I must admit I didn't read your "here, here here links", either.  (Hangs head in shame). 

As you know, I'm a number cruncher....so there are lies, damned lies, and statistics.  Truism.

Further....rationed care = zero sum game.  It's a law of nature, like gravity.

As for "physician extenders"....dude, I can do that myself.  I know when I get a bug, or a cut, what antibotics work and don't.....why would I possibly need some junior college reject for that? What, after all, is the point.

Now....on to my real question.

Swine Flu Pandemic.....call me a cynic, but I suspect old Rahm is at it again....let no crisis go unexploited.  I suspect (nay...lol, since I ride horses I should say neigh) that this is just another dodge by the Bamster, et. al., to "soften up" the population for what is next.....the insanely disgusting shoving down our throats of nationalized health care.

What says you, strat?  Curious.

Again, sorry I've been absent from this conversation for a while...I've been in an intellectually lazy mood.  I'll try to do better.

Regards.

I hope he fails, too.

at consolidating points.  And what you've written mirrors several of my concerns.

brief background : I recently had my foot bashed (well, more like smushed) at work was rendered unable to walk on it except with my trusty cankle (my children's word don't blame me - its the hardshoe with the velcro straps and rubber bottom)

My medical center recently got a brand spankin new computer system.  When I arrived at the center with my injured foot I spent more time waiting for them to bash their way through the system to get it to print the proper permissions  for my treatments and x-rays than I did actually getting the treatment and xrays.  And getting my prescription was the worst part.

I was told that I had to wait for a printed copy before I was to walk across the hall to the pharmacy. 
No copy printed. 
Wait... no copy?  (The nurse  bashes computer a bit more to entice a reprint.)
10 minutes and still no copy. 
(By this time the pain pretty much sucks.) 
Well, just go across the way there maybe its printed over there and they'll have it. 
So I hobble over there with my trusty cankle. 
"I'd like my pain meds, they sent me here." 
Sit down? *whew* Ok!  

They called me over twice more to check who I was and what I needed. 
Maybe the printer was just.... slow?
Keep in mind the clinic is literally ACROSS THE HALL. 
Its not in the system? 
It's not. 
Well its a new system.
Yes, I'd heard.
Well why don't you have a copy of your scrip?
For the third time they sent me over here saying YOU would have it. 
Ok, tell you what - go back to the clinic and get us a copy. 
Whhhhat? 
I look at my cankle.  Seriously you want the person who just had 40 pounds of concrete dropped on her foot to go across the hall for you? 
Goshthanks.
Yay cankle. 
Did I mention the Doctor said I should keep this elevated?
No? ok I will brb.
Finally after 45 minutes I had my scrip.

And this is what technology is supposed to do for me?  How will they be able to work their brand new system into the government system?  How will they pay for it and who will eat the cost of the (now defunct) new system if it won't integrate with the government one.

And this is just the most basic issue.  I have a lot of concern for the actual collection of data and the possible uses for it.  I find trouble with the idea of 'ease of use' being one of the selling points.   As a dependent of a military retiree I have already been subject to having my health care de-prioritized.  I really don't want to go back to it.

Hold on ‘cause the world will turn if you're ready or not ~ KT Tunstall

I have been and continue to be extraordinarily impressed with the highly informative and insightful commentary by you, stratman, Blonde, and all of the others at this forum.  But, please, in the name of all that is holy, spare me what Dick Morris may have to say about anything.

Jer

I'm pleased you joined us here....we always welcome those from teh other side of the aisle who join us in the true spirit of discussion of ideas.  So again, I'm pleased you accepted our invitation.

You have pointed out something that perhaps we've not yet discussed....the fact that we do, in fact, provide health care for those who are indigent, through various means.

I'll address your #1 first.  Part of every payroll deduction is comprised of a 1.65% tax (part of what you see as FICA) for Medicare.  This is matched by your employer....so a 3.3% contribution is made by every wage earner in the country, for every dollar earned, up to (last I checked, this probably has been increased) up to $125,000 per year.  That's alot of cash. 

It is "contributory".  Which means, it is like Social Security....you pay in all of your life....so you get to draw "benefits" when the time comes.  Ha ha, our trolls liken it to socialism...but when it's an involuntary deduction, then, my friends, it is not socialism....it is a "pre-paid" health plan, yes?

Secondly, through my property taxes, I pay a rather large sum each and every year for the public hospitals, which fund indigent care....and through the state, Medicaid for poor children.  Further, there are numerous federal, state, and local programs to provide services for children without insurance.  Also, not-for-profit organizations, for those who are without basic health care coverage.

I was an Executive Director at one time for Epilepsy Services...we provided no cost neurological services to the impoverished who had seizure disorders.  There are numerous non-profit organizations which provide wonderful services to those who are in need, without governmental intervention and direction.  Most are supported by those who have family members who have been afflicted...who truly care about their "issue"...and whom give from the heart.  I truly believe it's a wonderful way to provide both medical services and support...and government intervention in this private service delivery mechanism would totally destroy it, IMO. 

The point being, that we (okay I) already pay quite alot into the "public" health care system, without being taxed, yet again, for a "public option".  I do not care to pay for illegal immigrants, there is no reason for that.  I do not object to paying for those who are unable to do so (children)....but I refuse, flat out, to pay for thiefs and liars.

As to your last paragraph, I KNOW in my heart that anything the government touches will cost three times as much, and be one fifth as effective as anything done in the private sector.  I'll turn this argument around on you.  Other than the military (which no private entity can field)....name for me ONE THING which the government does more efficiently than the private sector.  After you've answered that question, we can again discuss "costs".  Because I, for one, and all conservatives like me, believe there is nothing that the government can deliver more cost efficiently than the private sector.

Again, mamabear, thanks for joining our conversation.  I truly appreciate your heart, even though I find it to be somewhat misguided.

Regards.

I hope he fails, too.

So my suggestion is that yes, costs will go up.  But do we really know how much they will rise?  You all seem to be going on the assumption thatit will be catastrophically bad.  How can you be so sure?

Since Massachussetts is the closest thing we have as an example of the current legislation making its way thru Congress, from Massachusetts Miracle or Massachusetts Miserable: What the Failure of the “Massachusetts Model” Tells Us about Health Care Reform June 9, 2009

(Page 4) The proponents of the Massachusetts reforms also promised that those reforms would reduce health care costs. Governor Romney said that “the cost of health care would be reduced” and the plan would make health insurance “affordable” for every Massachusetts citizen.[27] Supporters suggested that the reforms wo