26 people have expressed their views!

1. Puck, you knew I’d have to disagree with you.

   First, I do think we need reform. I think insurance being offered by work is a bad idea, because not everyone works. People change jobs more than they used to. I favor tax benefits being given to people rather than employers. I favor elimination of restrictions on insurance across state boundaries, allowing for greater competition. I think tort reform and the end of defensive medicine will help lower cost. Finally, I do favor universal coverage for children, because this is an investment that will pay off in the long run as childhood preventive care is a relatively inexpensive way to insure healthier adults and kids all deserve a fair start in life.

   Second, how your analogy breaks down. I have some questions. I haven’t been able to read the bill. Have you? Has anyone? So I ask out of ignorance, is this “public option” limited like the public defender? Can you only get it if you have a certain income? Or would Bill Gates be eligible?

   I’ve always thought the main barrier to using a public defender was fear of what sort of lawyer you were going to end up with. My perception (and it may be wrong) is that all lawyers are required to do so pro-bono work, but the chance of getting a poor lawyer is higher with a public defender. Supposedly, with the public option in medicine, you can use it to see whoever you choose. If it’s just a really bad insurance plan, it’ll be like military’s Tricare. Nobody will want to accept it and we’ll start the debate again very soon, because the poor will be “covered”, but not really covered.

   There’s supposedly a lot less variation in physicians, because of the legal environment. I’m not an expert on law, so I can’t really speak to the variation in that profession. I’d love it if David were to comment, but I don’t know if he reads your blog.

   My concern about the public option is twofold. One that private companies can’t compete with the government due to its size and its regulatory power. Recently it effectively bought several car manufacturers and half the banks. Name an insurance company that has that kind of money laying around. How is that competition? The government makes the rules. They set reimbursement rates (which is a big part of what screwed everything up and why everybody wants to be a surgeon and nobody wants to be a family doc, because the surgeon makes 3x as much). So how can you compete with a guy who has infinite pockets and makes the rules? That’s not competition. Eventually the insurers will lose, will fold, and then we’ll have one insurer and it’ll be us.

   Secondly, I don’t really want to government to be involved in healthcare for concerns that once it becomes a political hot potato, medical decisions will be decided by politicians. Hot topics, like HIV, will be overfunded and diseases that are significant but not in the media will be underfunded.

   Right wingers aren’t just dipshits that want Obama to fail. We don’t all carry assault rifles to protests (although it was completely legal where they were, so what if they did?). Some of us actually believe what we say and argue what we think is best. We don’t want the poor to die because they don’t deserve to live. I know I deserved to live when I was poor. I just don’t want the government taking on another entitlement program that is going to snowball into huge costs on months of sort-of-kind-of talking about some hypothetical plan that nobody’s really talked about.

   Let’s quit fighting and start actually talking about how we can fix a broken system. Let’s talk about real costs and not go lying and say it can be budget neutral (does that even make sense, it’s like a perpetual motion machine). It can be done, but not like this!

   By Hawkins on August 18, 2009 7:36 pm

2. Lie? Obama says in 2003 and 2007 that he is for a one payer system. In 2009 he says that he never said that. Sounds like a big lie to me. I know that the Left is bussing in and making a call to arms of union members blocking and BEATING people trying to get into the town hall meetings. Perhaps people are trying to defend themselves. The whole time Mr. Bush was PotUS the left used the Shout Down Any Debate method. They were worse in so many ways that it is sick. The concept of comparing healthcare to the justice system is easy and false. People get public defenders and such in law because they are accused by and being judged by the government. Due process is a part of LAW access to healthcare and the government take over of it is not part of the constitution or the bill of rights. It is so easy to say that if the people that disagree with you they will lie to you or try to hurt you. It is a fear method and you are spreading it. I am ever so proud of you. Have you been to the DMV to get a driver’s license, tried to get an appointment with a specialist at the VA, spoken to a Native American about their healthcare, tried dealing with the post office on an issue where they were wrong? It is no picnic my friends. Healthcare works when the people running it have to stay in the black. When the government gets involved with their spending and always in the red finance style taxes go up and care goes down. If you are getting treated for cancer today and the healthcare program that was funding that treatment runs out of money because the money was moved to pay for clunker cars the program gets cut and you don’t get treated with the best care as you can. Even Canada a few days ago reported that they can’t keep going the way they do things and will have to change including some private medicine. Funny that the Canada system is what Obama wanted to be like.

   By Peter Wohlers on August 18, 2009 7:52 pm

3. That’s a very interesting argument. It boils down to that Miranda gives people a legal right to counsel regardless of means. And that access to health care should also be considered a basic right regardless of means. All public option means is that the gov’t provides affordable insurance for those who aren’t able to through the current system. It’s providing competition in the system. Who’s against real competition? Private insurance won’t go away. Obama did say something stupid the other day about saying the US Post Office has problems but not UPS or FedEx. Somehow I doubt that is what he meant. Actually, I’ve been quite pleased with the USPS. Has anyone used their online web services? Their website is very good. I’ve had problems with UPS and FedEx as well as the USPS. I think it’s just natural to rail against the guv’mint. I’m disappointed that single payer wasn’t on the table. So what if Obama changed his mind?

   I went to the DMV here in Tucson to get my Arizona car tags and license. I had to wait a long time, but it was open on Saturday and despite the long wait they handled everything efficiently and courteously. I’ve gotten worse service at the privately owned tag agencies in Tulsa.

   The idea of public health care for helping the poor has been around since the founding of this country. Ben Franklin helped to found the first public hospital and part of it’s mission was to provide health care to help those who could not afford it. Teddy Roosevelt, one of our greatest presidents, tried to set up a national health care system 100 years ago. In fact, Richard Nixon, certainly not one of our greatest presidents, also tried to get national health care passed. America should be #1 in health care. Not #37.

   By Chris M. on August 18, 2009 8:33 pm

4. Hola Hawkins,

   Glad to see a response from you on this.

   “First, I do think we need reform. I think insurance being offered by work is a bad idea, because not everyone works. People change jobs more than they used to. I favor tax benefits being given to people rather than employers. I favor elimination of restrictions on insurance across state boundaries, allowing for greater competition. I think tort reform and the end of defensive medicine will help lower cost. Finally, I do favor universal coverage for children, because this is an investment that will pay off in the long run as childhood preventive care is a relatively inexpensive way to insure healthier adults and kids all deserve a fair start in life.”

   There isn’t much here that I disagree with. In this case, I’m reading “defensive medicine” as treatment of specific medical issues without much concern for preventative care or maintenance care. If that isn’t what you mean let me know.

   “Second, how your analogy breaks down. I have some questions. I haven’t been able to read the bill. Have you? Has anyone? So I ask out of ignorance, is this “public option” limited like the public defender? Can you only get it if you have a certain income? Or would Bill Gates be eligible?”

   Addressing your concerns about the current bill, you and anyone else can read it. Wikipedia has a summary of key issues:

   1. Establishes a mandate to purchase health insurance for most legal United States residents with an income above poverty level.
   2. Prohibits pre-existing condition exclusions.
   3. Prohibits premium variances, except for age, geographic area, or family (vs. individual) enrollment.
   4. Prohibits cancellation of coverage except for evidence of fraud.
   5. Limits annual out-of-pocket expenses to $5,000 for an individual and $10,000 for a family.
   6. Outlines a public health insurance option to be established which would operate based on average private insurance pricing.
   7. Establishes a Health Insurance Exchange (HIE) within a proposed Health Choices Administration, to provide individuals and employers access to health insurance coverage choices. The HIE would contract with various insurers to offer benefit plans at competitive prices, by establishing a risk-pooling mechanism. This will allow individuals and small companies to band together to bargain for lower rates.
   8. Provides a tax credit for low-income individuals and families to help pay insurance premiums.
   9. Requires employers with payroll costs over $250,000 that are using the HIE to provide health insurance.
   10. Provides for a tax on individuals without health insurance and employers that do not provide the required health insurance.
   11. Provides for a tax on individuals with adjusted gross income exceeding $350,000.
   12. Reduces Medicare payments to hospitals with excessive re-admissions.
   13. Establishes a Center for Comparative Effectiveness Research, which would analyze cost variances for similar treatments across the country.
   14. Further expands Medicaid eligibility and scope of covered preventive services, for lower-income individuals and families.
   15. Increases Medicaid payments to physicians for primary care.
   16. Provides for a phased-in elimination of the Medicare PART D coverage gap and requires drug manufactures to discount and/or rebate additional qualifying drugs originally excluded from the plan.
   17. Requires the Secretary of Health and Human Services (HHS) to develop quality measures for the delivery of health care services in the United States.
   18. Establishes the Health Benefits Advisory Committee chaired by the Surgeon General of the United States.
   19. Prioritizes any eventual implementation of best practices in the delivery of health care.
   20. Establishes a National Prevention and Wellness Strategy along with appropriations for its trust fund.
   21. Outlines Administrative standards that reduces costs and improves service, including the ability for Administrators to determine an accurate total financial estimate at the point of service as well as enabling real time electronic transfer of funds to take place if possible (mirrors currently existing laws}.

   You can read the legislation yourself here:
   H. R. 3200 – http://thomas.loc.gov/cgi-bin/bdquery/z?d111:H.R.3200:

   “My perception (and it may be wrong) is that all lawyers are required to do so pro-bono work, but the chance of getting a poor lawyer is higher with a public defender. Supposedly, with the public option in medicine, you can use it to see whoever you choose. If it’s just a really bad insurance plan, it’ll be like military’s Tricare. Nobody will want to accept it and we’ll start the debate again very soon, because the poor will be “covered”, but not really covered.”

   I don’t disagree with you in principle. The point of private insurance would be to obtain better health care than you could receive by purchasing the public option. At this point I have no choice as to my health insurance provider and they have screwed us once already when they refused $600 dollars in medical bills.

   In addition, many people have no insurance so even a bare bones medical plan would be better than nothing. A single mother very close to me recently experienced a medical emergency with a toddler and a fractured skull. The clincher is that she was in the process of being laid off by her company. If the injury had occurred a few days later she would have been without medical insurance.

   “My concern about the public option is twofold. One that private companies can’t compete with the government due to its size and its regulatory power. Recently it effectively bought several car manufacturers and half the banks. Name an insurance company that has that kind of money laying around. How is that competition? The government makes the rules. They set reimbursement rates (which is a big part of what screwed everything up and why everybody wants to be a surgeon and nobody wants to be a family doc, because the surgeon makes 3x as much). So how can you compete with a guy who has infinite pockets and makes the rules? That’s not competition. Eventually the insurers will lose, will fold, and then we’ll have one insurer and it’ll be us.”

   Private companies are killing us now and there is a serious need for reform because of a sort of system-wide administrative evil that permeates the entire culture. Health care for profit is a no-win situation. It might work on an individual level where you and your doctor have personal trust, but not at a corporate level where success is measured in dollars and not lives. My insurance provider was successfully sued for rescinding expensive policies and awarding cash bonuses to employees who were able to find loop holes to do it. Where I come from we call that “killing people” and we have corporate insiders like Wendell Potter telling us that is how it works.

   On top of that we’re close to 50 million uninsured in this country. That’s a big number and I think it would be the height of idiocy to assume that 50 million uninsured isn’t a national issue that needs addressing. The most common argument I hear is “Why should I have to pay for their insurance!” That tracks pretty well as a rural versus urban argument.

   For example uninsured homeless people aren’t much of an issue in Stillwater, Oklahoma. With a smaller community the consequences are small. If someone drops dead on the street, it gets cleaned up pretty quickly. When you look at a larger population like San Francisco, you have bodies dropping at a regular pace and you need some sort of plan to address it. The urban argument is “We need some kind of plan to handle the large number of homeless deaths.”

   “Secondly, I don’t really want to government to be involved in healthcare for concerns that once it becomes a political hot potato, medical decisions will be decided by politicians. Hot topics, like HIV, will be overfunded and diseases that are significant but not in the media will be underfunded.”

   In any case, this isn’t an argument against public health insurance for the poor. The same is true of any publicly-funded research. Do you think I was happy when Bush outlawed federal funding of stem cell research? Private insurance can still fund whatever it likes and wellness programs and alternative medicine can breathe easier for it. In our case, California passed the Christopher Reeves act to fund stem cell research at a state level and now California has all the research talent in our state. Because of innovation California has a significant lead in funding and talent.
   From that we draw 2 conclusions:
   1. Politics is politics and we can’t change that.
   2. Competition rewards

   “Right wingers aren’t just dipshits that want Obama to fail. We don’t all carry assault rifles to protests (although it was completely legal where they were, so what if they did?). Some of us actually believe what we say and argue what we think is best. We don’t want the poor to die because they don’t deserve to live. I know I deserved to live when I was poor. I just don’t want the government taking on another entitlement program that is going to snowball into huge costs on months of sort-of-kind-of talking about some hypothetical plan that nobody’s really talked about.”

   I don’t have an issue with a well-informed discussion in which you and I disagree. I have an issue if you shout at me while holding a gun. If you don’t think that is an intimidation tactic, I am agape with amazement.

   I have an issue when people argue based on lies and try to pass these lies off as an argument. I had one person try to define socialism as “when the government takes your money and gives it away.” By that measure any taxation is socialism and we need to stop funding our public roads.

   “Let’s quit fighting and start actually talking about how we can fix a broken system. Let’s talk about real costs and not go lying and say it can be budget neutral (does that even make sense, it’s like a perpetual motion machine). It can be done, but not like this!”

   I know you and I know you’re a softie at heart. So what is your solution for the rising number of Americans without insurance?
   ~P.

   By puck on August 18, 2009 10:20 pm

5. Piet,

   Could I just pay you to be the spokesperson for the other position?

   As far as the DMV and U. S. Postal Service these might be slow, but I haven’t had issues with them.

   When we were concerned my wife had cancer in her gum, we had three different forms of insurance and none of them covered the procedure to test for cancer. We found out after the fact and had to pay $600 out of pocket. That’s three different insurance policies all ditching us at once.

   Here’s my private insurance company:
   http://www.ama-assn.org/amednews/2007/12/10/bisc1210.htm
   “it rewarded its employees who canceled individuals’ health insurance.”

   Wendell Potter former executive at Cigna:
   http://www.youtube.com/watch?v=YTv_BBpp3zs

   If you’re so affronted, what’s your solution to the situation described above?

   I’ll take U. S. Postal over corporations that actively try to profit at my family’s expense any day.
   ~P.

   By puck on August 18, 2009 10:53 pm

6. Interesting discussion – the editing box on the blog site just isn’t big enough –

   >>> Peter said: It is a fear method and you are spreading it. I am ever so proud of you.
   Interesting, I actually thought Puck’s blog was more satire than fear. I did not map it to reality too much. It provoked thought in me, but not fear.

   >>> Peter said: the left used the Shout Down Any Debate method
   >>> Puck said: an issue if you shout at me while holding a gun.
   Yea, sadly both sides have used intimidation and fear inciting tactics. It sucks, and it has gone on for years. Both sides claim to despise it but it still goes on. Public news loves it… but it really can get in the way of valuable discourse.

   Despite not being their points clearly or calmly stated – I would hope that the lawmakers can extract the essence of the debates and address that responsibly.

   >>> Hawkins said: is this “public option” limited like the public defender? Can you only get it if you have a certain income? Or would Bill Gates be eligible?

   As I read it, anybody would be eligible for the public option. (caveat, as with all of life… Implementation may differ.)

   I am still under-informed about the details of most of the plan – However… from what little I have researched – my top thoughts about recent headlines are:

   1.
   Don’t spend more money – if you want to do something that’s great… please cut money from somewhere else. I’m honestly scared by how much we’ve spent this year.

   2.
   Requiring Insurance is fine – similar to, but not quite the same as, requiring auto insurance. (Now… I would prefer just enabling everybody to get insurance as opposed to requiring it – similar to flood insurance in sacramento… the insurance companies have to provide it for reasonable cost if the home owner wants to have it.) Universal Insurance for children seems good – kids are the future, better keep them healthy to pay for all this debt we have (grin)

   3.
   Public Option is fine – I’m likely to keep my own insurance with private companies. I don’t buy the un-fair competition claims, there are areas where private companies compete with the government subsidized industry (UPS vs USPS vs FedEx for example) and government is not very efficient most of the time – so any company that honestly thinks they can’t compete with the government should be sacked (grin) Some protest the government jobs to create the public option – see point 1 (don’t spend more money) … I’m ok with it if I see cuts elsewhere.

   4.
   End of Life counseling is fine – let people ask about living wills if they want to and allow that to be covered at a reasonable level.

   I think the single statement that I most agreed with was
   >> Hawkins said… The government makes the rules. […] which is a big part of what screwed everything up […]

   Yes, I know this is pulled out of context and not journalistic quality. I think a tremendous amount of what we deal with today is 2nd and 3rd order ripples from past policy. Medicare, Social Security, Big Budgets, Tax Code, Farm Subsidies, Welfare… they may have accomplished their main goals, but they implanted signficant and not always beneficial side-effects in society.

   I favor health reform… I don’t have the answers… It is easy to point at the problems… it is vastly harder to fix them.

   Cheers,
   Jack

   p.s. I do like seeing people get involved… even if they have different opinions… because the Apathy in America is Apalling.

   By Jack Smith on August 19, 2009 4:01 am

7. If you don’t allow premium differences, exclusions for pre-existing conditions, or much of what I’m hearing – then that’s not insurance. The analogy is to car insurance. “Well, Mr. A. You’ve wrecked 500 cars this year. You have 100 speeding tickets. You’ve cost our company $100,000. Your premiums are $200/month. And Mr. B! So glad to see you! You’ve been a client for 30 years, never had an accident and never had a ticket. You’ve never cost our company a cent. I actually feel bad, because we’re up several hundred thousand on you (which we spent on Mr. A there). Your premiums are $200/month.” Does that make sense? What does it encourage? Mr. A behavior or Mr. B behavior?

   We might need to stop calling it insurance and start calling it an “all-you-can eat buffet”.

   What about it suggests that buying private insurance would lead to better care? Is there any possibility I, as a private physician, can choose to not accept the “government/public option plan”, especially if it requires excessive paperwork or reimburses me at too low a rate? If I am required to accept it, then there is no difference and no sane person will keep private insurance. Private insurance will go bankrupt. Do you see the path I’m envisioning? Does it or does it not make sense? Why will that not happen? What mechanisms are in place to allow private insurance to remain competitive?

   Your concern, Puck, about intimidation is valid. However, I can also see their side that if free speech is legal and openly carrying guns is legal, then free speech while carrying guns is legal. They’re right, yes? Shooting the guns is illegal and there are very many incentives for them not to. It came out that nobody was shot, which is what I would expect to happen. Hopefully that lessens the intimidation for the future and there are few municipalities where that can legally happen anyway.

   Many more points I want to address, but just got off a shift, treating people at the ER. Oh, yeah. EMTALA. Google it. Your friend can feel comfortable taking her kid to the ER. They have to access the child and provide emergency treatment (such as for a fractured skull). Give a fake address if you’re really that worried. Children will always get seen. Please just don’t bring your kid in for some of the stupid stuff I saw tonight. Like the hurt foot that wasn’t really hurting and only hurt when he ran at max speed while playing soccer. His range of motion was better than mine at my best and I could fold his foot up in origami without provoking pain. Lady, your kid is fine. If he still wants to play, it doesn’t really hurt.

   By Hawkins on August 19, 2009 7:39 am

8. Hawkins,

   I don’t see anything about forcing all premiums to be the same. That wouldn’t be competition. (I did see a requirement that limited the out of pocket expenses with regards to deductibles on an annual basis.)

   Refusing to accept people with preexisting conditions is what got us into this mess in the first place. If PuckCo Insurance can refuse care to all diabetics my company should be more profitable because honestly those guys cost a lot and the upside is pretty low. Of course diabetics get screwed but my bottom line looks great and as a private company I don’t have any moral obligation to them. If they wanted insurance, they should have been born with a better pancreas. Diabetics don’t represent a voting majority and there is no clearly stated right in the U. S. Constitution concerning insulin.

   The problem with your car insurance analogy is that it makes a value judgment about behavior that doesn’t typically exist in a health care situation. It would seem terribly unfair that a person that chooses to drive badly enjoy the same insurance rate as a safe driver. However, unless you want to attribute illness to divine vengeance, birth defects, cancer, disease, and injury don’t have a value judgment attached. Or to put it more plainly, it isn’t the patient’s fault if he has stomach cancer.

   The “deserve” issue keeps coming into this discussion in different ways. I find that pretty stunning from the party claims to represent Christian morality but cognitive dissonance has never really been an issue with politicians in the past. It puts us right back into Social Darwinism and the idea that the poor don’t deserve medical coverage. You can see a similar “deserve” argument in Victorian England when the infant mortality rate for the urban poor was about 50% and the middle class blamed this on the incompetent mothers when the relevant factors were poor sanitation, dirty water, overcrowding, and the pervasiveness of disease. It’s no surprise that Herbert Spencer is writing in 1851 about the “beneficence which brings to early graves the children of diseased parents”.

   I’m also surprised at your recommendation that we provide false names in order to receive emergency care. If that’s what medical students are recommending, we are in bigger trouble than I thought. I think we can both agree that EMTALA isn’t an ideal solution for medicine. Without regular preventative care and maintenance, the emergency room becomes the catchall medicine for the poor. Without preventative care, it naturally follows that serious illness is more likely. It’s a net loss and any honest measure can see that this model doesn’t work.

   You also haven’t addressed the monetary incentives to deny care that any profit-motivated organization will naturally encounter. I realize that as a career military officer and a soon-to-be doctor you won’t experience this. With government medical coverage you may not have to worry about your medical care, but there have been times when my family has been too poor to visit a doctor or when we had insurance and were denied coverage for procedures our doctors told us were medically necessary. The truth is that the more difficult insurance companies make it to receive care, the more money they make.
   ~P.

   By puck on August 19, 2009 5:41 pm

9. You’ve never heard anything that would force all premiums to be the same? I took it from your reply above: “2. Prohibits pre-existing condition exclusions.
   3. Prohibits premium variances, except for age, geographic area, or family (vs. individual) enrollment.” Am I misunderstanding “premium variances” to be variations in premiums?

   Many, many medical issues are direct results of choices. Some aren’t. Type 1 diabetes is not. Type 2 is even more strongly genetic than Type 1, yet it’s also strongly associated with obesity and if the obesity goes away, usually the diabetes does too. Hypertension can be controlled with diet and exercise. Heart disease has many behavioral related risk factors. Finally, two people can have the same health problems and one can choose to make a big deal. 90% of people I saw in the ER the last few days aren’t really that sick. Seriously, would you go to the ER because your nose was swollen? No other reason?

   Then you say, “Oh no! This friend had a child who might DIE!!” Then you get all judgmental that I gave you a response. You came to me with a victim example. I gave you an easy way to solve it. I have paid for all my medical care my entire life. I haven’t found it that hard. I paid for a serious chronic condition for a close family member. It meant I couldn’t lose my job and admittedly there was an element of luck involved in having that job when I did, but I think I’ve established my belief is to pay for your insurance. However, I think letting your kid die of a broken skull is a bigger sin than giving the wrong address to admissions. If you can’t deal with the thought of paying for the visit out of your pocket, there are alternatives and I gave one morally suspect one. I’d use it if I had to. There are many other alternatives, but to say “OH NO!!” is ridiculous. Victim mentality sucks.

   Preventive care isn’t likely to prevent a skull fracture. I believe in preventive care, but recent articles I’ve read suggest it’s not likely to be the panacea I believed it would be. Sure, it’s great, but it costs some money for a lot of people to prevent a few more expensive procedures later. My understanding is that overall it works out to be more expensive than how we currently do it. I’ll find some links another day.

   I think incentives to deny care are a problem. Just as the lack of incentive to not go to the hospital for stupid crap is a problem. I think insurance overall is a big part of the problem in our healthcare system today. It confuses the issue. People start thinking they can pay a certain small amount for all the healthcare they can use. Then they overuse the system. That’s why I compared it to a buffet. Pay $10 and then eat until you feel sick. It’s probably better to pay $2 for a salad, $7 for a hamburger and fries, and finish with a $9 bill and no tummy-ache. Insurance should be a risk sharing pool, not an all-you-can-use free medical ride. Because then you have people coming in for stupid crap, like a swollen nose for 3 days when they’ve got an appointment with their family doc already scheduled the next day. That’s not emergent! I’m a big proponent of pay out of pocket for medicine. Docs should share info with patients. Yes, you can have the MRI, but you don’t need it and it costs $1000. Do you really want to insist on it?

   By Hawkins on August 20, 2009 6:48 am

10. Well… I think the “except for” means there are ways of varying premiums. Or to paraphrase you, “Am I misunderstanding what an exception is?”

    You’ve again referred to a value judgment to make an argument. You’re also creating a fallacious chain of reasoning:

    Some people abuse medical coverage –>
    Some people’s health problems are caused by behavior–>

    –>Therefore the poor shouldn’t receive insurance.

    Maybe it would be better to address those issues directly instead of sabotaging health care reform completely.

    Victim mentality does suck but to be fair, being victimized by the powerful sucks worse. You aren’t disputing the corporate abuse or the lack of medical care.

    At this point we are in antagonistic conflict much like a fencing match. (Each of us has opposing goals that are mutually exclusive.)

    Because my party won a majority in the house, a super-majority in the senate, and the executive branch in the last election there is a good bet that some form of health care reform will be passed. While the Republicans have contributed to the bill and I would love to have moderate Republicans like Snow, Romney, and others engaged in the process, there’s no requirement that Democrats compromise at all.

    If the house bill has a public insurance option, the senate can easily avoid it in their own bill and then include the public option in the reconciled bill. The reconciliation can pass it with 51 votes without the threat of a filibuster.

    There were plenty of times when I was on the losing side of these policy conflicts in the last 8 years so while I recognize that you are unhappy, it doesn’t change my desire to achieve my own goals especially after the previous administration ran rough-shod over so many of my issues like the environment, human rights, executive power, and preemptive war. We both voted and that’s how the game is played. Vote again in 2010 and we’ll see how it turns out.

    (For the record, Romney-Care seems to be working for Massachusetts from everything I hear. The Republicans need to stop crucifying the moderate wing of their party or they risk become so extreme they alienate everyone who isn’t a ditto-head.)

    By puck on August 20, 2009 8:48 pm

11. Ok, let’s focus down on this one issue. I understand exceptions. What you wrote above seems to forbid exceptions on the basis of anything except for age, geographic location, or family size. Is that right? Or are you saying I’m missing something?

    That neglects the biggest driver in accounting for expenses, which is projected costs. So to continue the automobile insurance analogy, we could look at how old the driver is (which, admittedly is a surrogate for costs in both health insurance and driving, but low correlation compared to driving record or pre-existing condition), where the car is garaged, and how many drivers the policy covers, but forbids looking at the drivers record.

    I’ll end it here except to acknowledge the flaw in the analogy that Puck pointed out. Health conditions are not the moral issue that driving violations are and I have not meant to argue wholly otherwise. However, they are not totally un-alike, either, which I would hope Puck would admit. There is an element of conscious choice in many health conditions and some element of unavoidable physical reaction time, eyesight, and luck in moving violations.

    By Hawkins on August 21, 2009 7:13 am

12. The talk about opposition pisses me off to the point of discontinuing my participation in this conversation. Sure, do it unilaterally. I don’t think you’ll get as far as you think and you’ll ensure the return of Republican government much sooner than our inept public relations abilities could.

    The Democrats have always been their own worse enemies. Look outside of Huffington Post or the Daily Kos to see how much real Americans are concerned about this poorly thought through “reform”.

    By Hawkins on August 21, 2009 7:17 am

13. Ok, almost to the point of discontinuing… I’m a sucker for an argument.

    http://www.washingtonpost.com/wp-dyn/content/article/2009/08/19/AR2009081902261.html?nav=emailpage

    I’m part of one of the largest “public option” health plans in the Nation, namely the US Military. Do you really think I don’t understand many of the weaknesses? It’s difficult to explain, but I’m trying. Without any disincentive, people come in for stupid crap. You’d like to think they wouldn’t, that they’d be disciplined and conscientious users of scarce public health resources. If you really think that, you’re not a very astute student of human nature.

    Sure, we get the cracked skulls in children that we’re thrilled to treat. However, for every one clear emergency I’ve seen in a public-option setting, I’ve seen dozens of drug seekers, alcoholics, and just not-very-sick people who somehow have decided that a swollen nose in the absence of any real risk to their health needs 24 hour treatment. The lady with the swollen nose came in very late. She would have come in sooner, but her family wanted to get ice cream.

    I’m not being judgmental! Or I am, but not without reason. A system needs to have controls to prevent this kind of misuse of the system. We need to design our system to take the best care of the cracked skulls, the children needing immunizations, the 200/100 BP with headache and blurry visions, but to discourage the guy who got tired of the cast on his arm and decided to remove it with a Gerber knife, not knowing that he caused his partially healed fracture to shift enough to require surgery to ensure proper function. He hasn’t been to medical school. How could he know? At least the surgery is available and free. If he had to pay 10% of it, he would at least feel the sting of the resources he cost the system. There HAVE to be controls, yet Americans hate rationing. “My side” is using rationing as a boogie man, but there has to be rationing. Otherwise the drain on the country might be enough to bankrupt us.

    I don’t oppose reform, but let’s make it rational reform. I understand that Microsoft when they create each new Windows version has to weed through endless lines of legacy code. I’m not very knowledgeable about computers, but our healthcare system is similar. Why do so many civilian medical students pick surgical subspecialties and why do so few pick family medicine or internal medicine? If you don’t know, you’re like most of our senators and representatives, but the answer is significant and it’s due to already existing governmental control of healthcare dollars. The medicare fee schedule reimburses procedures far more than non-procedural medical care. Thus, a surgeon who works a 12 hour day doing procedures earns far more than an internist who works a 12 hour day adjusting blood pressure medications for the elderly, even though those careful adjustments, along with careful adjustments of cholesterol lowering medications, dietary and exercise advice, and similar medical care could eliminate the need for some future procedures, such as a coronary stent or coronary artery bypass graft. Isn’t it a little suspect that President Obama is touting the importance of primary care while his government is the driver behind the disparity between procedural and medical care?

    As a medical student near the top of my class, I’m going to be an anomaly when I go into primary care. The reasons for that are good evidence that governmental interference in the health care market is not necessarily benign. When you interfere in a complex system you have to think through the ultimate ramifications of your interference. That doesn’t happen in 1 month or 6 months, so why is President Obama pushing so hard for reform to happen before it has been adequately designed, discussed, considered, and ONLY THEN implemented?

    By Hawkins on August 21, 2009 7:42 am

14. To address your argument that I’m using value judgments to falsely conclude the poor shouldn’t receive insurance, I’m not saying that.

    First, you insist on equating insurance with care. I understand the confusion, but it’s a point of confusion that is dangerous in this setting. I feel you really want to argue that I’m for denying the poor medical care. Medical insurance means nothing, just like the dollar means nothing if it’s not backed by either physical collateral (the gold standard) or the backing of a reliable and solvent government. For instance, take a theoretical scenario where 100 people are on a plane, 1 of whom is a doctor. They crash on a remote island, but luckily the airplane was loaded with medical supplies and the doctor sets up a practice. If 100 people all need care at the same moment, all the insurance in the world won’t let 1 doctor give it.

    Far-fetched? Perhaps, but right now we’re suggesting suddenly giving some number of people insurance that they have not had previously. If that lack had indeed kept them from receiving medical care, suddenly we’re going to increase the denominator of a fraction without changing the numerator. The result, if these assumptions are true, is that everyone who was previously receiving health care will now have to cope with less of it. True, the people who supposedly were receiving little to none will be receiving more, but the majority of people are covered, so will be receiving less. Why? Doctors are all working about as much as they want to now. We’re not like lawyers. There are very few unemployed doctors. It would take a lot more money to motivate most doctors to work more, thus missing even more baseball games and dance recitals. Since this is supposed to be budget neutral, that can’t happen. You also can’t suddenly add a lot more doctors. Pre-med programs take 4 years. Medical school takes 4. Residency training takes at least 3, surgery 5-9. Then many physicians, like cardiologists do more training in what is called fellowships. So if we cued in pre-meds today and medical schools started ramping up class sizes, we’d see fully trained doctors ready to see these newly insured patients in 11 years. Of course our population dynamics (Baby Boomers) already means the denominator is going up. Schools are trying to increase the numerator, but most of us acknowledge that’s lagging such that there will already be a shortage even ignoring the prospect of a sudden increase of newly insured to add to the denominator.

    Of course, Puck will argue that’s not a reason for a portion of the population to have nothing, just so the rest can continue to have what they have now. I’d agree, although I’d argue that it’s more complicated than that and there is some element of having earned some portion of how insured you are, but he’ll argue there are some very good, very deserving people who didn’t ask to be poor. Having been one of those, I’d have to agree.

    So that’s just to address the difference between insurance and care. Simply paying for it doesn’t suddenly conjure trained providers out of thin air.

    Besides that, I’m not arguing the poor don’t deserve care (or insurance if you insist). I’ll motion to leave the word “deserve” out of the discussion. It’s too complicated. All human beings are deserving of perfect treatment. Nobody’s worth more than anyone else. It’s just this damn physical world with limited resources that keeps us from pumping out endless Porsches and Ferraris so that all can enjoy plush leather and a fine sound system while driving 100 kph through the mediteranean.

    I’m not arguing that we shouldn’t try to increase the availability of medical care for everyone. Seriously. I just think there are competing interests. I think human nature in many, but not all of us, is to do as little as possible for as much of a return as possible. Yet some amount of work is required in this physical reality to turn naturally occuring resources into Porsches and Ferraris. And food, clean water, shelter, and medical care. Our society has developed a system where those who do more of this receive more of the benefits. It’s not perfect and I recognize that, however there is some correlation. If our system fails to reward those people and begins to reward people who do nothing at all, fewer people will work and more people will do nothing at all. Sure it’s not exact. Sure some people work and achieve no material comforts. This is not an exact correlation, but I think even hippies from Davis will recognize there is something to what I’m saying. After all, I’ve been to Davis and it doesn’t look that different from Edmond, OK, known as the yuppie center of the universe (or at least it was when I was poor and hating the yuppie scum).

    So to give to those without, we’re taking from those with. You have to do this carefully to insure there’s still enough motivation for them to work their asses off and die younger than they should of a myocardial infarction or else suddenly everyone will stop working and start playing golf (or WoW or PSIII or XBox or surfing porn or however they like to spend their time if they’re not working.

    Perhaps we can find ways to be more efficient and give to the poor without taking anything away from the rich, because we’ve found the pennies in the cracks. But you can’t do this without doing the hard work of looking at where your system is inefficient. You can’t do this in a month, though, no matter what Obama says. It’s going to be hard. There has already been motivation for the rich to find these inefficiencies and eliminate them (except to put the money in their pocket, not give it to the poor), so there aren’t that many low lying fruit around.

    It’s easy to say, “electronic medical records, yadda yadda” when you and your audience have never used electronic medical records. They’re not guaranteed to increase efficiency. The military system, AHLTA, is one of the top reasons doctors quit the military and go elsewhere. Many agree it takes longer and is more inefficient than paper records. It’s built by the same government who insists they’ll find enough of these efficiencies to insure tens of thousands of people without costing an extra dollar (budget neutral, right?). So there is a lot of bullshit in the talk so far. I say we move away from “Hope and Change” and start talking about the hard realities of how to implement the change that I agree we need. Stop accusing me of not wanting to fix it just because I question where the line between these tradeoffs needs to be made and question the sincerity of those who insist we can produce something from nothing.

    By Hawkins on August 21, 2009 8:15 am

15. http://www.cnn.com/2009/HEALTH/08/20/pho.doctor.shortage/index.html

    Last comment for the night. I’m on East Coast time, BTW, so it’s 4:30 a.m. Came off shift in the ER, posted here, and was overall too wired to go to sleep. I’ll pay for it tomorrow.

    By Hawkins on August 21, 2009 9:30 am

16. I don’t have an issue with medical insurance premiums being adjusted based on medical risk factors such as obesity, age, drug use, etc. If I choose to eat too much, drink too much, smoke too much, then I should pay more.

    And if the government were to mandate a minimum insurance premium that each person would have to pay based on preventable medical risk factors, I wouldn’t be apposed to it. Especially if there were clearly advertised premium levels that produced the same payment to the hospital/doctor no matter the patient.

    Then private insurance could by charging additional premiums to augment the payments to the hospital/doctors, should patients want service levels greater govt. mandated base-levels.

    What I do have an issue with, however, is tying premiums to income. Base-level care is base-level care no matter your income level. Why should Patient A pay a higher premium for the same procedure as Patient B if there risk factors are the same? Especially if the hospital/doctor gets paid the same for both procedures.

    I think that a toll road analogy would be more fitting:
    You charge X for a car and Y for a truck because a truck causes more impact to the road. You do NOT charge X for a Honda and Y for a Mercedez.
    Now if the driver wants to avoid the toll he pays X+A or Y+B to get a toll-tag and receive a better level of service…

    By Mark on August 21, 2009 4:31 pm

17. Hola Hawkins,

    I think the issue here is that you and I could probably sit down and hash out a list of exceptions that meet both my needs as a liberal to protect the working poor and your needs as a physician to prevent frivolous medical demands. If we started with Mitt Romney’s plan for Massachusetts we could probably reach middle ground pretty quickly and then add in federal measures to control cost and streamline the system.

    Unfortunately, the reality of the situation is that the right-wing conservative members of Congress are not good-faith negotiators and it is impossible to discuss the policies without discussion the meta-policy or the politics if you prefer. My previous statement about the political realities of majority, supermajority, and executive office aren’t meant to provoke you so much as to provide an accurate accounting of the situation on the ground. I perfectly understand your frustration as policy you violently disagree with is passed into law without so much as input from representatives sharing your position.

    The Republican Revolution of 1994 was largely fueled by the failure of the Clinton health care plan of 1993 and tactically the Republicans have everything to gain by working against any sort of health care reform. If they can give the president and the Democratic Congress a black eye on health care, they may be able to recreate the same events that brought them into a majority in both the house and senate in 1994. With that understanding, it is no wonder that compromise is off the table.

    The real debate over policy is going on within the Democratic party itself, but the Republican Revolution of 1994 isn’t forgotten on the left either and you can bet that some form of policy will make it through congress to the president’s desk. As congress returns to session, you can expect the party leaders to start turning the screws to produce legislation. Expect Joe Biden and Obama to make visits to the Senate and you’ll see some vote whipping in both houses as pressure is applied to achieve a bill.

    On the other Republican side, expect louder dissent and more stalling tactics. With the Republicans actively trying to drag their feet and sabotage the process, we enter into antagonistic conflict with mutually exclusive goals as I described earlier. When a conflict of this kind occurs and compromise isn’t on the table, the game gets rough but that is the way the game is played. Compromise and bi-partisanship is a good achievement, but the goal is the policy and not bi-partisanship for its own sake.

    If the Republicans negotiate in good faith, it is tactically good to give them a seat at the table. If their desire is to sabotage the process, there is no upside to working with them. In a gunfight, when your adversary runs out of bullets, you don’t typically toss him some of yours just to be sporting about it. There’s no tactical upside to choosing failure.

    The U. S. Constitution provides veto power if the minority represents a large enough block of the American population, but that is no longer true of the Republican party. The Republican party doesn’t enjoy any special privileges they don’t earn by courting the electorate and they’ve been almost gleeful about crucifying the moderate wing of their own party. If they can’t rebuild the party and win votes outside the white South, we may see them eventually dwindle and be replaced by a moderate conservative Libertarian or “Blue Dog” party.

    Your final defense against abusive policy is the Supreme Court. For example, if the Democrats outlawed the display of the Texas flag, you could sue to overturn the law on constitutional grounds. When Bush claimed his powers as commander in chief permitted warrantless wiretapping of American citizens, that’s the first place the liberals went. Many of the Bush policies were overturned by the courts as they served as the check to executive power. It sucked and it took time but it’s how the system works.

    Don’t let this stuff bother you too much and don’t lose sleep over it. The influence you and I have over politics/policy is pretty limited and there are times I despair of our political process completely.

    ~P.

    By puck on August 21, 2009 11:35 pm

18. Hola,

    As it turns out the exact same chain of tactical reasoning I describe above was also voiced by the president:

    “On the Michael Smerconish radio show Thursday, the president said: “Early on a decision was made by the Republican leadership that said, ‘Look, let’s not give them a victory and maybe we can have a replay of 1993-94 when Clinton came in. He failed on health care, and then we won in the midterm elections, and we got the majority.'””

    Wall Street Journal:
    http://online.wsj.com/article/SB125076789379445975.html?mod=rss_Today%27s_Most_Popular

    In any case, I think we both agree that if a bill fails passage, the blame lies with the Democrats.

    As far as the CNN commentary goes, if I had my choice the government would provide incentives to primary care doctors or at least work to remove disincentives. What if the government covered a portion of education expenses to doctors that committed several years to primary care before moving onto a specialty? (I don’t know if medical education requires you to choose your specialty or not in order to access higher course work.)

    Stepping away from the discussion of policy, NPR had an interesting discussion with the doctor who is a technical adviser to the House TV show and she said that doctors get paid much more for “doing” and almost nothing for “thinking”. She was specifically arguing that time to listen to symptoms and formulate a diagnosis are not valued while tests and procedures are compensated at a higher rates.

    By puck on August 22, 2009 12:38 am

19. You’re not being on objective commentator. You use words like “sabotage” and “refuse to compromise”. From my point of view, the Republicans have offered compromise, it’s just linked to taking the “public option” off the table. Many (but not all) Dems think that’s essential. Therfore there’s refusal on both sides. I think there is a political component on both sides. Dems want a victory to enhance their reputation, because if you control the entire government and can’t accomplish anything it’s obvious to the American people.

    I think we might be able to compromise, but I do believe the public option is dangerous. Health care is too emotional a topic. Government will be afraid to limit it because there will be an outcry, yet failing to limit it will bankrupt our government. BTW, this is one area that if I haven’t been clear, I vehemently disagree with Repubs. They say rationing like it’s a bad thing, but rationing would be essential to any public plan. It’s innate to “pay as as you go”, because people won’t spend their own money if they think they don’t need to. They will spend government money – there’s no real disincentive.

    As for the government paying a portion of educational expenses, it would have to be a big portion. A family practioner, general internist, general pediatrician, or psychiatrist all make around $12o,ooo/year. This isn’t exact, but ballpark. Many surgical specialties or medicine subspecialties easily make $200,000-$300,000. So what kind of economic incentive will drive someone to give up $80,000-200,000 per year and do 3 extra years of training (when residents are paid $30-40K for 80-100 hours of work/week)? It would have to be significant incentive. Better probably to decrease the disparity between thinkers and doers. There may need to be more thinking.

    By Hawkins on August 22, 2009 8:38 pm

20. My biggest hesitation is letting government, which I don’t have a lot of faith in, run something so complex and so important. From an admittedly slanted source, here’s an example of why: http://corner.nationalreview.com/post/?q=YzJjZDU3ZmQ2MWU1ZGZjNWZhMjNmNTU3MTg4ZmI2Y2U=

    By Hawkins on August 22, 2009 8:54 pm

21. I’m not as favorable towards former Governor Palin as I once was (quitter), she makes a good argument about tort reform here: http://www.facebook.com/note.php?note_id=120607013434&ref=mf

    KevinMD, who I think I’ve quoted earlier, supports reform, but here makes the point that costs will have to be cut, care for the elderly is the largest target to cut, and yet government won’t be able to try to cut these costs for political reasons. Read him here: http://www.kevinmd.com/blog/2009/07/cutting-health-care-costs-means-spending-less-on-the-elderly.html

    By Hawkins on August 23, 2009 5:02 am

22. Scary pop up mazes made it through moderation, but I’ve got a comment pending?

    “I’m being oppressed!” ; )

    By Hawkins on August 24, 2009 3:49 am

23. Well, I like scary pop-up mazes but you disagree with me so I either lose your posts in moderation or edit them to make it clear you are losing the argument.
    😉

    Spent the day working through material for WMAW and didn’t get back until later.

    ~P.

    By puck on August 24, 2009 3:54 am

24. Ah, have fun? Is it already that time of year again?

    By Hawkins on August 24, 2009 12:40 pm

25. Well, perhaps is not out of point to provide an outsider’s view, not obviously of what it should be in the USA, but what is in other countries (in this case, Spain).

    The main principle here is that health care is a citizen’s right, just like freedom of speech, so basic health care must be provided by the state for everyone, regardless of rents. “Basic”, in this case, means everything outside odontological care and aesthetic surgery.

    But that public health care is not imcompatible with private health care. Private health insurance companies makes a fine profit in Spain. Why? Because they offer quality: not exactly on the health care itself, but in what surrounds it: shorter waiting times, private (instead of shared) hospital rooms, choice of doctors, second opinions, international coverage and such. You can bet M.D.’s on the public system are as good, and have the same means to make their job that the ones in the private companies (actualy, many work part-time at both), but the way to get to his hands is shorter and easier in the private sector.
    So we have a public health care that is useful, and private companies that offers better service for those who think that pays off and can afford it.
    I have a private health insurance (as my job’s benefit), and don’t use the public health system a lot, but just as I don’t have ride over all the roads built with my taxes or have been served by all public officials.
    And yes, the public system is not as cost-efficient as it could be, is overused and misused and abused. but you can’t have everything. At the end, is not an issue of clever design, but of choice: you can have a cost-efficient system or a care-efficient one, but not a cost-and-care-efficient system, as they are oposite objetives.
    So, from the experience of my country, for those who think that a healthcare public system in the USA will cover (if properly done) everyone with reasonable quality, I’ll say that it will do. And to those who think that it will be an expense to the taxpayers and that it will be abused by many people, I’ll say also that it will do.

    Have a nice day.

    P.D. It’s somewhat ironic that a system (the public healthcare system) that is seen in the USA as leftist by ones, and as democratic and rightfull by others, was created in Spain by a rightwing dictator (Franco)

    By Miguel Palacio on September 11, 2009 11:08 am

26. The quality argument is the big difference. People normally use private lawyers because they think they’ll get a better quality of lawyer and thus be better represented.

    Is there any such difference in any of the socialized healthcare plans currently being talked about?

    Or is it more an option of paying through taxes for your insurance and then being given the opportunity to pay again if you want for private insurance. Both will pay for the same doctors. Who would pay in that scenario? Go for “free” (or the taxes you already going to be forced to pay) or pay extra for the same level of service.

    That’s not competition.

    By Hawkins on October 29, 2009 12:52 am

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