Health Care Reform’s Deeper Problems


Congress’ health care reform debate has highlighted how American governance is broken and the difficulty of addressing our national problems.

Take, for example, whether health care is in crisis at all. Conservative commentators argue that America’s health system is fine, that our excellent care simply costs more than other countries’ poorer quality, and that most uninsureds can afford coverage. They ask why we should revamp a great system for the two or three percent of Americans who get less.

This misrepresents reality, though. Care and outcomes are often superior in other developed nations. In America, the ranks of the uninsured and under-insured have skyrocketed, from insurance costs that have grown four times general inflation for a decade. Health coverage is employers’ most unpredictable major cost, a threat to their businesses’ competitiveness, and they have increasingly offloaded costs onto employees. So while  the marginalized uninsured are an important problem, declining coverage for the mainstream is the greater worry. Most know that, even with insurance, any major health problem can spell financial ruin.

As businesses and individuals have been priced out of health coverage over the last four years, commercial health plan enrollment has plummeted by as much as 20 percent, or about 36 million people. The Kaiser Family Foundation reports that 40 percent who lose group health coverage probably become uninsured.

Fewer people buying coverage means less money to pay for health care products and services, so the industry is experiencing an unprecedented financial decline. With reforms looming, it has fiercely advocated for universal coverage, which would provide stable funding for a larger patient population. Meanwhile, the industry has opposed changing business mechanisms that encourage waste, even though experts agree that one-third or more of all health care cost is unnecessary or inappropriate. But this raises an important question. Why not spend less by recovering wasted dollars, and then improve access?

The industry has pressed its goals through lobbying, which lets special interests exchange campaign contributions for policy influence. The non-partisan Center for Responsive Politics reports that, between January and June, the industry gave Congress more than $260 million. One lobbyist commented, “A person can reach no other conclusion than this is a quid pro quo [this for that] activity.”

The funds have gone mostly to Democrats, the party in power now, and are producing their contributors’ desired results. The current proposals expand coverage, but do little to reduce cost, failing to heed any of health care’s management lessons from the last 25 years. For example, they won’t re-empower primary care, which other nations have found will maintain a healthy populace for half the cost of our specialist-dominated approach. They fail to make care quality and cost transparent, which would let health care finally work as a market, and help identify the best health care vendors. They continue to favor fee-for-service reimbursement, which rewards delivering more products and services rather than rewarding results. And they all but ignore our capricious medical malpractice system, which most doctors say encourages defensive practice.

These problems and their solutions are structural, and are well understood within the industry. If reform does not pursue these structural approaches, health care will continue to drag down the larger economy. Our current problems will remain and intensify, at enormous cost.

Out of this experience, the American people should become aware of a couple of harsh truths.

First, so long as Congress willingly exchanges money for influence, American policy will favor special interests rather than the public interest. We’ll be unable to meaningfully address our national problems: energy, the environment, education, and so on.

Second, so long as partisans distort the truth to discredit their opponents, rather than focusing on our very real problems, America’s future will continue to be compromised.

Which is to say that we have deeper problems than an inability to fix health care.

Brian Klepper, PhD is a health care analyst based in Atlantic Beach. David C. Kibbe MD MBA is a physician and Senior Advisor to the American Academy of Family Physicians.

David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians. Brian Klepper PhD is a health care analyst.

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59 replies »

  1. Hy all over there….
    Hope u all fine and dng well….
    Here I wanna some information about a Medical term that is called Tubal reversal…. A tubal reversal, also known as tubal reanastomosis, is usually performed when a woman wants to try to achieve pregnancy after undergoing a tubal ligation. In many cases, surgery for tubal reversal is successful. However, a number of factors can affect the success of the procedure. Estimates vary, but health experts approximate somewhere between 50 to 75 percent of tubal reversals are successful in reopening the fallopian tubes. However, the success rate may be much lower.

  2. America cannot afford health care, so the natural next step is to redefine health care so that little health care exits, and the most useful privilege of design is end of life counseling so that the right to die because no health care exists works to unburden the system.

  3. I have done my best to educate myself by reading all of the bills that I can get my hands on. My two major issues with the Senate Finance bill is that it does little to bring down the cost to consumers and it forces people to buy overpriced and bad products. Those in the lower income brackets, except the very poorest, will be penalized because they won’t be able to afford insurance. Of all of the bills out there, the Wyden-Bennett bill is the only one that is so straight forward, it would never pass muster for congressional standards for complexity and obfuscation. The Wyden-Bennett bill does not add to the deficit over the long term as scored by the CBO.

  4. Providers are paid less than stewards. Doctors’ compensation per thing done has been reduced. Thus, more of each thing are done, quicker, and with less thought and quality. This transcends all types of physicians.

  5. “Arrogance, Avarice and Addiction (“AAA)”
    The Senate, the House and, yes, our President all suffer from AAA. So god forbid a legislative health care act does pass it will never work. The costs imposed, the bureacracy and, lets not forget, the physicians who retire or quit because of the nonsense. The health reform bill care bill will make the present health care system look like a walk in the park.
    Arrogance, Avarice and Addiction always results in failure. They will bring down the professional, the politition and the acts that follow in their path.
    So get ready. There will be “change” and, unfortunately, it’s coming.
    So remember, you might not like what you get. So be careful what you ask for.

  6. Interesting blog. I’ve been looking at elder and senior care and keep coming across issues involving denture creams and neurological problems. It seems that some popular creams are involved and lawsuits are beginning to be filed. I found a site that is sponsored, I believe, by an attorney group, but that has some good health and legal information: http://www.denturecreamlawyer.com/ I hope this is of help to your readership.

  7. Americans have brought the health care debate on themselves, and it is the natural companion to the job outsourcing that now leaves few companies to participate in health care financing programs. Without jobs, Americans cannot afford health care insurance, and that suits companies just fine because they are busy using overseas employees for whom they pay no health care costs.
    America cannot afford health care, so the natural next step is to redefine health care so that little health care exits, and the most useful privilege of design is end of life counseling so that the right to die because no health care exists works to unburden the system.
    What kind of health care reform is this except the same argument used to allow companies to hire outsourced employees from other countries in place of American workers?
    Health care was already reformed when the prices of Medicare went up because Congress spent that which would have been reserved by Social Security for health care. How to have both became the imposition of Medicare and contributory expenses, even by Medicare recipients themselves. So, where is the problem?
    The problem lies in the fact that there are few companies operating with American employees so there is no health insurance by companies which can help to spread the risk among all Americans, those working and not working.
    Beggars can’t be choosers, and therefore, health care reform is at the top of the U.S. agenda politically because of past choices by government to allow the NAFTA, CAFTA, etc. of accepting low costs for corporations by offshoring, outsourcing, and globalizing. America cannot do both health care and war. But no one will confess to that reality.

  8. Reversal of sterilization and microsurgery for the repair of damaged tubes secondary to pelvic adhesions and/or closure of the tubes in cases of previous pelvic disease are all becoming increasingly common and successful. With today’s micro-surgical techniques, a being who has had a previous tubal ligation has a 50-70 percent chance of becoming pregnant after a reversal of sterilization is done. A diagnostic laparoscopy is generally done first to confirm that tubal repair is possible. Subsequently, a two to three inch incision is made at the top of the pubic bone. This is sometimes known as a bikini incision. All next micro-surgical repair is done through this incision. When the fallopian tubes are blocked in the middle of the tube, which is most common with a tubal ligation, the coagulated or blocked part of the tube is removed and the ends are sewn together. This is know as an end-to-end anastomosis. If the tubal ligation is done near the fimbriated end of the tube, this end can be surgically opened and tacked back. Although this may result in a shortened tube, if pregnancy does not occur naturally a follow up procedure of tubal transfer can be done in order to achieve pregnancy. This is a procedure where the eggs are recovered from the ovary, mixed with the partner’s sperm and placed back into the fallopian tube.

  9. The deeper problem with health care reform is whether or not illegal immigrants will have the right to purchas private health insurance. There is no way to provide subsities to illegal immigrants. Anyone not being able to show proof of being a US citizen should not be granted access to private insurance.

  10. While we are waiting for the reform to come, I’m using the prescription discount card that I found at http://www.rxdrugcard.com. The membership fee is low. And they post drug prices online to check before you enroll. That’s transparent!

  11. Interesting blog. I’ve been looking at elder and senior care and keep coming across issues involving denture creams and neurological problems. It seems that some popular creams are involved and lawsuits are beginning to be filed. I found a site that is sponsored, I believe, by an attorney group, but that has some good health and legal information: http://www.denturecreamlawyer.com/ I hope this is of help to your readership.

  12. I believe Americans have been making poor life choices for generations. Really our entire culture has been pushing the idea of gluttony, more means more money. This idea when applied to the health care DRAMA reads like this… Those choices have been condoned by the health care system through a profit motivated codependence. Barack is basically staging an intervention. The American people are not only being forced to face their behaviors as a choice but they are being forced to “quit.” On top of this Americans’ are afraid they will be left high and dry when it comes to the ramifications of those choices 10 years from now. If Barrack wants to make some headway he needs to treat this like and intervention.

  13. No one should die because they cannot afford health care, and no one should go broke because they get sick.

  14. Brian:
    I believe the AMA set up the CPT codes. I also believe they were requested to revise them in 1996. And I believe they were integral to the process regarding the establishment of the reimbursement algorithm used by CMS for payment to PCPs, specialists and others.
    Answer me this: What is the compensation paid to AMA for use of the CPT codes? Does the reimbursement algorithm favor specialist work over PCP work? If we change the algorithm to favor work done by PCP would health care quality increase? To what extent do these items affect overall cost of service and health care quality?
    I also beleive you are in the best position to answer the questions and provide an unbiased assessment?

  15. Nice comments and i m happy about your knowledge because every person have not so much knowledge the main reason is that knowledge in unlimited. as u know that a famous quotation is that get the knowledge from where u can learn.
    as the time passed different knowledge are introduce like technology , science and the permanent birth control but the now a day tubal reversal make it possible that a women can get a baby even she have done the permanent birth control.
    tubal reversal provides this opportunity for the women who desire to adopt the child after the permanent birth control process the results are mostly 100%

  16. Your August 27th article “Health Care Reform’s Deeper Problems” is right on target. It was well written and succinct. I agree and I’m sure millions of Americans agree with you, i.e., unless and until the US makes care quality and cost transparent; and through regulation, forces sick care delivery to react to citizen buying pressure, health care reform is dead.

  17. For supporters of a new government “Health Plan” the fact that Medicare is government run, has been the Ha, Ha Gotcha, because “folks” [Presidential speak meaning citizens] don’t want “government to take it over”.
    What these supporters don’t mention is the small word “entitlement” that goes along with government, and is feared because Medicare is going bankrupt and instead of lowering costs of fraud which studies show amounts to somewhere between $1 and $5 billion a year, the Presidnt instead is going to cut Medicare the lower of that amount over 10 years, which matches the bankruptcy date and recently announced $2 trillion addition to the ntaional debt. So obviously this is just one of many cuts the President intends to make so he and other government employees don’t have to do any “heavy lifting”.
    If he is denied these cuts, he and AG Holder would be forced to address the real causes of health costs, so stopping these cuts are most important.

  18. Um, Nate, I join Peter and a lot of THCB readers who find themselves unable to follow or stomach your arguments, mostly because they’re generally hare-brained, uninformed and idiotic.
    Many of us are also really tired of your abusive language, which demeans an otherwise excellent professional forum, and which, if you had the slightest bit of manners or savvy, you’d avoid. We’ve asked you several times before to stop this kind of behavior, but apparently you have a personality disorder that prevents you from remaining within the bounds of socially acceptable discourse.
    I’ve asked you before to disclose your identity to the rest of us, the name and location of the firm that you refer to so often, and how many covered lives your firm manages. The fact that you have refused to do this shreds what little credibility you might have had otherwise. It also suggests that you’re a coward who simply likes to snipes at others while hiding, or that your firm and position don’t actually exist.
    In any case, why don’t you raise the quality of the conversation here on THCB by either making an effort to behave like an adult, or by gracing a different forum with your nasty, moronic comments.

  19. Alice Walker’s thoughts on Health Care:http://www.alicewalkersblog.com/2009/08/understanding-health-care.html
    People are falling sick and dying all around us and when, and if, we go to the hospital most of us hope we don’t, from lack of care, die there. How bizarre it is that President Obama, this thoughtful, kind, smart being we’ve at long last been graced with as a leader, has to spend so much energy trying to get Americans to accept what we so desperately need: a system of health care that means we don’t have to be terrorized by the thought of getting sick. We would laugh, except it’s really sad.

  20. um Peter, I posted the link to the article, I obviously am aware of what it said. Your failing again to make the logical step in thinking. Once again your beating strawmen. I know full well people in the US receive terrible care, I never claimed this doesn’t happen in the US. I was refuting the silly notion that any system prevents it like the author of the quote I rebutted said. Do you really think any system we put in place or for that matter in system in the world prevents
    “a situation where he received subpar care because he didn’t have insurance. No one would have to fear watching a loved one die in screaming pain because the doctor never explained that “palliative care” was available.”
    Once again you post a thoughtless comment that has nothing to do with what I said and everything to do with arguments you make up in your head. I have come to accept no matter how simple I make an argument you just can’t follow.

  21. Nate, maybe you should take a look at an important fact in the article you provided.
    First the article says this:
    “The charity has disclosed a horrifying catalogue of elderly people left in pain, in soiled bed clothes, denied adequate food and drink, and suffering from repeatedly cancelled operations, missed diagnoses and dismissive staff.”
    Do you believe that here in the U.S., under private elder care (if people can afford it) that this does not happen? In my state there are a never ending amount of stories about private nursing home abuse.
    Then the article goes on to say:
    “They cite patient surveys which show the vast majority of patients highly rate their NHS care – but, with some ten million treated a year, even a small percentage means hundreds of thousands have suffered.”

  22. It’s so refreshing to read an article that takes the time to place the current health care debate in the context of our political system. I completely agree–the ability of special interests to curry any real or perceived influence through campaign donations will undoubtedly impede any meaningful solutions to our national problems.
    Which begs a simple question: why not make all political contributions blind?

  23. Dishman’s conclusions are not at all conflicted. What an honorable man of consequence!

  24. It’s refreshing to hear a healthy dialogue about the need for health reform to expand beyond just the private option debate and actually to improve quality and reduce costs. I agree wholeheartedly about the need to invest in a primary care workforce as a major pillar for reform. Today’s fee-for-service reimbursement system is a throwback to the 19th-century mainframe model of healthcare that waits for illness and injury and requires patients to travel to a medical institution for treatment. We need to shift from this mainframe model to a more personalized, 21st-century model of personal health that shifts the focus from institution to individual and hospital to home. Primary care champions need to be at the heart of this transformation—I don’t know how we will achieve care coordination with them. This will require a fundamental restructuring of how clinicians provide care… giving them the flexibility to provide customized care however they see fit, whether that means managing more patients through home health monitoring or otherwise.

  25. “No parent would have to worry that her twenty-something might be in a car accident and then find himself in a situation where he received subpar care because he didn’t have insurance. No one would have to fear watching a loved one die in screaming pain because the doctor never explained that “palliative care” was available.”
    “In the last six years, the Patients Association claims hundreds of thousands have suffered from poor standards of nursing, often with ‘neglectful, demeaning, painful and sometimes downright cruel’ treatment.”
    just becuase a politician promises something doesn’t mean it is true.

  26. Let me amend my last post. We had over 100 employees and about 90 of them were nurses. So I guess, we actually were a part of the medical community.

  27. Alex and Peter, rofl, I’m just an average joe who used to run a system like I described. True, doctors didn’t run it, we did, but we were free of insurer influence and had the ability to make our own rules. We had our own national network and all care providers were paid fairly and promptly. In turn they voluntarily agreed to limit utilization. Of course, as Ronald Reagan said, “Trust, but verify.” and we did. We stayed on top of providers and patients. I don’t think that altruism had anything to do with it. Getting paid fairly and promtly was more important than scheduling a few unnecessary tests or studies.
    As far as creating a medical agency, there are many bright individuals in the medical community – not all doctors, who would love to play a part in actively reforming health care. So far, all they are doing is sitting on the sidelines and kibitzing. Great minds but few leaders. That will change, it has to because there really isn’t any alternative other than rationing health care. If we cannot develop a vehicle for managing and coordinating care, it will be a sad day indeed.
    Call me Don Quixote, or a Marxist but I’m right.

  28. Popster, are you a Marxist? 🙂 Communism would be the ideal system, if all people were altruistic. In real life, very few of us are able to give up something we feel entitled to, at least, voluntarily. The medical community at large is just fine with how it is now. Sure, they supports tort reform (actually, I too), primary care physicians want a bigger slice of the cake, hospital CEO’s would definitely prefer everybody insured, but other than that I don’t see that community driving healthcare reform.

  29. “Let the insurers, private and governmental, run insurance.”
    That’s what they’re doing now. Problem is the “medical community” is driving costs that government and private insurance is just passing along and insured patients are quite happy to use.
    Popster, just how do you see this great medical organization being created? Just who would they negotiate “fair” fees with, each patient? How would they control utilization when much of the present problem is medical community over-utilization? I do know that the big so called utilization control many in the medical community want is complete absolution from wrong doing/errors so that they don’t have to deal with lawyers or injured patients, even their own medical boards.

  30. Well, I don’t think we are going to know anything for sure until it all shakes out. The devil will be in the details.
    Under the present health care reform plan, no family would ever again go bankrupt because a child suffering from cancer had blown through their insurance plan’s life-time cap on reimbursements. No parent would have to worry that her twenty-something might be in a car accident and then find himself in a situation where he received subpar care because he didn’t have insurance. No one would have to fear watching a loved one die in screaming pain because the doctor never explained that “palliative care” was available.
    Critics have raised the specter that health care will be “rationed” to save money. The truth is that health care is already rationed. No insurance, public or private, covers everything at any cost. What would be different under health care reform is that care would be looked at by physicians and other health experts looking at medical evidence to determine which treatments work best for particular patients. The House bill calls for research and pilot programs to find ways to both control costs and improve patients care.
    The bills would alter payment incentives in Medicare to reduce needless readmissions to hospitals. They would promote comparative effectiveness research to determine which treatments are best (not one-size-fits-all) but would not force doctors to use them.
    As for healthcare without reform, in 10 years only, the wealthiest 5% of the nation will only be able to afford decent care. The rest of us will be lucky if we have Medicaid.

  31. “Why aren’t HDHP and HSAs more mainstream?”
    For which income group Dave?

  32. Limited thinking leads to narrow minded comments. Lets try a little creative thinking. Instead of government versus private insurers, why don’t we look for a third way… let the medical community run medical care in the U.S.
    As the congressional budget office reports, the government is running Medicare and Medicaid into bankrupcy. The private insurers are equally remiss in their pathetic attempts to manage care and costs. Is it reasonable to look to these loosers to fix and improve medical care?
    Let the insurers, private and governmental, run insurance. Let the medical community form a non-profit agency to run medical care.
    Now some will say that the medical community got us into this fix with all the waste and excessive costs. True, but they also know how to repair it. Let them negotiate fair fees, put into place methods for controlling utilization, help doctors and patients coordinate care, and collect the data necessary to establish effective treatment protocols. Let them build a support team to help defend against malpractice.
    Who knows better how to assure appropriate care for all patients? It certainly isn’t private insurers or the government.
    Why not consider the third way?

  33. Greg,
    I don’t believe that the foundation of our country is built on Governmental intervention to pool “communal resources”.
    You can call it “what’s in it for me” or you can call it “personal responsibility”, it just depends how you want to spin it.
    Why aren’t HDHP and HSAs more mainstream? If you want to cut costs, put the consumer’s own cash into the mix. It works for me.

  34. “We are consuming an ever-increasing portion of the GDP on healthcare, so we should borrow more money so we can spend less?”
    Where we “these” people when the illustrious previous president got our nation into a “war of choice?” Increase the portion of the GDP on war, so we need to borrow more money so we can “feel” safe? THAT’S crazy!!!
    What we need is affordable health care. We have is the best health care for those who can afford it.
    Do Americans view health care as a communal resource that should benefit everyone or do we view it mainly from the standpoint of “what’s in it for me?”
    Do they view themselves as citizens working together for a “greater good,” or as patients and consumers of health care, worried about retaining access to all that medicine has to offer? The longer we delay, the higher health care costs rise, while more and more Americans lose their health insurance.
    The private insurance health care system controls costs by dropping coverage for many workers, a safety valve of uninsured to dump out of the system. If private insurers keep increase prices and force people to drop out, you’ll find enough people staying, paying into the system so that the total amount paid keeps going up.
    In another five years, the $10,000 cost of family insurance will be $15,000 and more and more employers will have dumped people either into higher-deductible health plans or into the uninsured pool. The continued increases in health care costs will impact virtually everyone before it will create a constituency that will support universal health care.
    In the meantime, you’ll continue to have a corporate bureaucrat between you and your doctor.

  35. Peter,
    “We” don’t have to throw anyone anywhere. Leave them alone. People will be chronically ill if they are not free from the likes of you.

  36. ” in the same listing, concerning “responsiveness to the patient” the US is number ONE.”
    I think they meant; responsivness to the patient’s (and taxpayer’s) bank account.
    “Myself and many of these Conservative radio and TV commentators know things do need to be corrected in our Health Care System”
    What are you and rant radio hosts willing to give up to get there?
    “Why should health care be given to anyone who does not pay for it?”
    We’ll just throw them in the gutter then.

  37. Why should health care be given to anyone who does not pay for it? Why should I pay for someone elses healthcare? Why should those who do not pay receive the same services as one who does pay? If you give everything away, the producers will quit producing and the receivers will want more not want to better themselves.

  38. Ravi,
    Who are you to take anything from anybody? Thre is no “national healthcare”. All healthcare is individual.

  39. Well. Here is a way to change their mind. Take the insurance away and see how they cope up with.
    We do not have the best care in the world….we have the best care for those who can afford it. We are not talking individual level healthcare reform…we are talking about national level.
    We did several articles busting this myth on our blog. But it seems like it is going to deaf ears. We had one of the lenthiest debate on one of the articles last week of so…same thing.

  40. What we need is affordable, limited government. We did it once and we can and should do it again. The dark side of the current discussion is the government conficating freedom in return for the illusion of security.
    We have no right to spend more than we have or will have in our lifetime. Medicare and Medicaid costs are out of control because the government cannot control itself. By injecting billions of dollars into the health care industry for the last 44 years, the market has become so dysfunctional so as to be on the verge of the bubble bursting. Expectations of the people are based on an addiction to attention and services that are of no proven value and would not be purchased if individual responsibility was required.
    This mass hysteria is going to have an unhappy ending.
    This country needs a reality check. We are consuming an ever-increasing portion of the GDP on healthcare, so we should borrow more money so we can spend less? Are you crazy?
    As for wasted dollars, they are the dollars of individuals who choose to spend them, albeit choices driven by the current dysfuntional government mandates and their predecessors. They are not dollars to be taken by government to redistribute. Anyone advocateing that is in their collective mind.

  41. I agree fully.
    I have been very skeptical from the beginning that we would ever have any meaningful reform because there are just too many people making too much money from the current system. These people can buy influence with congress to protect their profits. The $260 million they have spent has effectively purchased our entire congress and this guarantees that we won’t have any meaningful cost savings.
    Larry Lessig has started an effort http://change-congress.org/ to try to improve this situation. However, I am pessimistic that we will ever have a congress that is responsive to voters rather than corporate interests.

  42. On whether American health care is the best in the world or not: It is certainly true that complex, technologically advanced, heroic medicine is both sophisticated and widely available in the USA. Thus, if you develop an acute problem with a serious disease, you’d be wise to do so in the USA, as long as there is an emergency room willing to take you in (note, in many parts of the country, county and religiously affiliated hospitals do a pretty good job in this role also for the uninsured).
    However, USA health sector is weak in managing the simple, systematic elements of care, so that, for example, the chronically ill do not develop acute incidents. We’re the second highest of 17 countries in the level of avoidable hospitalizations, that is, procedures provided, where proper medical management on an outpatient basis should have eliminated the need for hospitalization altogether. We’re inconsistent on preventive care, so that we end up with higher infant mortality than “the world’s best medical care system” would ever allow.
    We do the complex tasks well, but the simple and ordinary medical management tasks inconsistently. But then, that’s how incentives are aligned, with the complex paying very well and the ordinary paying poorly, so there is nothing to be surprised about.

  43. Insurance (any kind) is unique because it completely defies normal economic supply/demand curves. The principle of “Adverse Selection” says that the risk spreading mechanism itself is damaged by low-risk people who opt out. In essence, young healthy people say, “I’m young and healthy… I’d rather just NOT participate and keep my money, but thanks anyway.” And the market is left full of high risk participants.
    Now I pose the question: Should anyone be able to opt out of paying for roadways? (Highly socialized…except in Orlando and a few other places where there is a toll booth every 50 feet. Last time I traversed the city I wanted to shoot myself. Thanks so much, Mickey Mouse).
    Should anyone be able to opt out of paying for police, fire departments, or military? (Much like health insurance, all risk spreading mechanisms. All incredibly socialized).
    People with families should not have to work for large companies (groups) to attain low cost coverage. That effectively dampens job liquidity and hinders broader economic markets. What happens when GM closes down a plant and 800 workers find themselves constrained to working for another big company in order to find health care comparable to what they had before for their family? (Ever notice how manufacturing plants are often planted in small towns where there aren’t a lot of other big companies?)
    Job liquidity demands that job decisions be completely separable from the health coverage decisions. So the current system patently discourages broader free markets and discourages massively liquid value flows rather than encourages them.
    There has not been enough head-on discussion of “Adverse Selection” and the underlying economics involved. “High Risk” pools are not going to get the job done.

  44. Interesting approach. The key to reducing costs rests with the stewardship of physicians, who, incidentally, control how every health care dollar is spent (except for vitamins, supplements, and naturalists). Instead of calling physicians “providers” or “vendors” of care, why not call them stewards of care? Providers are paid less than stewards.
    Doctors’ compensation per thing done has been reduced. Thus, more of each thing are done, quicker, and with less thought and quality. This transcends all types of physicians.
    How does this decades long trend get reversed and how long will it take to see meaningful results, that is, affordable care?
    It starts with paying the doctors to be the stewards instead paying them as if they are window washers and farmers.
    Incidentally, how many people have access to 50% of the care he received and how many insurances would have allowed care at Duke when the “same expert care” is provided by the insurance carrier’s network oncologists?

  45. The very begining of your article says “Conservative commentators argue that America’s health system is fine”. That is a false, inaccurate statement. I have to drive often from client to client during the week day and often I have on a radio with these pundits you speak of. Every Conservative commentator on radio, TV or print have made it clear we need to correct and fix things in our current Health Care System. We do have the Best Health Care System in the World. (In the WHO ranking that has been brought up with the US overall ranking at 37, in the same listing, concerning “responsiveness to the patient” the US is number ONE. I won’t go into the criteria now of how these WHO lists are put together.) Myself and many of these Conservative radio and TV commentators know things do need to be corrected in our Health Care System but there are MANY OBJECTIONABLE ITEMS IN THE HOUSE’S HEALTH CARE BILL that are VERY CONCERNING.
    Thank You, Colleen Barry

  46. I guess the 10 line rule doesn’t apply to posters. Start by taking a misrepresentative shot at the right, standard for a THCB post. Then the thoroughly debunked “their outcomes are better and it’s the fault of our system argument”. Which industry are you talking about that opposes mechanism reform? I’m the insurance industry and I’m telling my representatives and clients this all the time. I’m thinking you mean large insurance companies created by politicians that are now feeding on their contributions, they are a very small number of the insurance industry. If your going to complain about distortions shouldn’t your post be free of them? What you fail completely to discuss is how all of these problems are a direct result of reform. Reform begets more reform, so on and so on until the system collapses. To solve this you propose more reform?
    Just for you bev M.D. if no one tries painting him the saint I promise not to point out the horns.

  47. I will and so will most of you be satisfied with a reformed system of health care under which the Senators and Congressmen will be willing to obtain their medical services. I know they would need to change the current laws but that is very possible.

  48. Well done overview – thank you! Lost in the fray of “how can we afford health care?” is the real, underlying question: “how can we make healthcare affordable?” You do a good job of directing the discussion in that direction.

  49. Great piece! I was listening to the town hall debates and was banging my head against the wall (theoretically or course) at the lack of education around the health care industry and care delivery.
    I would love to see more education for the lay folks – the reality of how care is delivered to who, at what cost and the future if nothing happens.
    It has been amusing to see 55+year olds saying they want goverment out of healthcare – Medicare isn’t goverment?
    More work to be done – nice job!

  50. THANK YOU for saying what I have been trying to say for months regarding fixing the delivery system (costs) first, rather than insurance “reform.”
    I just wish to make one comment upon the death of Senator Kennedy. I believe it was on this blog that we debated, when he was first diagnosed and treated, the aggressive treatment he received at Duke and whether it would make any difference to his prognosis and/or was cost-effective. At the time I cited the average survival of patients with glioblastoma multiforme (his type of tumor) as approximately one year.
    Senator Kennedy survived approximately one year. Now who knows whether all of his treatment, taken together, was more expensive than standard treatment for this tumor. However, it is a fact that, in this anecdotal case, survival was not extended.
    That said, my condolences to the nation. Whether or not one agreed with his politics, I believe his heart was in the right place. And Nate, don’t speak ill of the dead. Please, just this one time.