American Healthcare: Caught in a Bad Romance

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“I want your Ugly.  I want your Disease
I want your Everything, as long as it’s Free.”

—America’s leading contemporary philosopher, Stefani Germanotta (aka Lady Gaga)

Insight comes from unlikely sources. Lady Gaga nailed the health reform dilemma. We have a healthcare delivery system that is an orgy of profligacy and excess that offers the false promise of making ugliness, disease and death all optional. And, we the public love all of it, as long as it’s free, at least to us as individuals. We want high tech, high quality, high expectations met, highly trained professionals delivering high standards, paid by someone else. And the magic fairy that will pay for all of this? Health insurance. Give everyone an insurance card and they can have their everything and it will be free, or close to it.

But wait, isn’t the cost of insurance tied to the costs of care? Doesn’t the sum of all healthcare costs for a covered population (plus administrative costs) divided by the number of people equal the premium. Doesn’t the premium come out of my pocket as taxpayer, employee or individual? How can I have everything, as long as it’s free?

Short answer is: you can’t.

We are caught in a Bad Romance with healthcare.

The brutal truth is that the average American household cannot afford the average costs of care. With household income stagnant to declining at $50,000 a year and typical total healthcare costs at $15,000 per household, average people cannot afford the average costs of care. Even if we were to fully accept the notion that rich people have to subsidize poor people (which still seems a bit of a stretch to some on the right) you would think that in a wealthy county like America, the average household could afford the average cost of care. But as the healthcare debate showed both in Massachusetts and at the national level, nearly all of us need a subsidy to make health insurance affordable. (Say what?)

How can “affordable care” mean we need to subsidize nearly everyone?

Well, that’s a problem. There are really not enough rich people to go and tax. And those rich people are not having a good year. The revolting people of Massachusetts were independent voters who are paying their taxes and mortgages and mandatory health insurance premiums and who when asked to step up and pay taxes for a healthcare bill that wouldn’t help them any, said no to big government. (By the way, they also said yes to a telegenic, former nude centerfold who outhustled the dullest politician in America by a factor of 10 to 1). And they baulked at being asked to pay federal taxes to subsidize the mean-spirited people of Texas and Alabama who really don’t want to be forced by the federal government to cover poor people through Medicaid expansion or insurance exchanges or worse yet a public option.

Health reform may be dead. Sensible centrists like my friend and fellow futurist Jeff Goldsmith, the always sane and insightful Bob Laszewski, and my physician policy wonk pal Bob Wachter have all written eloquently on this blog about the possible political path forward. I will not repeat their points with which I nearly always violently agree.

Nor do I particularly want to unleash a flurry of rehashed mini-essays from all of you regular contributors about how health refom should or shouldn’t go from here. I know that each of you believe that your idea is the right one. I get that. And I am in reverential awe of the time you pour into these pages.

We should all be very grateful to Matthew Holt for creating this blog.  His vision has created a meeting place for all of you out there who care deeply about healthcare and about politics and policy of healthcare. (I should say by way of full disclosure that I had the pleasure of working with Matthew for many years, hired him from Stanford to join the Institute for the Future, and played some modest mentoring role in his professional development.  Matthew was also the inspiration of IFTF’s then dress code: “no shirt, no shoes, no salary”.)

So my plea to all you healthcare bloggers of America is this: Please turn your attention to the central problem. How can American healthcare delivery be better, faster, and cheaper in the future not more expensive and worse. And please no ideas about giving people insurance cards subsidized by someone else (especially not the Chinese or my children) as in the current proposals.

This community must have some good ideas about how to get us out of this mess. We are caught in a Bad Romance.

Ian Morrison is an author, consultant and futurist based in Menlo Park, Calif. He was indeed Matthew Holt’s boss at IFTF until Matthew quit the restrictive dress code and exchanged it for the blogger’s PJs.

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43 replies »

  1. I live in Germany. Our healthcare is sooo different from yours.I am 62 years and never had any problems with our healthcare. I pay my monthly health insurance can go to every doctor I want to. If we have to visit a doctor we pay 10 Euro for 3 month to him thats new and many people are angry about this. I have to kids, born in a hospital. We never get any bills from a hospital this is all covered by our insurance. My husband had, when he was young , a motorbike accident, he broke his leg several times had to be in a hospital for month, we never had to pay anything to the hospital. I do not have any special insurance just the one who everyone has. Once we planned to move to the US but a health insurance is not affordable for us. We are so glad we live in Europe everything is covered and any neccessary operation or treatment will be done and never denied by an insurance, thats just not possible.By the way we have democracy like you.

  2. I have lived in seven countries and as I see the USA was the last country where there was more freedom than anywhere else. This is coming to an end. First the right-wing used 9-11 as an excuse to decrease freedom, and now the left-wing led by Obama wants to take away any remaining advantage in the USA. The left-wing always wants to increase government intervention and the only business is healthcare where there was until lately more freedom in the USA than elsewhere. A great recession is coming in the next years caused by the “baby-boom demographic wave” and by the out of control federal debt. This will wipe out the healthcare program. The more the federal government is increasing
    spending, the deeper the recession will be. There is nothing to be gained from increased spending. Any tinkering with healthcare should be based on present (before the Obama bill) level of spending.

  3. The problem is the industry. Lobbyists. The money is rolling behind your backs.
    I am from Europe, and guess what? I never payed a cent for healthcare. I can go and see a doctor whenever i need one. And it costs me nothing.
    Just yesterday i saw that film from Michael Moore about the American healt care sytem and i am truly shocked.
    I am glad to have been born in Europe. And i am glad it is as social as it is.
    Americans should stand up for their rights, they should go and demonstrate, strike…whatever. Its you people that go and elect the politicans.
    And if they lie to you or do nothing for your needs then you should let them feel it.

  4. Great article. I think it resonates in anything…people, at least myself, are more willing to work with people who have a desire to learn, Spanish health system is dual, we have good private hospitals, some of the best in Europe in terms of investigation and treatmens, but the best of the spanish system is that the public system is even better than the private. The only problem you can find is that sometimes you have to wait some weeks for an operation, but no one dies on the street, enfront of a hospital, because of not having money enough to get operated.

  5. “Blues in MA had the clout and instead of using it to pressure partners to lower cost they conspired with them to raise it. We see the same thing in Medicare, providers and the goivernment allow mutual growth at the expense of the public. The large carriers don’t have lower cost they have monopolies to drive business. It is a lack ofcompetition that allows rates to grow out of control.”
    Nate, I can’t agree with you move on this but on the one side you recognize the power of clout (Blues) but then say we need 100’s of carriers, each with less clout, to lower costs through competition. Part of the competition is negotiating lower reimbursements with providers. How will 100’s of small carriers trying to attract providers as well as premium payers into their stable, compete with the Blues, who will not share their large banks of data to accurately assess risk with the small guys?

  6. “You know, I think there is something in the middle, between free Medicare and 100 private plans.”
    I’ll bet you weren’t thinking 50 plans where you?
    “The VAT money is dedicated. The Feds cannot divert it or anything like that.”
    Medicare 1965 by law must reimburse providers a fair amount, The feds can’t pay less….until they did.
    I’ll just remind you how Social Security and that huge tax windfall worked out for the public. Government can not be trusted with our money period. Any VAT would be funding other programs or obligations before the ink dried.
    Every month I also read an article about VAT fraud in europe. The concept is something only a politician could dream up, why do we continue to insist on finding the lease efficient and most fraud prone ways of doing things. Google VAT fraud and see how much of a mess it already is
    en.wikipedia.org/wiki/Missing_trader_fraud
    http://www.rtvat.eu
    news.bbc.co.uk/2/hi/uk_news/5178788.stm
    VAT fraud in the UK has reached record levels, HM Revenue and Customs statistics show.
    This is the same as health care, you liberals pick an obvilously failing sytsem, ignore all the problems and short commings and hold it out as a solution that will fix everything.

  7. Margalit – While I like a lot of what Dr. Emanuel said in his book “Healthcare Guaranteed,” I thought the weakest part of his thesis relates to the VAT and how much money it could raise. Due to exemptions for necessities, the broadest based VAT’s in Europe raise about 0.4% of GDP for each 1.0 percentage point of tax. On that basis, to replace funding for Medicare and Medicaid, which currently costs about 5.5% of GDP combined plus cover the uninsured (excluding illegal immigrants) which would probably add another 1% of GDP or a bit less, we would need a 15% VAT rate to get the job done while leaving employer based insurance and the individual health insurance market alone. Moreover, the VAT is easiest to collect for manufactured goods which are steadily shrinking as a percentage of the economy while the service sector is growing. It would be easy to avoid for lots of people who provide personal services off the books for cash further fueling the already huge underground economy. Finally, even if we had one, the revenue base would grow only in line with the economy at best while healthcare costs are growing 2.5 percentage points faster than nominal dollar GDP and they have been for years.
    That all said, I think we will eventually have a VAT to help deal with the country’s overall fiscal imbalance, not to finance health insurance. Until the broad middle class recognizes and accepts the fact that it will have to pay something like 15% of income for health insurance if we finance it through the tax system we’re unlikely to make much progress. That should not stop us, however, from making a serious effort to bend the medical cost growth curve. There are plenty of good ideas to attack that issue but they all gore the ox of some powerful interest group. It’s a mighty tough issue to say the least.

  8. You know, I think there is something in the middle, between free Medicare and 100 private plans.
    The vouchers that Dr. Emanuel proposed and the progressively structured VAT to pay for them. That way, seniors continue to pay their share until the end. There is no mammoth government plan to administer. Government would only be involved in collecting VAT and paying for the risk adjusted vouchers to the private guys. No more Medicaid either (the states should be happy). Of course, there will be regulation of what insurers have to provide for the vouchers, but as far as supplementals go, the sky is the limit.
    No more employer care and no government run plans and no free Medicare and no disgraceful Medicaid.
    So why not? What’s the catch, Nate, if there is one?
    The VAT money is dedicated. The Feds cannot divert it or anything like that.

  9. “how do you propose to deny seniors their advocate and lobbyist?”
    I wouldn’t seniors are free to give money to whom ever they wish, but they shouldn’t be getting any of my tax dollars and they should stop being viewed as the voice of seniors when they gave that up 10-20 years ago. They should be taxed like any other business, as that is what they are.
    “How will 100+ different plans have the power of the dollar to lower costs,”
    Innovation. The same way 100 MA HMOs beat Medicare. the same way my little company can out perform Anthem on a daily basis. Technology is a great equalizer, you don’t need 10,000,000 lives to be efficient.
    Blues in MA had the clout and instead of using it to pressure partners to lower cost they conspired with them to raise it. We see the same thing in Medicare, providers and the goivernment allow mutual growth at the expense of the public. The large carriers don’t have lower cost they have monopolies to drive business. It is a lack ofcompetition that allows rates to grow out of control.
    “I thought the whole system was wasteful and inefficient?”
    Not at all the self funded sector is extremely efficient
    raises taxes to pay 50% of a debt doesn’t accomplish anything. Thats like paying half your mortgage, there still going to kick you out. Raising taxes to make people see the problem would have been solution 20 years ago or ideally when it first passed. That opportunity is gone.
    a 50% increase in poverty is not acceptable. If Medicare hadn’t been passed cost would not have increased like they did.
    I think a very strong argument could be made for passing catstrophic plans in 65 and we would have avoided all of this.
    At the time they considered months in the hospital to be catostrophic, that is the fear democrats used to sell it. on’t let grandma lose her shirt.
    of course seniors would hate it, your taking away the free lunch. That is why they need to get the bill for the mess they created, force them to deal with it before they “pass” the buck.
    That is total life expectency, once you make it to 65 the chance to live longer then 77 is huge
    I would toss the medicare prompt pay law out the window in a heart beat, perfect example of unintended consiquences
    They should be private workers hired by the administrators of the 100s of plans.

  10. “AARP needs to go down. They don’t serve the needs of seniors they’re nothing but government sponsored pimps.”
    I’m no fan of AARP and gave them back their membership after they supported Med PartD, but how do you propose to deny seniors their advocate and lobbyist? Certainly you don’t want the government doing this.
    “1. Break Medicare into 100+ different plans. There needs to be competition for service and management. How do to this while not corrupting it I am not sure.”
    How will 100+ different plans have the power of the dollar to lower costs, if Medicare ever gets around to getting the political manadate for doing that? If there does need to be competition then that supposes that Medicare is the fat of costs rather than the provider having the fat and using Medicare to get it’s money. I just don’t see your “reasoning”.
    “This is the problem with government plans, by nature they are wasteful and inefficient.”
    I thought the whole system was wasteful and inefficient?
    “The benefits will remain the same but instead of 20 mega payors who suck open it to competition like Medicare Part D.”
    If the benefits stay the same then where will the savings come from – insurance, hospitals, doctors, or maybe drug companies, is there that much fat out there to make a difference? Is part of keeping the benefits the same making Medicare pay providers what private insuranc pays them? Med Part D was the “solution” for bus loads of seniors going the Canada to buy cheaper drugs. But instead of the private sector solving the problem the drug companies had the government solve their problem with another entitlement program. http://www.propublica.org/ion/health-care-reform/item/medicare-drug-planners-now-lobbyists-with-billions-at-stake-1020 By the way no one ever mentioned that the bus loads of U.S. seniors going north for affordable drugs passed bus loads of Canadians coming south for better healthcare. Here’s a good take on Med Part D by the WSJ: http://online.wsj.com/article/SB126282080941818727.html
    “2. There is no way we can raise 100 trillion in taxes to pay for current benefits.”
    But isn’t that the point? Raise taxes to offset costs (because surely we’re all for reducing the deficit) so that everyone then understands what this is costing us? If we raised FICO instead of hiding the costs in deficits wouldn’t that cause reform?
    “Before Medicare was passed 87% of seniors could pay 100% of their medical expenses. Now 19% are on Medicaid.”
    You can’t draw the conclusion that seniors would be better off if eveything had stayed the same, especially with the increased cost of healthcare. But 13% instead of 19% is not much difference. So I could just as easily claim that Medicare is a success in keeping healthcare for seniors affordable.
    “We need to move to the catostrophic insurance everyone originally wanted.”
    What would be catastrophic for a senior – death?
    “Before all you leftys start crying at the meer thought the majority of seniors can easily afford this and those that can’t are on Medicaid.”
    Would Medicaid pay providers what private plans pay? I’m not sure if it’s lefties you’ll have to get this past, I think you’ll need seniors on board too. I guess they’ll all get HDHP’s as well.
    “3. raise the age, now that people live till 100 all the time we can’t put them on the public dime at 65. 40 years of taxes don’t cover 35 years of retirement healthcare and death.”
    I wonder what a private insurance plan at 70 or 80 years of age would cost? I’m not sure about “all the time” as the life expectancy is about 77 years.
    “4. Actually enforce insurance fraud and treat it like a real crime.”
    I think it already is a crime. What it needs is better/more enforcement. The FBI is now on a fraud campaign. Of course we’d have to hire more government workers.
    “If 10 million of charges show up the day after a provider gets its payor number investigate them before mailing the check.”
    You’ll have to repleal the law that says Medicare must pay within 30 days and then get all the providers to stop screaming so loud.
    “There should be a real credentialling process like PPOs do. Verify who these people are and that they are qualified.”
    I can’t argue with this even though I don’t know what PPOs do. I agree that I don’t think much of Medicare’s credentialing or how they do it.
    “5. Regular communication with members the can understand. Having administered a Medicare supp for 15 years I know Medicare enrollees have different needs then normal plan members. Yes it cost more when they like to call and talk for 30 minutes but the cost savings, fraud prevention, and baked goods at christmas are well worth it”
    How many more people do you think Medicare should hire to do this? Would this be more U.S. government workers or should we farm this out to India?

  11. rbar, before we ruffle the feathers of CMSA (Case Management Society of America) I’ll come to the defense of Case Managers and Discharge Planners. I’m in favor of RN Case Managers and Discharge Planners in direct patient care settings, they really do play a vital role in coordinating patient care. The backbone of a nurse’s skill set is in assessing, planning, implementation and evaluation . . . and in a supported environment these positions use those skill sets effectively. Nurses get frustrated (and are leaving the profession in droves) when the business model of any healthcare entity gets in the way and prevents them from effectively performing this nursing process.
    I have found that many nurses who work in a call center environment feel their skills are greatly under-utilized. Many, but not all, call center environments reward nurses who can process the most calls in the shortest amount of time. While they like the concept of their job, in reality they don’t feel that they are given the opportunity to really make an impact. Disease management is a great concept, but the business models of most companies do not support true disease management, despite all the lip service they will pay to their metrics and “outcome measures”.

  12. Ian and Heidi,
    I have written this before, but I was asthonished to see how many people worked in non patient care medical services in the US. In the US, you have tons of those people running around (case managers, discharge planners), sitting behind desks (credentialing, billing) or telephones (insurance call centers), it’s only a fraction of this in other countries (remember Michael Moore’s sicko – yes, he is simplistic and at times falsifying – going to that Canadian hospital’s billing department?).
    I know these are OK jobs, but are they really doing something worthwhile? Couldn’t these folks use their skills to do something productive?

  13. You’re right, Ian, but the BLS figures don’t even begin to tell the story. The BLS figures count “healthcare workers” who are employed by systems providing direct care. It DOES NOT factor people who make their living in the healthcare sector. For example, it doesn’t include the Pharmaceutical and Medical Device industries. There are currently between 90,000-100,000 pharmaceutical reps calling on slightly under 800,000 prescribers. The pharmaceutical industry estimates that roughly 1/3 of industry employees are in marketing. That does NOT include R&D employees. The Medical Device, BioPharm, and DME industries are similar. Then we have all those employed in managed care and the insurance industries.
    I don’t know the exact number of Medicare-certified Home Health agencies in the U.S., but there are 2,421 in my state of Texas. That’s not a typo. 2, 421. All of them have marketers, administrators, people who spend all day coding (often nurses) so that they can get the proper reimbursement, IT staff, etc.
    The BLS statistics also do not cover consultants and consulting companies who are hired by direct care providers to provide business support and consult on issues such as HIPPA compliance, JCAHO audits, EMR and, oh yes, marketing.
    All of these salaries make up a slice of the pie that is the health care dollar.
    Somewhat ironically, I fall into the BLS statistic of a healthcare worker. I’m a registered nurse (with a business degree) and I work in the direct care system. Although I do a little patient care work on the side from time to time to keep up clinically, I haven’t made my living by performing direct patient care in over a decade. Many of my nursing colleagues that are counted in the BLS numbers are not doing patient care . . . and I’m not even talking about those who are nurse managers. Even so, nurses still make up only 28% of hospital employees.
    I would not suggest that we cut back on employees at the hospital or direct patient care level. We would, however, be wise to look at all the industries and occupations that are funded by our healthcare dollars.

  14. Nate
    Actual BLS employment data in healthcare are at:
    http://www.bls.gov/oco/cg/cgs035.htm#related
    See Table 2. I think they confirm the general point that US has a lot of people in administrative roles. Using another measure from the OECD (cost of insurance and administration) US spends 7.2% of total costs compared to OECD average of 3.4%. This underestimates the provider costs of pluralistic payment systems.
    We have the most bureaucratic healthcare system in the world (both public and private) with lots of people in offices, lots of people selling things to each other in healthcare, lots of consultants, managers and so forth compared to most other countries. It seems to me that most of your suggestions would increase the administrative bureaucracy (both public and private) not reduce it.

  15. AARP needs to go down. They don’t serve the needs of seniors they’re nothing but government sponsored pimps. The discussion needs to go strait to the seniors and it needs to be a huge helping of guilt.
    1. Break Medicare into 100+ different plans. There needs to be competition for service and management. How do to this while not corrupting it I am not sure. This is the problem with government plans, by nature they are wasteful and inefficient. The benefits will remain the same but instead of 20 mega payors who suck open it to competition like Medicare Part D. Have a body that audits a percent of claims to make sure they are doing their job and automatically fire anyone that falls below a certain level. Performance guarantees are very common in the private sector.
    2. There is no way we can raise 100 trillion in taxes to pay for current benefits. Before Medicare was passed 87% of seniors could pay 100% of their medical expenses. Now 19% are on Medicaid. We need to move to the catostrophic insurance everyone originally wanted. Starting 2-3 years out every new enrollee gets an HSA. THe first wave will start low like $1500 indexed to CPI for healthcare. 5 years later he next batch starts out higher say $2500 till finally they are around $5000 in todays dollars. Before all you leftys start crying at the meer thought the majority of seniors can easily afford this and those that can’t are on Medicaid.
    3. raise the age, now that people live till 100 all the time we can’t put them on the public dime at 65. 40 years of taxes don’t cover 35 years of retirement healthcare and death.
    4. Actually enforce insurance fraud and treat it like a real crime. If 10 million of charges show up the day after a provider gets its payor number investigate them before mailing the check. There should be a real credentialling process like PPOs do. Verify who these people are and that they are qualified.
    5. Regular communication with members the can understand. Having administered a Medicare supp for 15 years I know Medicare enrollees have different needs then normal plan members. Yes it cost more when they like to call and talk for 30 minutes but the cost savings, fraud prevention, and baked goods at christmas are well worth it
    I’ll think of more but look forward to comments on these

  16. “3,000,000 nurses currently”
    “where are all these wasted positions that can be eliminated to save money?”
    They usually start with the nurses. My wife’s state hospital has 17 vice presidents and I bet the CEO can justify their existence.
    Nate, other than fraud reduction which will take more people to oversee, how would we make Medicare less costly for the taxpayer and that will be supported by the AARP group? Margarlit is right about allowing them to negotiate prices but we know that Congress forbid them from doing that, at least with drug companies (I wonder who that benefits).

  17. wonder what the healthcare debate would be like if people had a clue what they where talking about.
    3,000,000 nurses currently
    250,000 dentist
    1,000,000 physicians
    300,000 dental assistants
    60,000 PAs
    250,000 pharmacist
    1,000,000 home health workers
    etc etc …. where are all these wasted positions that can be eliminated to save money?

  18. From the EEOC:
    “The occupations within this field are many and varied, including but not limited to physicians and surgeons, dentists, dental hygienists and assistants, registered nurses, licensed practical and licensed vocational nurses, physician’s assistants, social workers, physical therapists, psychiatrists, psychologists, radiologists, audiologists, chiropractors, dieticians and nutritionists, pharmacists, optometrists, podiatrists, medical records and health information technicians, clinical laboratory and diagnostic-related technologists and technicians, emergency medical technicians and paramedics, ambulance drivers, nursing aides, home health aides, orderlies and attendants, occupational therapists, speech-language pathologists, medical assistants, personal and home care aides, medical transcriptionists, custodial and food service workers in medical facilities, as well as those functioning in either management or administrative support roles for workers who provide direct services”
    The last category (management and administrative) could probably be reduced, but somebody has to cook, clean and keep the lights on….

  19. Ian, I am reposting this quote from you because it is a thought worth repeating:
    “Highly trained doctors and their staff spend inordinate amount of valuable time on useless paper chases to get authorization, payment, or other mundane administrative feats accomplished. Think about it, there are 15 million people employed in healthcare: one million doctors, two million nurses, and I’ll spot you two million more assorted dentists, lab techs, and therapists. So what the hell do the other 10 million do? As best I can determine they either fill out forms or give powerpoint presentations to each other.”
    Exactly. Why are two-thirds of people employed in healthcare not direct healthcare providers? The answer to that question, my friend, is the answer to how to make healthcare better, faster and cheaper.
    It may just be a conincidence, but did anyone notice that the increasing costs of healthcare are in direct proportion to the increasing percentage of MBAs running healthcare over the past 25 years? That’s when we bumped aside the clinicians, nuns and non-profits who traditionally ran healthcare and started focusing on healthcare as a business . . . complete with profit centers and marketing departments. Is it any wonder that healthcare is now in the same boat as profit and greed-driven Wall Street?

  20. Nate, can you run some estimates of savings just due to the simple fact that Medicare does not negotiate with providers individually? And while we’re at it, let’s also figure out the smaller savings of global negotiation with pharma & device.
    And this time around it will be for everybody.
    So even if all the pilots and programs fail, there has to be something to be gained. Yes, I know, we need to keep the fraud and waste down too. Maybe they can use local TPAs for that….

  21. I know Nate you have written about this in other posts, but please repeat to me in a few words why you think that private insurance will somehow remain affordable, even though premiums are rising steeply? If your answer is that we need more copay/deductible in order to curb excess costs (I don’t think that’s the most reasonable and certainly not the only way), that is something that medicare, nedicaid or any conceivable 3rd party payor could do as well.

  22. rbar what if we put everyone on Medicare and the cost savings/changes don’t happen or fail? You just bankrupted the entire nation and set our health systems back 60 years. This is the same thing we went through when we put everyone over 65 on medicare. That mistake might bankrupt us.
    We need to fix Medicare and Medicaid before a single new person is added.

  23. You people should really read the US News Feb publication, ’cause it is illuminating about various facets of the expectation of living well into the 80s to 90s of life.
    Hey, if you have the genes and fiscal opp’s to do so, then great for you. Oops, the majority don’t. And, the majority shouldn’t.
    Just to put in full perspective for all you pro lifers for the elderly, I have no intention of living beyond 70 to 75 years old. If I am fortunate to make it to that age and see my children have children, then I have done my share. This country is so full of narcissism and denial, it is no wonder why other countries despise us so much. And, the usual commenters here just don’t get it, as you espouse the bs I have no respect for.
    Bad romance. This is not about love, sir. It is about reality, and more and more people are out of touch with it. But hey don’t believe me, you elitists have such a lovely shade of purple in your sky in your world, eh?

  24. Ask other doctors who work in the US now (for reasons of high wages, spouses, research funds) but who trained/worked abroad as well: the US has an extreme culture of medical overutilization that is created by patients and doctors alike. It will be hard to change that culture since there is no political will and no financial interest to do so – with the exception of course of the overall cost- and esp. medicare explosion.
    I agree with MD as hell with regards to his suggested cure, but there is another, more reasonable way, namely a 2 tiered system: offer medicare for everyone and cut down on the excesses, approve imaging, procedures and surgery only based on already existing EBM criteria, and adjust the fee schedule, removing the imbalance favoring procedures/technology. And everyone who wants surgery for axial back pains or repeat MRIs for recurrent migraines needs to pay out of pocket or pay supplemental insurance, or have cadillac insurance. People will learn that lean medicare will deliver the same or better outcomes … but everyone is free to choose overutilization if he/she can afford it.

  25. James
    Just checked my facts again. Texas has the highest rate of uninsured in the country at 25.2% of the population and the second highest (behind California) absolute number of uninsured at 6,0023,000. But you have enlightened me that Texas is just one Medicaid waiver away from generosity.

  26. “And they baulked at being asked to pay federal taxes to subsidize the mean-spirited people of Texas and Alabama who really don’t want to be forced by the federal government to cover poor people through Medicaid expansion or insurance exchanges or worse yet a public option.”
    FACT: The State of Texas passed groundbreaking legislation in 2007 (SB 10) to try to rework their Medicaid program to provide expanded coverage for the low-income uninsured. However, it required a federal waiver — and the waiver request has been sitting in DC gathering dust ever since.
    If you are going to bash “mean-spirited” Texas, please do a little research first. Look at what they tried to do and where it became stuck in limbo before bashing them.

  27. “I don’t know what is worse: clueless politicians selling fake hope, clueless media reinforcing fake hope, or perhaps, the clueless society that expects to be sold the fake hope.”
    I think it’s the medical community gladly profiting from fake hope.
    “Another blessing to come from the entitlement of the boomer generation,”
    Actually the “entitlement generation” are their parents who got education, housing, SS and Medicare after WWII. Boomers were brought up in an affluent time period made possible by government spending and expanding markets due to the rebuilding of Europe and cash at home to spend on a protected manufacturing sector. If you think boomers are self indulged and think everything is their’s, you should meet their kids.
    Exhausted, the healthcare bill tried to address end-of-life and living wills, but the (fiscally responsible?) Right seized on this and distorted it to mean “Death Panels” in order to kill the bill and destroy Obama. Lefties I talk to all recognize end-of-life issues and the limits to spending fortunes to keep the heart beating while quality of life is abandoned. Ever see an oncologist willing to say uncle.

  28. Ian, regarding your bullet points, there is big money associated with all of them and the big money wants things to stay exactly the way they are now. The death panel shouting was generated by those monied interests as a diversion in order to preserve the status quo.
    The public is being hoodwinked, as usual. They never got any freebies and they never will.

  29. Primary care docs and midlevel providers have no standing in a court of law when it comes to defending a case. They should have refered the plaintiff (or their loved one).
    Prevention does not cost anything.
    Emphasize palliative care all you want. Grandma is going on dialysis right after she gets her PEG tube or I’ll sue your a**.
    The only environment that encourages greater personal responsibility for managing healthcare choices is having to pay cash out of pocket.
    Medical technology that is new will always cost a fortune. The four function calsulator in 1973 cost $110. Adjusted for inflation that is more than a new laptop today.
    Doctors don’t care for “whole populations”. That is what insurance is supposed to cover. The only competition created will be to not take care of the sick ones.

  30. It seems to me that ExhaustedMD and Margalit just played out the bad romance I was talking about. The things that would actually work to reduce costs (and thereby enable us to expand access) involve hard choices and change on everyone’s part including the public in general and patients in particular. The public want change without sacrifice.
    Pete asked how they do it in Europe? As a Scottish-Canadian-Californian who has family members living, getting sick and dying in all three countries, I would say that all healthcare systems around the world, that I know, are an ugly compromise on costs, quality, access, and security of benefits. So there is no perfect system. We just have the worst value for money, because if you just isolate the cost factor, for a moment (there is a huge amount of comparative analysis that basically says the US doesn’t do any better on most outcome and care measures and worse on many) but on costs why do we spend 6 percentage points of GNP more than every other developed country?
    I was always taught that there were three buckets of reasons each of about equal size.
    Bucket 1. Higher prices and incomes. Everyone makes more money for the same job in healthcare as other countries and we pay much higher prices for everything medical. The two notable exceptions are our generic drugs are cheaper than the Germans. And British primary care doctors make more now than their American counterparts.
    Bucket 2. Administrative waste motion. Pluralism breeds bureaucracy, both public and private. Highly trained doctors and their staff spend inordinate amount of valuable time on useless paper chases to get authorization, payment, or other mundane administrative feats accomplished. Think about it, there are 15 million people employed in healthcare: one million doctors, two million nurses, and I’ll spot you two million more assorted dentists, lab techs, and therapists. So what the hell do the other 10 million do? As best I can determine they either fill out forms or give powerpoint presentations to each other. Certainly that’s what I do.
    Bucket 3. High Technology. This is where we get squeamish about change. America loves the machines. Some of the high tech difference is at the end of life, although every country I know has experienced increase utilization rates in older years. Some of it is aggressive diagnostic intervention driven by provider preference if not conflict of interest, by patient desire, by malpractice concerns, and above all by the “that’s the way I was trained” defense. But most of the difference is the fact that nearly all other countries (and Kaiser) have a balance of primary care to specialists that is 60/40 towards primary care rather than the other way around as we have in the US.
    So people who say why can’t we be like Europe in terms of costs, well we can if we had a very different healthcare delivery system.
    Last summer the Obama administration and the President himself, seemed to fully understand that the delivery system structure and incentives was the source of higher than necessary costs. But as they found out, the public doesn’t want to hear about changing the healthcare delivery system, they just want access to it for free.
    I believe we need to focus the attention of the American public (Republicans, Democrats and Independents alike) on a long run change in the delivery system that:
    • Emphasizes primary care and prevention over procedural interventions
    • Expands the supply of primary care resources while restricting the supply and utilization of expensive and marginally effective high-technology interventions
    • Emphasizes palliative care solutions instead of expensive futile care at the end of life
    • Creates environments that encourage healthier behaviors and greater personal responsibility for managing personal health
    • Simplifies the administrative mess by standardizing payment, measurement, and review systems
    • Encourages medical technology innovators to produce new technology that is better, faster, and cheaper not more expensive and worse
    • Encourages competition based on the creation of risk-adjusted outcomes for whole populations and individual patients rather than paying for procedures based on provider preference.
    None of these things are easy to accomplish and none of them are politically popular.
    But we should at least have an intelligent debate about it. Not a shouting match over death panels.

  31. Very well, I’ll pick up the proverbial glove… 🙂
    I am not a physician. My financial interest lies with Healthcare IT adoption, and despite that I am on the record, both on this blog and elsewhere, advocating for physicians to NOT blindly adopt government regulated HIT, to get involved and to stay on paper if it feels right for them. So much for my personal interest…
    Feel free to Google my name. It is my real name.
    As to the mortally wounded healthcare reform bill, I think it leaves much to be desired in compromising the original goals of providing universal, affordable and quality care. However, I would still support this bastardized solution, just so that the status quo is broken and hoping for better changes to come. Personaly, I would probably see my premiums go up, just like everybody else that has no “special” circumstances.
    As incredible as it may seem in today’s atmosphere, I do want to see healthcare reform because I believe a healthy society must be somewhat equitable. It is wrong for some Americans to have no access to what is arguably the best health care system in the world, while the taxpayer money (including theirs) goes to subsidize the same financial institutions that are causing these disparities by making financial speculation the main driver of our economy. This is not capitalism anymore. Capitalists used to create capital. Wall Street creates debt.
    Rereading your last comment, I really have no idea what exactly it is that you are opposing or supporting. Should we, or shouldn’t we treat and support ALS patients? And you do know that Dr. Hawking has ALS and has somehow managed to live a full life including grandchildren? He is 68 years old.
    The notion that health care reform is pushed by boomers afraid of dying is a bit strange, considering that extending care to all, will by definition provide a bit less for each individual. Boomers have made some serious changes to “established social orders” during their tenure. Maybe they are due for one more change….
    I do understand that you are opposing this particular bill, but is it because it is too mild, or is it because it’s fraught with Socialist ideas and death panels? If the former, I understand and to a certain degree share your discontent. If the latter, sadly, I believe I do understand as well.
    To Ian Morrison: I do apologize for totally derailing your thoughtful post…

  32. Fine, Ms G-A, since I have the moment to come here and read your recent rebuttal, I’ll reply.
    What about ALS? An illness that has a 100% fatality rate regarding premature death, until research can have a miraculous impact for the better. So, per your perspective that the health care reform debate is basically “mundane fiscal quandries”, which by the way is a comment straight from political perspective alone, as much as I know of your backround (which is none until you care to share your backround to be an ongoing participant here), then it is easy to problem solve this as a politician would. Hence my recommendation to read B Healy’s piece as noted above in my last comment, as mundane fiscal quandries are only resolved by black and white interpretations of problems. ALS patients are only a drain, so resources should be minimized for the good of the many. Note that is NOT my position on the matter, but what this reform will do, as set now.
    So, what is your agenda with debating this matter here, ma’am? In my opinion, a lot of the backround to this legislative effort is in fact being laid by boomers, as they don’t want to face, as you call it, “age old subjective fears”, so they want to change the rules. Gee, what a surprise from my generation bracket!
    The way I read your comments at these postings, you support this legislation, and then want to banter with people like me who see the consequences, and you think you can amend things after law is passed? As I asked of the general readership here, what reality are you living in? I’m a provider as an MD for 20 years, and I know disruption and discord when I see it coming. When you let non-clinicians set clinical policy, it ends up a disaster at the least, and just screwed up care on average.
    So, as I ask active providers who come and read here, what are you saying and doing to make sure anything that Washington interfere-ists try to implement is repelled? It really is a “road to hell is paved with good intention” metaphor, and it is the non-participants to the daily grind of health care interventions who want to jam this bs down our throats.
    And, by the way, I consider patients an active participant to the process, not just providers. And the patients I talk to who seem to have a good read of things do not like this legislation either.
    So, I guess I have to accomodate the needs of the few to screw the needs of the many, eh? More than 50% of the country seems to think this is not the time and place to start historic legislation. So, as I have asked honestly and directly of the advocates, what’s in it for YOU!? ‘Cause it ain’t about helping peoples’ lives when you look at the facts.

  33. Dr. Exhausted,
    “And, I am not just talking about the elderly or neonates! I see people who have chronic, severely debilitating illnesses, who would not survive in true universal health care programs, because these people would eat up at least 20 to 30% of the total services for ALL, and that is the 800 pound gorilla in the room”
    I would say someone with ALS fits the particular “chronic, severely debilitating illnesses” description.
    The problem is that we are all happy to make generalized statements, like you made, but once we go down to specifics, like Dr. Hawking or a family member, all bets are off.
    On a general note, people have always been afraid of death, hence the myths and legends of “fountains of youth”, all sorts of Immortality grants by gods, and grails and stuff like that. Not to mention religion and its eternal promise. Baby Boomers did not invent this. There’s just more of them coming into this life stage all at once.
    I don’t think our current health care crisis has much to do with these age old subjective fears. More likely it has to do with mundane fiscal quandaries.

  34. Does anyone who comments favorably for health care reform actually provide day to day patient care as a health care provider? If you do, I would love to be practicing in your reality, ’cause it is not mine!
    When those of you actually wake up and see what truly goes on these days in what is now basically the battlefield of health care, and us physicians under the friendly fire of alleged colleagues who believe this legislation will do much more good than harm, hope you are figuratively wearing a helmet!
    By the way, Ms Gur-Arie, if your above comment is a proverbial shot across my bow, I have never said or advocated for executing people, so if that is your interpretation of my comments, thank you for reinforcing my concerns about this hopeless utopian mind frame being sold to people who want to be grounded.
    Hey, why don’t all you hopeless romantics expecting health care to save America go out and buy the Feb ’10 US News & World Report issue on “How to Live to 100”. Here is the bs reinforcement that average America gets exposed to so it can then storm in and demand up to the moment health care advancements, so they can then be waited on by others, and thus they get to this three digit life span.
    I don’t know what is worse: clueless politicians selling fake hope, clueless media reinforcing fake hope, or perhaps, the clueless society that expects to be sold the fake hope. Ah, it’s a trifeca!
    Hey, Ms G-A, one more thing to point out, you should read Bernadice Healy’s piece in the “On Health” column entitled “It’s not Your Parent’s Medicare” in same issue above. Another blessing to come from the entitlement of the boomer generation, which by the way I unfortunately am part of, but for me fortunately born at the end of it so I wasn’t brainwashed by the idiots who predominate the era.
    George Carlin was right in his bit about boomers: they are cold, bloodless, and think everything is theirs. Now they are looking down the barrel of entrenched middle aged years, and they don’t like it. So, they want generations after them to give up what these newer generations deserve to pursue, ’cause boomers can’t handle the truth! We are going to die in the next 2 to 3 decades as a whole, which this planet intended of our species, and all of you who want to deny the natural process, I’d say shame on you, but wasted breath. Instead, take your narcissistic bs and suck on it!
    Oh, which, by the way, is better said by Jean Twenge in her Pro piece about limiting Social Security benefits to those well off (www.usnews.com). I think her comments about Narcissism say it better than I could in this limited commentary section.
    I guess I am just advocating for Stephen Hawking to die. Where did I write this? Oh, I didn’t. Sorry, don’t have room for other people’s words in my mouth!

  35. If we rule out raising taxes (CBO thinks rates would have to at least double just to get Medicare out of the hole–to say nothing of the cost for private insurers), and cutting benefits (see the angry seniors at last summer’s town hall meetings for details on that one), then taking it out of the collective hides of providers and suppliers is the only realistic choice left. The doctors and hospitals (not to mention the biopharma, diagnostic, and device industries) will howl, but they’re going to get outvoted.
    As Ian points out, nobody can afford the current system. Since we now appear to have given up trying to adjust what we pay for (remember how CER got transformed into “death panels”), then adjusting how much we pay is the only other game in town. Strap in tight folks, the ride’s going to get bumpy real soon.

  36. Well, thank goodness we haven’t come to talking about provider price controls.

  37. …and executing 3,000,000 Americans won’t work either.
    Stephen Hawking should thank his lucky starts that he was born across the ocean, and so should the rest of enlightened humanity.

  38. I disagree with the premise that “average people cannot afford the average costs of care”.
    Average people currently have good insurance and get good care. True, the employer is paying most of the premiums for average people. Also true, these employer payments are in lieu of wages. To be clear, the employer is not really spending his own money. So basically, average people are currently paying for 100% of their average premiums.
    Is the price to high for health care? Absolutely.
    You want to pay less and get more services? Get rid of the middle man, negotiate better prices all the way down the supply chain, eliminate fraud and waste and get more paying customers. No different than any other business, but since health care is so big there is big muscle needed to affect change. The only big enough muscle is on Capitol Hill.
    Tinkering at the edges with this or that pilot or timid reform here and there won’t work, or at least won’t work well enough to stop the Chinese version of “The Brain” from taking over the world (not buying cheap trinkets might).
    And, yeah, as Peter points out, the Europeans are already doing it.
    I hope this wasn’t a rehashed mini essay…..

  39. Nothing will change until at least one premise is put out there and seriously debated: prolonging lives that were not meant to be continued. And, I am not just talking about the elderly or neonates! I see people who have chronic, severely debilitating illnesses, who would not survive in true universal health care programs, because these people would eat up at least 20 to 30% of the total services for ALL, and that is the 800 pound gorilla in the room that is not just ignored, but it is like the saying in the Wizard of Oz: pay no attention to the man behind the curtain! You know it is there, but denial is pandemic.
    Except, we are not just talking about a man. We are talking about a sizeable quantity of people, a percentage I will not try to put a number to, but it is not less than 1%, that I’ll say. This country can’t handle death, and as a doctor for 20+ years, this still really disturbs me how we are asked to go full court press for matters that instead require prep for grieving. And, often it is not the patient who would raise issue with the discussion of focusing on quality of remaining life, but other family members who just can’t handle the truth!
    When, and only when, this topic is up front with others like money and uninsured access, then, and only then, will the opportunity for true health care reform make more responsible and efficacious strides.
    Sorry, it is part of the problem!

  40. Few if any bloggers are just talking about care. If we are to solve this problem we must break it into its components. This leads to two forks in the road.
    Fork one: The care people really need.
    Fork two: All the care anyone could possible want, with EHR, based on fear, attention seeking, prevention, early detection, living forever, federal control, insurance for first dollar coverage for a hangnail,oh, and the care people really need.

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