Sunday, November 30, 2008

Post No. 68d: An Argument Why No Government Entity Should Have Responsibility to Provide Healthcare for Citizens (Except Vets)

Much debate has been waged in our nation for quite some time now about the establishment of a national health care system available to all US citizens. Former First Lady Hillary Clinton's efforts in this regard were met with extreme resistance. The issue has been revived again recently by virtue of the election of Sen. Obama.

Is it really the government's responsibility to ensure the good health of, and the provision of health care facilities and treatment to, its citizens? Why do so many citizens feel that it is something which the government, at some level, should provide? Is there a reasonable expectation on the part of the taxpayers that health care is a "service" due them by virtue of their current level of tax contribution?

What responsibility should be placed on the citizens themselves to make the "best efforts" to maintain their health, and utilize the very latest in scientific knowledge about health risks, particularly nutrition, and the detrimental consequences associated with certain behaviors? Should citizens be required to show that they engaged, or failed to engage, in certain behaviors, prior to being extended heath care benefits by the government?

Our next article shall explore an argument to the effect that the government should not provide any medical or health care benefits, to any of its citizens, with the possible exception of veterans, and those individuals injured during the course of service to their nation.

We invite you to weigh in with your views before we present that argument.

46 comments:

  1. There are many reasons not to trust the government with a task of this magnitude. Things that come to mind immediately are the lack of privacy, the lowered availability for timely care, all the ills of massive bureaucracies such as runaway cost and corruption that is found in Medicaid and to a lesser extent in Medicare, the dreadful conditions found in many VA hospitals and facilities foreshadowing the care to be expected when that sort of bureaucracy without accountability is in the driver's seat etc.

    On the other hand certain basic care made available to all could be extremely useful to the nation. If all children were given basic care such as vaccinations and if neighborhood and local regional ( for country folk ) clinics that were staffed with perhaps one Doctor but many PAs and nurse practitioners were available for garden variety ailments then hospital ERs would not be drowning in non-paying patients thereby driving many hospitals out of business and most others to have the cost of patient care go through the roof. As someone who sees a nurse practitioner regularly at an "Eagle Family Medicine" office I can tell you that care from a practitioner can be as good or better than seeing an overly rushed MD. A good nurse practitioner will know if the situation requires an MD and should filter those in need of more than they can handle to the MD. The number will be pretty small compared to the number that come in needing care. I am a firm believer in an ounce of prevention being worth far more than a pound of cure and while this type of governmental sponsored care may have some of that bureaucratic mess I was talking about it might be worth SOME of it to stem the tide. I also believe that catastrophic illness needs to be dealt with by society as a whole. I'm just not sure about the right way to handle things. Having some sort of universal coverage is desirable but how to get from here to there with a bankrupt nation is very difficult. Perhaps a start could be made by having persons who currently are either rejected because of pre-existing conditions or simply unable to pay the high premiums of insurance outside a group plan have access to wider pools making insurance possible for them?

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  2. June: Thanks for your thoughtful, succinct, well-reasoned, and analytical comment. All of your points are well-taken. We'll also tell you in advance that one aspect of your position has made us alter, to some extent, our previously stated position. Without tipping our hand as to our impending analysis, we have one observation, at this point, prompted by your analysis.

    You mentioned the issue of a massive bureaucracy. As we previously noted, we have found that as organizations grow in size, they become increasingly more difficult to manage, and when problems develop, it is more difficult to address them. We suspect that the federal government related-health care system will grow even larger should current calls for a national system be pursued.

    Interestingly, that is not our most significant concern from an organizational management perspective. Think about this. When a business enterprise fails in some way, people are dismissed, and significant changes are undertaken. The company may even cease to exist. The problem with government bureaucracies is that with failed management, execution, and poor decisions, the people at the top may change, but the remaining infrastructure and employees, and antiquated equipment and systems, continue to function and exist. It is not a model of efficiency and constant self-examination resulting in constant improvement and innovation.

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  3. I am not a fan of government run healthcare. I spent a hitch in the Navy and experienced government run healthcare directly. There are things government can do, healthcare is not one of them. When I was a boy, back in the 50s, doctors were opposed to the creation of Medicare, calling it "socialized medicine". Now, most doctors appear to depend on it. I am not sure whether its benefits, and there are many, outweigh its deficits. I think it has, along with private medical insurance helped increase the cost of medical care. One of the problems with medical insurance is the overuse of medicine. When we paid for each doctor visit ouyt of pocket, we made sure we needed a doctor and not simply bed rest and time. On the plus side, we are aren't doctors and don't know what might be more serious. I have no answers and I am not sure there is a satisfactory one. I like June's comment and agree with her about Nurse Practitioners. They are capable, responsive (sometimes more so than the doctors), and are definitely the best way to staff a public clinic. And I do like the idea of public clinics. In the 60s, Free Clinics were available in many places and were well used. They seem to have fallen out of favor. Perhaps a plan where medical education can be paid for by service at a public clinic after a short internship at a teaching hospital with both comprising the AMA requirement for internship. In any event, it is a problem in which the AMA needs to be involved and it should not be something simply mandated by government.

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  4. Thanks Douglas. Like June's comment, your brief itemization of numerous issues helps the analytical process. It also highlight another problem with the current system: it is a hodgepodge of programs which form a complicated and confusing patchwork. We suspect that there are many administrative costs associated with inefficiency alone.

    Just today, I had to call the State Employees Heath Care plan, administered by Blue Cross / Blue Shield of North Carolina in an effort to acquire another membership card for my 88 year old Father. Just making that call required me to sort through Medicare / Humana Administrator issues. It's all too complicated just on the administrative end. Imagine the reduction in costs if we eliminated the adminstrative complications.

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  5. Yes, imagine that reduction. But the government seems the least likely entity to be useful in eliminating administration complications. It is the epitome of bureaucratic complexity and administrative inefficiency. I looked after my late mother's health and financial affairs in the last 8 years of her life. Dealing with SS and Medicare gave me more headaches that I thought possible. And her care was fairly uncomplicated.

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  6. While we are at this we might as well discuss the possible benefits of having a single payer system vis a vis the nightmare that exists today. With some sort of national plan a single-payer system would be possible.All hospitals, doctors, and other health care providers would bill one entity for their services. This alone reduces administrative waste greatly, and saves money, which can be used to provide care and insurance to those who currently don’t have it.
    Back in Yonkers my internist/cardiologist Dr David Mack was in a solitary private practice. It took a bunch of office workers to sort out all the different types of paperwork required but the myriad of health insurance/HMO/Pops/Medicaid/Medicare systems. Redundant red tape out the wazoo. I remember he sent me to have a CAT scan because he pretty much knew my insurance carrier ( Oxford Ins at that time ) would turn him down if he asked for and MRI for me at that point in time. When I got to the outpatient facility of the hospital there was a lot of confusion and the person on duty at the hospital insisted that Dr Mack get on a conference call with the person from Oxford. He did and then he asked to speak to me privately. He chuckled and said that I was going to get the MRI that I needed and he wanted because evidently the Oxford worker was POed at Oxford that day and OKed the procedure. Can you believe that my physician was not only put in the place of a supplicant to a non medical staffer of an insurance company but that he had to be gleeful about winning a small victory for his patient? You just KNOW something is wrong in this system as well as in the governmental ones.Oh and while we are at it the cost of malpractice insurance is also killing our physicians. That doesn't mean we should take away the right of people to sue for malpractice nor even limit the amounts that can be awarded. What it does mean is that when a doctor has been found guilty repeatedly of malpractice it may be time to A. suspend him or her till what is going on can be corrected and B. If the situation can't be remedied it is time for them to lose their license. If that doesn't lower the cost of malpractice insurance then it will be time to see about whether or not the insurance carriers her cover malpractice are price gouging.

    Tough but fair with a large dollop of compassion with the clear understanding that we are none of us perfect. That's my inelegant but real philosophy of living with government.

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  7. Thanks Douglas and June for your comments. In the world of organizational management, at some point, the processes and policies needed to ensure some minimal level of execution, begin to take over the original underlying goals and purposes of the entity. It's the nature of the beast unfortunately.

    Additionally, those in charge of their specific baliwicks begin to exercise control over their turf, and affirmative conduct to advance the interests of entity becomes less important (partly because it becomes more difficult to quantify a recognizable impact from your actions) and not being noticed coupled with ensuring that you do not complicate the mechanism become more admirable traits and talents.

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  8. Have y'all noticed how Barack communicates with the people? The web, e-mail, TV ... all the time. Technology and efficient communication. I have no first hand experience with the VA, but I have heard some good things about the care there lately. I have Viet Nam era friend who suffers from PTSD and he got some great care in Durham recently. One reason ... they have one common consolidated shared information system. A patients entire history, no matter where he is treated and for what in the country is at the fingertips at the next treating physician. There are privacy concerns that have to be overcome for such a system to be implemented as to all of us, but IMHO it needs to be done. Our system is BROKE. You go into a MDs office, they hand you a clipboard and you fill out your basic data for the fifteen millionth time on the damn sheet! That's the start. If your wait time is under 45 minutes, you're feeling real lucky. If you can get the MDs office to help you with the insurance claim, you're lucky twice. Safe bet the insurance company will deny your claim the first time just on the off chance you'll go away, That's how they make money, by not paying your claim! They have to pay your claim, they lose. Technology and communication Logie, that will overcome your big org problem. It's a big problem. We used to be able to say we pay a lot for health insurance, we have some shortcomings, but US healthcare is the best in the world. Not anymore, and it hasn't been that way for a long time. Buld the program so people have incentives to stay healthy and not abuse the system. See Moore's Sicko for more on US heathcare vs. the rest of the developed world.

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  9. Thanks Stever for joining us. We do not dispute much of what you have to say. We will say this: virtually everyone is so focused on the system, its delivery, its costs, its participants, its administration, the legal issues, the insurance issues, the taxation issues, the government issues, and the private entity issues, etc.

    Where is HEALTH in this whole mix? What are WE as citizens going to do about improving our health? We pretty much know what needs to be done to live a healthy lifestyle. Why so little conversation about health and the current state of the science and research?

    Let's hear from you folks!

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  10. You make a good point, Log, there is an amazing amount of good health information out there if one looks for it. Unfortunately, there is also a lot of misinformation and fraudulent claims. There are a lot of claims, mostly poorly (or un-) substantiated claims about "natural" health products. People want to take care of themselves, want to live healthy lifestyles (for the most part), I think.

    Stever, I once went to the VA to see if there was any recourse for me (a small monthly stipend) for my hearing impairment suffered while in the Navy. According to an acquaintance who worked there, it was supposed to be a simple process. I went in, was handed a 2 inch stack of paper and told to fill out the forms.

    I left.

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  11. Douglas; We've found the second issue on which we significantly disagree. The first was the macro versus micro management extrapolation concept. The second has to do with the difficulties associated with sorting through the "information and claims" regarding health products. How about the American public doing a few simple things relating to health:
    Stop smoking.
    Stop drinking.
    Stop the use of illegal drugs.
    Stop driving while drunk.
    Stop driving while under the influence of anything.
    Stop spousal and child abuse.
    Stop drinking fried foods.
    Stop eating fatty foods.
    Exercise regulary 3 - 4 times a week.
    Eliminate the use of personal cars and resort to mass transit public transportation.
    Stop having unprotected sex, or even at all for that matter.

    Now don't get us wrong. We're not prudes, nor are we judgmental. We engage in a significant number of the preceding activities. However, we simply believe that the American public can not justifiably have its cake (literally) and eat it too, and expect for someone else to pick up the health related determinal consequences tab!

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  12. I can't think of anyone I know, or have ever met, who does not agree that those items you mentioned are bad for you (with the possible exception of "drinking fried foods" which may not be understood). What we know and what we do often conflict. Human beings do not always act in their own best interests. Wanting to improve our health (or regain it) does not preclude our doing things which harm it. We are masters at rationalization in order to ease guilt in satisfying our more basic desires.

    To illustrate what I meant, let me talk about my diabetic relative. She is a study in conflicting desires. On the one hand, she craves all the things which she should not have. On the other she desperately searches for ways to counter her diabetes and this leads her to want to believe some pretty bizarre "remedies" or "natural" methods of controlling her blood sugar. Her problem lies in evaluating claims of efficacy with little actual training in, of knowledge of, medicine.

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  13. While lifestyle changes have a profound effect on health my understanding of the original post was to show why a government entity should or should not be responsible to provide healthcare for its citizens. No mentioned was made as to whether care should be given only to those citizens who behave in a sensible manner. Now I do understand that people do not like to shoulder the cost of those who do not behave in a responsible manner but as a nation we will pay for it one way or another. It is unavoidable. Education can help in this area of life as in so many others however we must understand that it is not a lack of information or even motivation that keeps people from quitting smoking,drinking booze to excess, eating a healthy diet. Nor does misuse of drugs, DUI, domestic violence, lack of exercise and promiscuity caused just by ignorance. Many things have to do with early conditioning and societal expectations. As an example when I was a teenager a girl caught smoking was in big trouble, one girl in the neighborhood was known as the "loose" or "bad" girl and that meant she either was having sex or at least had the reputation for doing so. There was a HUGE stigma attached to promiscuity and while that didn't insure that all the teens in the area weren't having sexual relations I assure you that the numbers were far lower than they are at present. My old roommate assures me that this is just my perception but most people in my age bracket know that I am not far off about this. Another example is DUI. Some nations take this far more seriously than we do.In the UK, driving or attempting to drive while above the legal limit or unfit through drugs or alcohol carries a maximum penalty of six months' imprisonment, a fine of up to £5,000 and a minimum 12 months' driving ban. Sweden if far stricter. My feeling is losing not just the right to drive but the vehicle as well would get the attention of the public and probably a fleet of lawyers trying to protect the rights of the reckless as well. Serious consequences for actions that endanger not only oneself but others are necessary. My point in this ramble is that while all of these things need to be addressed and perhaps be considered as part of public health we are still in a muddle of how to deliver health care. Too many fall between the cracks and then overload emergency rooms etc.

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  14. Douglas, you mentioned the issue of humans not always acting in furtherance of their own best interests. A couple of rhetorical questions: Is this part of the "pursuit of happiness" ethic? With respect to your diabetic relative, are there things that she can do which have no questions whatsoever surrounding them in terms of efficacy, so that she would not need any training in medicine?

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  15. Thanks much Ruach for leaving a comment, and welcome to our forum. We do not disagree with much of which you have said. In the second sentence of your comment, you indicated that "no mention was made as to whether care should only be given to those citizens who behave in a sensible manner."

    We here at the Institute are generally not focused on the back end. We believe that everything should be about the front end as much as humanly possibly.

    We further believe that to solve problems, we have to address them from the front end. In other words, we need to address those conditions that make it necessary to have a health care system on the back end. Otherwise we get distracted by addressing the symptoms and not the cause.

    That having been said, a major component of the American lifestyle is rooted in "free will" and the "pursuit of happiness." We once again pose the question, should "society" or "government" which are totally separate entities and concepts although merger in recent years could be argued, or neither one for that matter, be responsible for coming to the aid of anyone in society who does not have enough concern for themselves to engage in risky or hazardous behavior?

    Does anyone suggest that we as humans do not have options or choices? If that is so, then the concept of personal responsibility theoretically goes right out the window? We probably could support governmental health care if someone could convincingly argue that our actions are not the result of our decisions or choices, and that we do unconsciously do things which are not in our physiological best interests. Or someone might suggest that we are hard-wired to do things adverse to our health. Is that what proponents of government sponsored health care are arguing?

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  16. Hello again-First I want to apologise for writing under a different "handle". I use Ruach for a good many forums and list (it is short for ruach v emess , Hebrew for Spirit and Truth ) and forgot to switch to my given name when I last posted here.

    I don't believe that anyone posting here was indicating they didn't believe in free will and personal responsibility.

    The act of coming into this world is not to my understanding one's own decision. Children do not ask to be born and they certainly do not choose to be born to parents unable or unwilling to care for them. If the criteria for governmental assistance with health care is based on choice then an argument could be made for universal health care for children below the age of accountabilty ( that age to be determined in a later blog entry :)

    Some people are born with diseases or the tendency to develop certain diseases and condition such as Huntington Chorea,Tay Sachs,Spinadifia, Downs Syndrome, Blindness or Sickle Cell Anemia? They did nothing to cause the diseases. How about disease caused by enviornmental factors over which the person has no control? What about pandemics?

    As a society are we to turn our back onthese people?

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  17. Thanks much June. We suspected that it was you, although it was not entirely clear. You're very well read and typically acknowledge history, and aggregate facts to support your views. It's your signature tone and analysis.

    Quite frankly, we have not yet dealt with children yet in our comments. However, we believe that there is even an argument that they should not be provided with medical care by a federal health care bureaucracy, but we will get to that later when we actually post our article.

    Any one else out there willing to comment perhaps on those types of health conditions which should be covered and those not?

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  18. I agree with June/Ruach on many things here. I think we need basic health care available at a reasonable cost. I think that can be done in a free market. It is catastrophic needs that should be considered for the role of government. The cost of a liver, heart, lung, or other organ transplant is well beyond the means of anyone below the incredibly rich. There was a story just recently about a 14(?) year old girl who went three months on an artificial heart before receiving a donor heart. And the odds are that this heart will need to be replaced in the future. The costs involved have to be well beyond anything I can imagine. Then we have so called "orphan" diseases and all of the things that June mentioned.

    To rhetorically answer your rhetorical questions:
    I do not think this (making bad choices) is part of the "pursuit of happiness" ethic, just human nature. We tend toward the comfort or the pleasurable, not the best for us. If you read up on the Founding Fathers, you may find that "pursuit of happiness" is nothing like it's commonly interpreted.

    My relative knows she should eat those foods which do not overly impact her blood sugar. She also knows regular exercise is helpful. And she has us to remind her to follow her doctors' advice. See previous paragraph.

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  19. In what ways did the founding fathers intend it, or in what ways is it interpreted today?

    A lot of people seem to think the Constitution trumps the Declaration of Independence, when in fact I believe the two are meant to complement eachother. The Constitution is in place to give the government authority to put sanctions into our lives, and the Declaration serves as a warning for what happens when the government goes too far.

    Speaking of the "pursuit of happiness" rhetoric, many people ignore the word "pursuit" and think that they are entitled to unadulterated and unearned happiness as a human being. But in no ways is this true. It's kind of cynical, but the "pursuit of happiness" is like a hamster wheel: we see the goal but we are always running towards it.

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  20. Thanks Douglas. I appreciate your concerns about our use of "the pursuit of happiness" in our discussion. However, our issue is one of personal responsibility, and that is definitely related to the pursuit of happiness. Either people think that their individual interests are paramount, or those of society.

    It is difficult to mix the two, and allow people to pick and choose when they are going to apply which construct. It's arguably arbitrary, capricious, and disorderly. It makes it more difficult to achieve society's goals, wouldn't you say?

    Is the provision of health care the government's responsibility, or society's responsibility? They are separate things. Why not have the churches take responsibility for health care? They collect a significant amount of the money of the citizenry. Instead of building huge edifices and buildings, and having beautiful facilities, why shouldn't the religious community take responsibility for nationalized healthcare? Does the government have more of a responsibility than the religious community? If so, why?

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  21. Thanks generic Brand for weighing in. We welcome all input. The debate about whether our foundational documents should be interpreted in light of the conditions extant at the time of their generation, or be living documents evolving as society evolves, will not be solved here. However, there is little doubt that an environment were individual liberties, freedom, self-determination, etc. exist bear on where a society ultimately finds itself.
    With freedom comes certain responsibilities, and we're not quite sure that the country still appreciates that.

    We thoroughly agree with your comment that many think that they are entitled to unadulterated and unearned happiness as a human being. Many in this country seem to perceive a nationalized health care system as something to which they have a right or which they should be entitled. It just seems to us that there has to be a better way to create a healthcare system than leaving it up to the same politicians who have guided us through the latest 35 - 40 years of our nation's history. Are politicians different from government? Why haven't any of our failed governments been fired for mismanagement of funds and programs? We require accountability in business, why not in governance?

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  22. Many of you have passionately argued for the retention of at least some portion of our current health care system, with some modifications. However, virtually no one has suggested any radical changes or a totally new concept.

    We are reminded of a comment by Mike McConnell, the Director of National Intelligence, earlier in the week. He essentially said that any large organization, or bureaucracy, will redefine "reality" to ensure its survival and self-interests. Consequently, oversight becomes very complicated.

    Let's talk about some new things. Should we scrap the whole system? Should we scrap the whole system and provide healthcare benefits to those below a certain age, or to those who did not have any decision making role in the way they conducted their lives, or chose what they consumed?

    Who should be the head of a system which provides benefits to a 300 million patient base? Who is qualified and what should we pay that person? Should we leave it up to the states to administer the system? Should we have employment contracts with all of those involved in the administrative system and when they fail to deliver the promised benefits, should we fire them? Should administrators of this new system be subject to legal or civil liability for their failure to perform? Should the payment of administrators be tied to their success in improving health? Should failed administrative people have to return their income received if the execution and management of the system is inefficient or ineffective?

    What incentives should be built into the system to ensure that people have some personal motivation to stay healthy? Are there some healthy lifestyle choices upon which we can all agree to which all should be held accountable? We have lots of complaints and criticism as citizen / recipients? Apparently that suggests that many of us feel that we are qualified to criticize or can perform better? Tell us how you would design this new health care business model?

    Would you rank or prioritize medical conditions in terms of severity and then apply budgeted funds accordingly? Would you offer bonuses to students to study medicine? Bonuses for practicing certain types of medicine? House and feed doctors and take care of their personal expenses in exchange for the delivery of services for a specified period? Instead of rewarding doctors monetarily, how about providing them with public service credits and awards? How about using our current prison population to serve as health care workers, or perhaps our current homeless population? How about inviting health care providers from other countries to immigrate into the US and serve our system in exchange for citizenship?

    We grand designers of the world, tell us something specific. Then tell us why taxpayers should have the responsibility for the taking care of the healthcare of others.

    By the way, by indicating that we could present an argument as to why the government should not have responsibility to provide health care benefits to its citizens, we did not indicate that we did not consider it to be in the long term interests of the country to do so. However, in order to design an approach to any problem, it seems to us that one must thoroughly explore the reasons not to take such an action. We believe that it results in more creative and innovative solutions. Small tweaks of the status quo does not.

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  23. Free national healthcare for all. No billing. Some people will consume more, some by their own poor lifestyle choices. So what? They are the ones suffering the self-inflicted miseries of the poor choices. It's also not easy to be the judge of what's risky. I read an article recently about aging boomers being very active and getting serious injuries.

    Did anyone chiming in here see Sicko? I am the first to admit that Moore has his own propaganda agenda through which his lens always focuses. But I found many sensible answers to the many questions posed above. No pay? No billing, no bureaucracy for billing. No worry about whether benefits will be paid or not. Everybody gets treated, nobody pays. I've paid about 1/4 to 1/3 of the state and federal taxes over the past few years to buy health insurance for my family. I would gladly pay that much more in taxes to get a free national system. All doctors and other health care providers in all disciplines work for the government. Liability? The medical profession beat the snot out of the lawyers over the past 30 years. Sizable med mal jury verdicts are few and far between.

    Suppose we start providing quality mental health care to the tens of thousands of incarcerated people who could really benefit from it and become useful to society as result of getting the same kind of quality psychotherapy Woody Allen and I have been getting much of our adult lives?

    Or, we can waste our time wringing out hands and watching the poor dropped in the gutters outside of our hospitals because no one will pay for them to get dignified care. I know Logie - they got poor on their own, they gotta live with the consequences of their poordom. I just wonder what happens to most people who are just not used to be treated with dignity when you start to treat them with dignity, whether you think -- based on our capitalistic/arbitrary measures of a person's worth -- they deserve it or not.

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  24. Thanks stever for stopping by. Free national healthcare with no billing, and thus no administrative expense associated therewith. Hmmm. We're not sure what the cost will be, but at least it is a radical and novel approach. There's alot to be said for the elimination of the bureaucracy.

    By the way, as much as we talk about personal responsibility, we don't think that all of the poor got poor on their own. Very much to the contrary. In a free for all competitive environment, without much structure, regulation, and restrictions, there are GOING TO BE some winners, some also rans, and many losers. It's simple social Darwinsim. It depends on your circumstances, your education, your support system, your geographic location, your health, your time, your age, and at least 57 other factors.

    What is ludicrous is to argue that all people are similarly situated and thus have the same opportunities and chances. That's simply not the case. However, when you choose to go with the free for all competitive construct, and accept the benefits of that, you implicitly agree to accept that there will be some casualties. We as Americans need to learn that we can not have it both ways. It's the problem associated with having your cake and eating it too.

    It's a tad disingenuous to support the system when you are a winner, and complain about it when you become a loser. Decisions need to be made and lines drawn. We're not good in this country at drawing lines. It would be an advancement for all of us to know what the deal is with respect to healthcare going in. That's what we advocate. Some clarity, some focus, and some planning associated therewith.

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  25. Stever - TANSTAAFL. Free healthcare is no more real than free highways. There is always a cost to an individual or to society as a whole even though that cost may be hidden or distributed. I believe that things need to be streamlined but to have NO billing system is to block knowledge of what things are costing the system. I don't believe it would work even as the present system does not work.

    In choosing what we as a society do about healthcare in this country we can look to other nations for guidelines but we need to remember at least two things while doing so. First, our model can never be exactly like that of another nation because our demographics and lifestyles are not exactly like any other nation and Secondly, that what seems to be working elsewhere is not always working at a level that we would consider to be adequate. Our neighbor to the north has a comprehensive and VERY expensive national healthcare system. Canadians though they are loath to admit it seem to be closest to the U.S. in lifstyle and economy. The Canadian system has caused a rush-to-the-border phenomenon among Canadian who would rather drive from Torornto to Buffalo or Sault Ste. Marie to Michigan to be seen immediately for health needs that would leave them on long waiting lists inside the Provinces. Canadian rates vary from Province to Province. Ontario, the most populous, spends roughly 40 percent of every tax dollar on health care, according to the Canadian Taxpayers Federation. How many Americans would be willing to shoulder an extra 25 percent in tax to pay for that sort of sytem?

    Not that we don't need reforms. If things were peachy here we wouldn't be having this discussion and we wouldn't have Americans (of the U.S. variety) going to Mexico for medications and all sorts of countries for "medical tourisnm".

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  26. Should we scrap the whole system?

    No. We should revisit the time things started to go downhill. That occurred when HMOs and managed health care plans took over. Twasn't always the case.

    Should we scrap the whole system and provide health care benefits to those below a certain age, or to those who did not have any decision making role in the way they conducted their lives, or chose what they consumed?

    Not exactly. Perhaps provide alternative affordable basic health care which can be facilitated by employing an even greater number of nurse practitioners and physician assistants. Also having more provisions for catastrophic health care.

    Who should be the head of a system which provides benefits to a 300 million patient base? Who is qualified and what should we pay that person?

    I've no idea who should head such a system as I am not in favor of a govern metal system to cover 300 million plus potential patients. If there were such a system I would hope to find it run by physicians. Someone who also has demonstrated plenty of administrative skills. The salary could never be commensurate with the job. It would have to be someone who is doing it for love of country and dedication to patient care.

    Should we leave it up to the states to administer the system?
    OhGodNO. Imagine the disparity between care for the average Joe or Jane in Mississippi versus that in Vermont!

    Should we have employment contracts with all of those involved in the administrative system and when they fail to deliver the promised benefits, should we fire them?
    YES


    Should administrators of this new system be subject to legal or civil liability for their failure to perform?
    No, they should get fired if the lack of performance is due to their negligence and given a raise if the problem is die to the structure of the system (provided they were not responsible for its design)

    Should the payment of administrators be tied to their success in improving health?
    NO. This to me is very much like saying the principal of a school that is performing poorly should be chastised on the basis of test scores alone. If you are starting with children who are seriously deprived of basic skills and/or familial support how can you expect the same result as you can find in an affluent school with every support from family to access to the latest technology. Inner city schools teachers have to outfit their classrooms out of their own funds and they have children who walk into kindergarten without knowing how to hold a crayon or pencil. So it is with medical administration in such a system. The poor and the uneducated will be in certain districts and how can we expect the performance in those areas to be on a par with those areas whose affluent citizens work out at the gym, make an effort to eat healthy, well balanced meals, and on the whole have fewer instances of violent crimes and accidents occurring?

    Should failed administrative people have to return their income received if the execution and management of the system is inefficient or ineffective?

    Only if the same prevails in private industry. Why should they be judged any harsher? We would want to attract halfway decent people to run this sort of thing wouldn't we? Personally I wouldn't mind seeing that happen if indeed it occurred in the private as well as the public sector.


    What incentives should be built into the system to ensure that people have some personal motivation to stay healthy?
    Many. How about if a person does all the right stuff and hasn't cost the system a dime in twenty years then he or she can have one cosmetic procedure of their choosing? :) OK , can't we have a little laughter here?

    Are there some healthy lifestyle choices upon which we can all agree to which all should be held accountable?
    Probably not. In an ideal world the answer would have been yes but we don't live in an ideal world. People are forever seeking to lay blame on someone other than themselves and will say these things aren't choices. The tobacco companies put extra addictive stuff in cigarettes..they did but I don't smoke. The fast food companies saturate the airwaves with commercials and even get into schools..they do but it isn't their fault that I'm eat too much of the wrong stuff.

    No, I'm afraid we all won't agree but it doesn't mean their shouldn't be acceptable standards of behavior.

    We have lots of complaints and criticism as citizen / recipients? Apparently that suggests that many of us feel that we are qualified to criticize or can perform better? Tell us how you would design this new health care business model?
    Redirect the funds being spent on paper pushers to actual care. That means putting HMOs and managed health care plans to the test. I would want health insurance available to all made more affordable by spreading risk. People need to see where there money is going and by taking charge of who they spend that money with they will start to find out that so many of those bright and shiny plans really don't deliver because the funds are funneled away from health and medicine into glossy brochures and vast bureaucracies

    Would you rank or prioritize medical conditions in terms of severity and then apply budgeted funds accordingly?
    Wouldn't that be better for physicians to determine?

    Would you offer bonuses to students to study medicine?
    I would offer student with the aptitude low cost or no cost loans to get through medical school.

    Bonuses for practicing certain types of medicine?
    No. It would draw people ONLY interested in more money.

    House and feed doctors and take care of their personal expenses in exchange for the delivery of services for a specified period?
    Yes

    Instead of rewarding doctors monetarily, how about providing them with public service credits and awards?
    Nice but would they be interested?

    How about using our current prison population to serve as health care workers, or perhaps our current homeless population?
    Wait..I'll get my magic wand and make them all qualified to do so.

    How about inviting health care providers from other countries to immigrate into the US and serve our system in exchange for citizenship?
    We already have a huge number who are doing that already. I haven't been hospitalized in North Carolina but in New York more than half the staff were foreign.

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  27. This is a fascinating discussion but it seems to be going about the way most politically oriented discussions go; in circles.

    My opinion:
    We do not need to scrap the system we have today. As bad as it is claimed to be, it is also one of the best in the world. It has its flaws, like all systems, and it has its successes, like most. People in Canada, which has a system often idolized, come to the US for treatment because we provide it faster and we provide treatment not available there. Consider that before jumping on a single payer or national health system.

    What we need to do is improve the system, not overhaul it. And what we don't need is to turn healthcare over to a bunch of bureaucrats. Government should guide by expressing the will (or consensus)of the people, it should not control human endeavor in all aspects because people are unhappy about a current trend.

    Aside:

    "Pursuit of happiness" meant the freedom to live one's life in a manner that was consistent with the mores and traditions of that period. One needs to examine context. They did not view it as license. It was seen as a right to pursue an individual's goals in life without government's dictation or interference but within reasonable constraints of civility and social responsibility.

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  28. June, June, June, thank you, thank you, thank you. NOW we are beginning to talk about crafting solutions from an analytical perspective. Not just about wants and desires, and complaints and frustrations. Your beginning to perform a comparative analysis is a great start. We'll get back to the details. Thanks.

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  29. Hi Logistician,
    I’m jumping in on the end of this conversation -but I’d like to address your original questions:
    “Is it really the government's responsibility to ensure the good health of, and the provision of health care facilities and treatment to, its citizens?” =
    I think this is two different issue. First -I think it’s mandatory we all take responsibility of our own good health and I think June’s statement of ‘the power of education and preventative care’ is the key.
    Second- No - I don’t think that medical care should be socialized -on the Government ticket just because we’re ‘tax payers.’(We'd pay for it anyway-just with higher taxes) Our government already provides Medicare and other free services (on the taxpayer’s ticket) for those that can’t afford public insurance.
    Granted Medical care is by all defintiion a service provider- but so are Exterminators, Gardeners, Utility companies and garbage collectors, etc.
    The problem is simply that the cost of medical insurance and doctor visits is at all time high (out of control) making it unaffordable for majority. Our government presently does put caps on what certain ‘services’ can charge in many areas of our ’free enterprise society’. Unfortunately, I really think that may be the only answer.

    “What responsibility should be placed on the citizens themselves to make the "best efforts" to maintain their health, and utilize the very latest in scientific knowledge about health risks, particularly nutrition, and the detrimental consequences associated with certain behaviors? “ =
    Total personal responsibility- I analogize this to car insurance premiums. If you are prone to a lot of car accidents, your insurance rates are going to sky rocket and potentially get canceled if you don’t change your driving habits. That’s not a bad idea.

    “Should citizens be required to show that they engaged, or failed to engage, in certain behaviors, prior to being extended heath care benefits by the government?”=
    Twenty years ago, many health insurance companies required applicants to have a full medical exams before approval. Today insurance companies advertise : No Medical Exam required.

    My neighbor is easily 400lbs. Her 27 yr old daughter is 250lbs. They told me recently that their grocery bill was averaging $300 a week. (by comparison to mine -$35-$40.) They both have acquired diabetes. They tell me that it ‘must be genetic.’
    Vikki

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  30. And BTW my analogy to 'car insurance' is in no way applicable to individuals who contract disease by no means of their own. I'm referring only to people who neglect their health through poor nutrition, smoking, drinking etc.
    Vikki

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  31. Very nice and thoughtful analysis of the many of the competing considerations June, and most noticeably, you examined each issue separately, and did not adopt a philosophy along one train of thought. It should prove to be ample food for thought for others to consider.

    Upon examining each of your responses, not one single one of them seemed to be irrational, or even motivated by self-interest or by the limitations of your experience. We as citizens, need to do a better job, which you have done here, of considering issues beyond those which affect us directly and those of which we think that we are aware. (Earlier today, I was engaged in a conversation with someone intimately involved in the auto industry for roughly 40 years, who explained many things about the industry of which I was not previously aware.)

    We will not examine each of your positions at this point. However, we will make one note. I studied industrial and systems engineering as an undergraduate, and specially the application of those principles to sectors of the economy with which they had not been previously associated, such as transportation, government, hospitals, and education. One of my professors was one of the designers of the HMO concept. It is important to remember that HMO stands for Health Maintenance Organization.

    The original idea was to get folks to come in regularly and receive lots of guidance regarding nutrition and preventive measures, and in theory, by catching problems early, the costs would be significantly reduced. The preventive maintenance concept never really caught on with patients. They still had a tendency to come into the ER once things got really serious, and also complicated.

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  32. Thanks much for your comment Douglas. Your statement to the effect that the "discussion ... seems to be going about the way most politically oriented discussions go: in circles," is of interest to us. Are you suggesting when you use the descriptive political, that it is partisan or polemic in nature? That it is ideologically oriented without attention being paid to the ultimate recipient of the health care? That the influence of the medical care lobbyists influence the thought process?

    Moving on to the "circle" issue, are you suggesting that nothing useful is generated during such an exchange of ideas? That one comprehensive plan detailing all of the competing issues should have been put forth by someone by this point? That there is no value to breaking down the issues and addressing them separately?

    If you have the opportunity and resources to overhaul a system, should advantage of such be taken? Should be always employ piecemeal fixes to societal or governmental problems?

    Here's our view on the pursuit of happiness issue. We'll actually use your words, "the right to pursue an individual's goals in life without government's dictation or interference." If that is the case, isn't it contrary to that principle that the government get involved in the health care system, take tax payer money to support it, and not pursue the individual's goal with respect to same?

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  33. Welcome to the forum Vikki. We're pretty much in agreement regarding personality responsibility for our own good health, and the power of education and preventative care. A question: Do we not now, as a nation, provide lots of information to our citizens (i.e. education), and conduct various programs with respect to preventative care? Is the current level of education insufficient? To what extent do our citizens pay attention, care, or are they distracted by other forces?

    You mentioned that the cost of medical insurance and doctor visits is at an all time high. To what extent do you think that the utilization of cutting edge technological equipment and procedures contributes to that? Would we rather have a system with more basic equipment and procedures, lower tech, but available to more people?

    We like your car insurance analogy.

    As you are aware, we're big on considering whether genetics and hard-wiring play a role in the human condition. Would a determination, by a scientific committee of some sort, of the various diseases or conditions which are genetic as opposed to environmental, assist us in determining how to parcel out the care or benefits?

    One thing occurs to us at this point. We, as individuals, usually do not appreciate, on a day-to-day basis, the numerous issues involved in such a system, and all of the different decisions that have to be made. The typical one of us just wants the system to work for us according to our needs or those of our loved ones.

    Thanks for further stimulating thought in this regard. We appreciate it.

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  34. Log, I am suggesting by my "circles" comment, that we are rehashing the same things over and over. Nothing partisan about it in this case. We all know what is wrong with the health care system, we generally agree on what needs to be "fixed". We have few ideas about how to fix those things. When we speak of "universal health care", we get vague. When we talk about how to pay for the concept, we get vague. We don't want a bureaucratic system but that is all that government is; a bureaucracy. To make any solution one run (or administered) by government means it will be, by nature, bureaucratic. Records must be kept, services monitored for quality and efficiency, budgets must be audited, and so on.

    Someone wrote twice about Moore's "Sicko". In that film, he praised Cuba's health care system. Indeed, it seems to be praiseworthy. But is it? We don't really know, do we? Doctors within that system make about twice the average income of Cuba, according to an article I just read. We know that they are short of medicines and do not have the latest technology (which they falsely blame on our embargo). So, is it a better system? I am not so sure. The waiting in Canada and the UK for routine procedures is incredible, something we wouldn't stand for here. Our problem with health care in this country is one of cost. It is not one of quality, efficiency, or availability. We should not give those things up in order to take the cost burden away.

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  35. Douglas-Quality, efficiency and availability vary to a scary degree in this country. I'm not just talking about the disparity between the wealthy and the poor. The loss of doctors in the heartland and in rural areas and rustbelt areas is phenomenal. The percentage of doctors from foreign countries staffing hospitals and the resulting problem of communication between patients and physicians is so systemic that you can hear jokes about it by stand up comics. The cutbacks on lab staff by hospitals have left patients in danger that most people aren't even aware of. Doctors are leaving the profession in unprecedented numbers. Driven out by the cost of keeping up with the red tape of a multiplicity of insurers and health management organizations.

    Logisitician-I know that HMOs were intended to maintain health by the means you mentioned. They didn't succeed or we would not be having this discussion. Was the problem the design? Yes,I think so. They had to know this was to be designed to work with humans and if the human factor wasn't taken in to consideration then it is as bad as designing a spacecraft without retraining belts for the passengers.

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  36. Fraudulent claims, and Fraudulent people who clain=m injuries at very young ages to collect early pensions and medical for them and their family is beginning to tally up to a large sum of good hardworking people suffering for it. Great blog log.

    KONYH

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  37. Thanks much Douglas for the clarification on "circles." Quite a few novel suggestions have been put forth by many people. We would probably agree with you that most have been discussed; however, most have not been placed into practice.

    Something new obviously needs to be done.

    As for Cuba, I had a number of friends who were citizens of South America countries who used to travel to Cuba regularly. They generally described Cuban citizens in this way: No one looked like they had excess, and no one looked like they were struggling just to get by.

    Our Russian friends, in describing the difference between "things," in general, in the U.S.S.R., as opposed to the U.S.: If you were an ambitious individual, and really hustled, the U.S. was a better place; if you were an ordinary person who was comfortable with a simple, subsistence level of existence with the basic necessities, the U.S.S.R. was a better place.

    We would suspect that how one views any system, both domestic and foreign, significantly depends on you are on the socio-economic ladder, and the "options" available to you.

    A couple of other things. This does not apply to you, since if we recall correctly, you had the good fortune to visit some foreign lands during your youth and during your Naval career. As you well know, it is one thing to visit a country. It is another to actually live there long term. I've always been amazed how so many of our citizens express judgments, both pro and con, with respect to conditions in our country, as opposed to other countries, without ever stepping outside our borders.

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  38. Ruach, thanks for your input once again. We are glad that you brought up the issue of the wide disparities in different parts of our country in economic conditions, which translates in dramatic differences in terms of health care delivery.

    During most of the Logisitican's professional career, he traveled throughout many sections of the country. He often remarks the people in certain parts of our country have been in a depression since the late 1970s.

    We continue to focus on the relative size of organizations, and the notion that once a certain critical mass is reached, the ability to control it becomes more difficult. In the case of medicine, the delivery of the services ends up taking a back seat to the administration of the service.

    You suggested that "humans" failed to behave in accordance with expectations in the design of HMO's. You're getting much closer to why an argument can be made that no health care services should be provided by the government at all, except for vets and those injured during the line of service for the nation.

    We suspect that it is theoretically impossible to design a system in which humans will behave in a manner that make the management of the system really "work."

    Should we just accept an imperfect system?

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  39. King of New York Hacks, welcome to the forum. There are all sorts of fraudulent activities which affect the system and its ability to deliver services. It is definitely a factor.

    You bring up an interesting point about "hardworking people." Should all people who equally hard receive the same level of services? Should those who pay $10,000 in taxes, receive the same level of care as those who contribute $100,000, or $1 Million? Should those who never utilize the system have their tax money used to treat those who have frequent and significant needs?

    Thanks for the compliment on the blog. We're just trying to stimulate some thought and hopefully some new ways of looking at issues.

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  40. I recently came across your blog and have been reading along. I thought I would leave my first comment. I don't know what to say except that I have enjoyed reading. Nice blog. I will keep visiting this blog very often.

    Sarah

    http://www.thetreadmillguide.com

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  41. Thanks for checking in Sarah. It's always good to come across folks who have already been partaking of our "stuff." Do visit often, and jump in when you feel the urge to do so.

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  42. Thanks for checking in Sarah. It's always good to come across folks who have already been partaking of our "stuff." Do visit often, and jump in when you feel the urge to do so.

    ReplyDelete
  43. Fraudulent claims, and Fraudulent people who clain=m injuries at very young ages to collect early pensions and medical for them and their family is beginning to tally up to a large sum of good hardworking people suffering for it. Great blog log.

    KONYH

    ReplyDelete
  44. King of New York Hacks, welcome to the forum. There are all sorts of fraudulent activities which affect the system and its ability to deliver services. It is definitely a factor.

    You bring up an interesting point about "hardworking people." Should all people who equally hard receive the same level of services? Should those who pay $10,000 in taxes, receive the same level of care as those who contribute $100,000, or $1 Million? Should those who never utilize the system have their tax money used to treat those who have frequent and significant needs?

    Thanks for the compliment on the blog. We're just trying to stimulate some thought and hopefully some new ways of looking at issues.

    ReplyDelete
  45. Douglas-Quality, efficiency and availability vary to a scary degree in this country. I'm not just talking about the disparity between the wealthy and the poor. The loss of doctors in the heartland and in rural areas and rustbelt areas is phenomenal. The percentage of doctors from foreign countries staffing hospitals and the resulting problem of communication between patients and physicians is so systemic that you can hear jokes about it by stand up comics. The cutbacks on lab staff by hospitals have left patients in danger that most people aren't even aware of. Doctors are leaving the profession in unprecedented numbers. Driven out by the cost of keeping up with the red tape of a multiplicity of insurers and health management organizations.

    Logisitician-I know that HMOs were intended to maintain health by the means you mentioned. They didn't succeed or we would not be having this discussion. Was the problem the design? Yes,I think so. They had to know this was to be designed to work with humans and if the human factor wasn't taken in to consideration then it is as bad as designing a spacecraft without retraining belts for the passengers.

    ReplyDelete

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