Two Letters Aug 27, 2009

Here are two letters I wrote today. The first is to Paul Krugman asking him to reply to those who whine about deficits and government intervention. The second, in a similar vein, is an email I sent to C-Span directed to M. Scully who was happy to point out the failures of our present private insurance versus Medicare but continues to insist on free market solutions:

Dear Dr. Krugman,

The problem, like in the commentaries to your article on the deficit, belonging to the opposition goes over their head unless it is spelled out in their own lexicon. This includes phrases like passing debt onto future generations, etc. Always missing in the conversation is the productivity of our workers and the hope it will produce more full fledged tax payers eventually. Also since it is the top 10% of income earners that will benefit most from the present programs, it is understood they will pay for it through higher taxes eventually. Like any debt. it is incurred, does its work, and then is paid for.

You just wonder who the real capitalists are anyway. The present whining group against the deficit and health care reform have no faith, it seems, in the future earning potential of our citizens given the proper education, training, and support. Health care reform, itself, especially Medicare For All, enables greater availability of capital, better workers, and higher profits and incomes. It should be a capitalist's wet dream. Instead they cry socialism when it is they who so readily seek government largess when they are in trouble. It is time to identify who's who. Those of us who want real reform is because we are capitalists. Those that don't are asking for even deeper government socialist intervention. Who's kidding who? Dr. Krugman, your style of writing carries weight and clarity. Could you illuminate this in an article directed to these phony capitalists and erstwhile socialists in sheep's clothing? The tongue is in the cheek but I hope you understand what I mean.

By the way, c-span had an excellent 3 part program on Washington Journal going over all parts of Medicare, A though D. It was wonderful and eye opening. It should be mandatory viewing for every concerned citizen, our President, and all members of Congress.

Dear Washington Journal:

Sorry I couldn't do this on air but wish to thank c-span for presenting these very knowledgible people on Medicare to the public. Hopefully it will make issues clearer as we move forward in the health care debate.

I am a Single Payer supporter and the rationale for this became even clearer this morning. The discussion between the two participants weighted the arguments towards a Medicare For All system. More money for services would be available by avoiding the overcharges by the private sector(some $400 billion dollars) and a simplification of the process as all parts along with the rest of our citizens would be rolled into one. Mr. Vldeck actually endorsed the role of private insurers in the Medicare system as claim processor, their only valuable participation, at an extremely competitive price for its users. He even acknowledged supporting private efforts to coordinate care and paid for by our government if it removed unneeded excess. These are proper uses of the capitalist system in its payment mechanism for health services. So if you ask me, Mr. Scully should rethink what capitalism's proper place in society is. The answer may move him to Mr. Vldeck's side of the equation and we'd all be better off. How many times do the so called free marketers get a chance to impoverish and cause unnecessary death of our citizens before they realize they are shooting themselves in the foot. They are causing harm not just to others but to themselves and their families now and in the future.

To The Workers In The Health Insurance Industry

It must be disheartening if you are one of the many employees of the health insurance industry to feel the resentment of policy makers and fellow citizens. The industry you work in is being blamed for a lion's share of the cost overruns of the health care expense in this country. However you are not to blame since you are, like any other loyal citizen, trying to earn a decent living for your family. The problem is the companies you work for have not fulfilled the bargain that established them. HMOs were created in the 1970s on the idea if people were guided properly through the health care system with a primary care gatekeeper and offering inexpensive preventive care everyone would be a winner. It didn't turn out that way. Those in your management embraced a model that no longer serves your fellow Americans well. It did for a few years but when they started to be more on their own, adding bureaucracy, and making deals that were too costly and consequently cost shifting to the subcriber, an ongoing era of double digit premiums ensued. Of course I'm sure a different view was portrayed in meetings and memos but ultimately it is clear that the path chosen by company executives has added expenses that no longer can be sustained by the general population.

To cover their tracks you were told it was the government that was the source of their problems. Medicare and Medicaid were not pulling its fair share according to their view. This is not true and in fact the current drastic situation would have come sooner if Medicare hadn't balanced out the shortcomings of HMO's business plan. For years your government was paying 130% of costs to hospitals, allowing heavy discounting to corporations such as yours. The spicket dried up in the 1990s with the Balanced Budget Act. Medicare reduced its payments via a DRG system to establish payments that paid essentially for costs. Since the insurance companies were no longer pulling their load, negotiations with the hospitals resulted in higher fees for their services. So now insurance companies had to increase their enrollments or cost shift to employer clients and subscribers. This process included some very expensive deal making inflating company negotiating and marketing teams. You should know that bureaucracy in private insurance has grown 1500% over the past 20 to 30 years. An astounding number.

All this is not your fault. However it must put a scare into you that moving to a more centralized efficient sytem will mean loss of jobs in your line of work. It cannot be sugar coated, this is true. The private health industry as it now constituted is dying. However there must be an effort to value your work contributions and no reform should take place if it adds to your misery. This would be highly unfair. This will take leadership from the President and proper action from the Congress. A tall order, I know, but not inconceivable. Other countries have made this transition and, quite frankly the handwriting is on the wall, There are too many people working in the insurance business to be sustained. It is no longer serving the needs of society. HR676, the Medicare For All Bill, now in the House of Representatives sets aside $20 billion dollars recognizing that layoffs will occur and provides for training and movement to more up to date services. If those of us who want to fix health care payment neglect you, our fellow citizens, we have not fully accomplished a fair solution to this problem.

There is a silver lining. Your own health insurance will cost less and the societal savings overall will allow entrepreneurs or present businesses to hire more people, create new positions, or even raise incomes. That would certainly be nice for a change. In this entire health care debate, you are the forgotten people and as a fellow countryman, your very survival should be part of the picture. We can not substitute one kind of suffering for another if it can be helped. Please join us in the Single Payer movement for the sake of your future, your family's future, and the future of your nation. We need your voices also to make sure you are not left out or mistreated for the work ethic you have shown. However there is also a caveat. Without changes the problem will grow and you will be left in a high and dry situtation. This must not happen.

Condolences to the Kennedy Family

In deepest sympathy for your loss and ours. I named my little 12 foot portable boat that I take out into Nantucket Harbor adorned with scratches and stains, "Almost Perfect." Although somewhat battered, it takes me to those most beautiful parts of the Island that are out of view for most visitors to this Isle. It is this kind of conveyance I saw in our senior Senator. Buffeted by life's rough obstacles, he led the way to better lives for so many. Rest in peace, Senator, you did good, almost perfect.

Private Health Insurance, A Free Market Failure

Dear Dr. Herrick, I, myself, am not arguing that health care is a “public good” or “public utility.” Health care is a human necessity. When people are sick or want to keep themselves well this is the service we almost all rely on. Is there any doubt in your mind that this is so? If impoverishment and death is the outcome when it is not available because of inability to pay, this really begs the issue. This suggests it is not following market place rules. Businesses are suppose to enhance wealth both to its owners and its users. I would refer you to Kenneth Arrow’s treatise on why health insurance does not fit the usual competitive model of the market place. It can be easily googled.

You could set aside money your whole life and still be behind the 8 ball if you get sick. Instead of hoarding it in this manner why not pay for meaningful insurance according to your ability to pay through a central mechanism. This removes the worry and tension and fulfills an essential part of the social contract. Rich or not so rich benefit when the population is as healthy as it can be. Thomas Paine: “No one joined a society to be worse off.”

To some extent everyone agrees treatment can not be withheld from anyone. People cannot be refused care in an ER or hospital whether they can pay or not(sort of like your defense argument). However this approach is both an overly expensive and insufficient way to deliver care. It would be less expensive and more life saving to give this group of people health insurance.

Public Health is already an accepted necessity. In addition without individual care in the range of affordability and accessibility our survival is in danger. I have already alluded to the numbers of dead and the loss to the economy because of our present system. It just stands to reason if everyone has this need but its costs in the society are too great, then a government imposed tax and/or regulations to pay for it is the next logical step. Will there be problems or complaints? Undoubtedly, but we in the US do not even come close to the 86% satisfaction rate of Canadian Medicare, for example. Anecdotal horror stories aside, reports from other developed countries echo this result.

By fixing this major hole in our economy we will provide more capital and opportunities to private entrepreneurs. Wasn’t it health insurance premiums for employees active and retired that helped sink GM?

Simply put, a rational health care system is presently out reach financially for too many people. It is time for Medicare for all.

To A Rugged Indiviualist On Gov Reform of HI

Dear Tom, It is naturally a political question and it is a question of finding the rosetta stone issues that cut across wide swaths of the population. There must be general agreement that it is not available adequately in the market place of the society. At no time do I think the government should intervene in every deficiency in society. However problems such as education, health care, mass transit, research, adequate defense can not be supported adequately by private means. In other words it is a legislative debate painstakingly leading to laws. The process will be ongoing because this is the messy business of a democracy.

Hopefully by choosing what keystone issues to adopt so opportunity is restored to marginalized populations and the true business of society, dealing with people's needs and wants, can be reasonably provided by individuals and companies. The idea is to improve opportunity not squelch it. You feel government interferes. I do not. Programs like Social Security and Medicare have provided the funds, not actual choices how it is spent within the limits of what is available to spend. It is certainly left to individuals, if they so wish, to embellish this if they can afford it. No one is or should stop you from doing this. The government just provides a floor. If it is wasteful, of course, it will have to be changed. Finally you live in a society with the social contract that assumes you participate because you believe it is necessary for your survival. If it is not doing this it must be addressed or you die.

You can live with a hole in your shoe but you cannot live with a hole in your heart. Twenty thousand of your fellow citizens die a year from lack of health insurance. Sickness incurred by the uninsured leads to non-productivity and higher unnecessary expenses or lack of production. Health care is a critical asset to the individual and the society as a whole. It should not be for sale. We should all pay for it. If you carry individualism to a certain place, it means moving back to the caves. However, I actually want what you want and since presently the private approach is costing us all $400 billion extra and there are proven models in the world to show a centralized system of payment, not delivery or managing health care, provides superior general care at a lower cost. Can't we at least give it a try? What we have now will bankrupt us in a generation. You think the government debt is bad now, just wait when the number of tax payers becomes even less.

The Swiss and the Germans actually provide health insurance with private insurers, if that is your preference. Medicare payments, incidentally, are actually done with private insurers following Medicare rules. The overhead is 1.5%. If true health care reform fails OK we'll go back to doing it to what the opposition suggests. However, like Medicare, I believe it will pay off in spades for all of us. My father was a Scot and my upbringing was in backwoods of Newark, NJ. I am certainly not looking to squander my money or cutting off any choices I wish to make or have gained. Yes I value my freedom as much as the next guy. I just happen to believe it is enhanced by widening the tent as the founders stated, "We the people.....in order to make a more perfect union...." I do not believe if someone is doing better I must have lost something. I actually think if things are working right, I should be better off.

By the way I have bought and sold several companies successfully, owned a few homes, paid off many loans, financed my childrens' education on my own. Therefore, I still consider myself an ethical capitalist. However I am also a "commonist survivalist." I could not have succeeded without others including my government.

Now I have answered you. I understand you may view life differently so the back and forth will continue. However if my view prevails it will not be because I wanted to harm anyone, in fact, quite the opposite. It comes from my knowledge and experience that tells me it will move us forward to a better place.

So Tell Me What Do You Propose?

Everyone suddenly points to government as the source of their impoverishment or lack of needed services. Pulling out costs that may exist or stating "hidden costs" in government programs lacks the power of evidence to make it stand up to the barest criteria for either a legal or scientific basis.

It is not government programs that have ignited this present crisis in the economy or health care. So if we remove Medicare, Medicaid, the VA, and the Indian Health Service from the equation what is your solution to reform health care? Obviously you are aware that I think a updated and improved governmental program is necessary. Article I, Section 8 of the Constitution gives Congress the power to promote the general welfare. Health care access and affordability(health insurance) falls into this catagory and should not belong to free enterprise. I am not saying the deliverers of care should not be private and entrepreneurial but this also demands strong ethics on their part or there should be strong penalties. It is time for those opposed to government intervention to put their cards on the table. So far the proposals increase the bottom line of what we pay for health care and continue the slow decline of the general business of this nation. People overwhelmingly want reform in this country. You will have to tell me how the history of the HMO movement and other private insurances have proven their value to this country. There is no there there.

Matt Taibi: The Only Way To Health Ins Reform

Matt Taibbi, an investigative journalist for Rolling Stone Magazine, has written on the failure of government, even present government, to do the critical work of the nation. We need a National Health Plan. Without it, 20,000 people a year die, and over 60 million are uninsured or under-insured. Without it medical bankruptcy occurs making up over 70% of bankruptcies.

Those of us in a comfortable position continue to think we are unaffected by this. However our current crisis was fueled not only by greed but also because of the poor resiliency of citizens at the lower end of the income scale. The cascade of events eventually threw people out of work who thought their jobs were secure. Having the cushion of reasonable health care for all would have softened this blow. We are now stuck for years to come unless we get real about providing Medicare for all.

Here is the link to Taibbi's article, please view the 3 videos to get the gist of this problem: http://taibbi.rssoundingboard.com/health-care-reform-sick-and-wrong#

This is Comptetion?, Boston Globe, Aug 16, 2009

Ah competition, the wellspring of all our prosperity. Is this how we get anything done at the least cost no matter what? In some arenas it takes a nasty turn that is actually detrimental to the claims it wishes to promote. Some of this was visible in an article in the Boston Globe today. It's title, "You Don't Want To Go To War With Me," although exaggerated, lends some insight into the reality of who the so called competitors in health care delivery are and what they compete for:

http://www.boston.com/business/healthcare/articles/2009/08/16/hospitals_aggressive_recruiting_efforts_in_spotlight/

Apparently a CEO of one hospital center(Caritas) wrote an email to another CEO(Mt Auburn) and mockingly threatened(his post exposure assertion) that he would take retribution because Mt. Auburn hospital had attracted 3 physicians to their staff. But, as they say, the plot thickens.

Deeper in the article it portrays a medical world unfamiliar to the general public. We have a new kind of paid slavery, based on fears and a destructive outlook for physicians entering practice at this time. Hospitals actually barter and cajole to have physicians sign on a dotted line to exact a kind of unthinking loyalty and dependency. This is turning the profession into a 9 to 5 job with a resultant attachment to the institutions that hire them. It forces patients to become the pot of institutional gold and consequently erodes the focus of the very personal doctor-patient relationship.

Medical schools are imbuing their student wards with the notion that small practices just can not make it. It is not that specialty care is so attractive but the control one needs to enter primary care practice has become a mine field. The student yearning to be a general care doctor hears stories of complicated billing procedures, poor pay, and the time consuming task of building a practice along with their other learning. This naturally discourages them from entering primary care on their own. If they do so, they look for a sponsoring hospital or large group practice. They refuse to get involved in the "business side" of practice since it seems so daunting.

What is more disturbing is the mythology of why the path of being salaried is chosen. A kind of overlying belief system has evolved for these young to be healers. The true dismay for not becoming an owner in a small practice is covered over. The cover story for their choice reads that being an employee brings a better lifestyle, an assured income, and will provide more time for patients. This happens when the aspiring physician is told that working for someone else removes pesky business routines. Further with the introduction of hospital paid hospitalists, they become attracted to this service, since for a new doctor it is a time waster, namely taking care of your own patients in a hospital. We are selling one of our most precious societal traditions to a corporate kind of medicine. Unbeknown to the general public, we are losing the physician owned small practice who makes his living attending as fully as he or she can to the personal care of the patient.

It is not enough to whisk away this tie between patient and doctor. Hospitals also will either make deals for favored treatment from doctors, insurers, or medical service providers. The goal is to assure their hospital remains full and meets or exceeds a bottom line. This produces redundancies in a region with concomitant under utilization and decreased expertise. It is also counter productive raising expenses by setting off a whole new "competitive" strategy to make up the difference.

The nature of all this undoubtedly drives up medical expenses but extra dollars are not paying for any extra care. It is all going to feed this competition beast that the present system has fostered.

On the health insurance side the same methods apply. These companies secure deals with medical services that have "brand name" appeal and the ensuing negotiations drive up the premiums. It is the highest bidder who wins in this game. Even the entities that buy the insurance as a group negotiate rates. If you have enough so called skill or the clout in numbers, you get a good contract. Without the leverage you are up the creek without a paddle. Remember also the insurer is coming to your company after the other deals are done so this sets the bar at a much higher level to begin with. This is the source of double digit inflation of premiums. It takes human capital by the insurance company(very expensive) and a complicated bureaucracy to pull this off(very expensive). Marketing departments, contract negotiators, and accounts payable departments are not cheap.

Nowhere in these shenanigans has the patient been mentioned. They are the silent commodity in this exchange and their prescribed role is not known until all the processes above are completed. They are put into a take it or leave it position. If their employer thinks his insurance charges are too high the company pay in will be cut and the patient pays a higher percentage of premium. If the business can obtain other options, namely a lower premium plan, this will be chosen. The higher deductibles and co-payments will be shifted to the subscriber. The employer may even do both or drop the insurance altogether.

The rhetorical question, "Where are we all going with this?" Instead of ethical competition we get backroom deals and clandestine arrangements. The patient only becomes front and center when insurers and employers sell this ill gotten fruit. It is camouflaged with health clubs, store discounts, beautiful brochures and TV advertising(most of it directed to healthier populations). It is time for the press to investigate this and open the eyes of the public

A Letter to the POTUS, August 14, 2009

Mr. President,

You must now urge the Congress to do their duty under Article I, Section 8 of the Constitution.:

"The Congress shall have Power To lay and collect Taxes, Duties, Imposts and Excises, to pay the Debts and provide for the common Defence and GENERAL WELFARE of the United States; but all Duties, Imposts and Excises shall be uniform throughout the United States;"

Without a doubt, health care has been shown, as Article I, Section 8 provides that laws to promote the general welfare is a duty of Congress. The second part is that such laws must be borne by all the states in an equal fashion through taxation.

It is time to forcefully explain this duty to the people of the United States. This is a Constitutional obligation of the Congress and it is time to end this too common suffering of lack of health insurance and its lack of accessibility to proper health care for all our citizens. The Constitution seems to even demand that it is for all not just for some. It must be clearly declared a universal asset and necessity. Too many feel it is a privilege or a simple commodity belonging to those of a certain class or a certain segment of our society. Our national document says differently. It is past time that these Tories among us be set straight. They live in the United States of America where all can be guaranteed survival by our founding laws. To let them think otherwise is a grave injustice. The time has come to act and put this too excessively powerful noisy group in their proper place. They will only benefit from a national health care insurance law. The law must be passed in spite of them. We will have to leave it to the future for them to realize it.

A Letter To the NY Times, Aug 13, 2009

The article: http://www.nytimes.com/2009/08/13/opinion/13gawande.html?ref=global-home

My letter:
Dear Editor:

Today's article by Gwande et al on "10 Steps To Better Health Care" is incomplete. It is not test volume that governs excessive costs but the hospital administrative policies behind it. Hospital costs are relatively fixed. A certain number people are needed for care and to keep the lights on. It is fairly constant and not dependent to a high degree on volume. This means if you cut down on certain services, that revenue stream is lost, launching a search for other sources of income. For example, if you lower the ER census, that income loss will need to be made up somewhere else. Real cost saving will only come from reduced administrative personnel and more efficient planning in a particular region. Without such planning, redundancy occurs with under utilized services. Presently the concept of competition among hospitals, maintaining "market share" predominates, instead of competing on improved service. Excessive costs are also dependent on deal making skills with various insurance companies. Instead of a rational budgeting process it requires a wing and a prayer to survive from one year to the next. It depends on negotiation expertise, rather than the quality of a particular hospital's care. Brand name institutions get better contracts leaving others with lowered payments. Medical economics has many deviations from a market place. It is time we realized that.

Words Matter: Definitions For Open Debate

In discussing any subject, especially health care reform, how we define words becomes important. I have chosen the dictionary definitions below that I use in my writings and I expect are accepted by others. If it is used differently that distinction will need to expressed so we can understand each other.

Privilege: "Such an advantage, immunity, or right held as a prerogative of status or rank, and exercised to the exclusion or detriment of others."

Right: "Something that is due to a person or governmental body by law, tradition, or nature."

Survival: "A state of surviving; remaining alive."

Capacity: "The ability to do something."

Belief: "Is the psychological state in which an individual is convinced of the truth or validity of a proposition or premise (argument). Belief does not necessarily confer the ability to adequately prove one's main contention to other people, who may disagree."

Capitalism: "A system of economics under which ownership of and investment in the means of production and distribution depends chiefly upon corporations and private individuals."

Socialism: " Any of various theories or systems of social organization in which the means of producing and distributing goods is owned collectively or by a centralized government that often plans and controls the economy."

Economic System: "The system of production and distribution and consumption."

Morality: "A system of ideas of right and wrong conduct."

Religion: "1. Belief in and reverence for a supernatural power or powers regarded as creator and governor of the universe."

Secularism: "1. a view that religion and religious considerations should be ignored or excluded from social and political matters.
2. an ethical system asserting that moral judgments should be made without reference to religious doctrine, as reward or punishment in an afterlife"

Ethical: "Of or based on a system of moral beliefs about right and wrong."

Moral: "Arising from conscience or the sense of right and wrong."

Health: " A condition of optimal well-being."

Wealth: "Is the items of economic value that an individual owns."

Distribution of Wealth: "Is a comparison of the wealth of various members or groups in a society, and is one aspect of the economy and social structure."

Money: "Is any token or other object that functions as a medium of exchange that is socially and legally accepted in payment for goods and services and in settlement of debts. Money also serves as a standard of value for measuring the relative worth of different goods and services and as a store of value. Some authors explicitly require money to be a standard of deferred payment.^"

Income: "In economics, factor income is the flow (that is, measured per unit of time) of revenue accruing to a person or nation from labor services and from ownership of land and capital."

Wages: "Economists define wages more broadly than just cash compensation and include any return to labor, such as goods workers might create for themselves, returns in kind (such as sharecroppers receive), or even the enjoyment that some derive from work. For economists, even in a world without others, an individual would still acquire wages from labor: food hunted or gathered would be considered wages and any returns resulting from an investment in tools (such as an axe or a hoe) would be deemed interest (a return on a capital investment). "

Profit: "Pure economic profit is the increase in wealth that an investor has from making an investment, taking into consideration all costs associated with that investment including the opportunity cost of capital. Accounting profit is the difference between retail sales price and the costs of acquisition (whether by harvest, extraction, manufacture, or purchase). A key difficulty in measuring either definition of profit is in defining costs. Accounting profit may be positive even in competitive equilibrium when pure economic profits are zero."

Social Insurance: "Government provision for unemployed, injured, or aged people; financed by contributions from employers and employees as well as by government revenue."

Government: "The system by which a country or state is ruled."

Society: "A group of humans broadly distinguished from other groups by mutual interests, participation in characteristic relationships, shared institutions, and a common culture."

Rent: "Economic rent, in economics, a payment to a factor of production in excess of that which is needed to keep it employed in its current use."

Interest: "A fee paid on borrowed assets."

Truth: "Extends from honesty, good faith, and sincerity in general, to agreement with fact or reality in particular. The term has no single definition about which the majority of professional philosophers and scholars agree."

Fact: "Is something that is the case, something that actually exists, or something that can be verified according to an established standard of evaluation."

Legal Evidence: "Tight rules governing the presentation of facts that tend to prove or disprove the point at issue. In law, certain policies require that evidence that tends to prove or disprove an assertion or fact must nevertheless be excluded from consideration based either on indicia relating to reliability, or on broader social concerns. Testimony (which tells) and exhibits (which show) are the two main categories of evidence presented at a trial or hearing. "

"A long habit of not thinking a thing wrong gives it a superficial appearance of being right"

What in the world is going on? Segments of the population seem so aroused that violence has erupted on a topic that should be everyone's concern. Health care reform. For a small group any change is viewed as an attack on their way of life. It is so distorted that while they accept the invisible hand of the market place as a positive force when there is no such sentiment for government and the rule of law. A lot of this springs from the concept of rights. What indeed is a right? It is actually not something given to you by government. It is one of a host of human capacities and how each individual chooses to express it.

The law makes a list of those you can not exercise or carries restrictions. Look at the language of the Constitution, the first amendment, for example:

"Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the Government for a redress of grievances."

The Constitution does not give you these rights. You already have them. It forbids the legislature from exercising their rights to restrict or eliminate these human acts. It is actually limiting the rights of government.

So when people try to assert a right it must be in the context of whether the law allows it or forbids it. If it allows it, there will usually be no expression in the law stating an opinion. This is the fine line at these town halls with people trying to assert their right to speak louder and in a hostile manner against others or whoever is on the podium. In addition, besides the law there are societal rules of decorum. Being rude is not against the law but it will isolate you from your fellow human beings. If you are not peaceful in an assembly, the law is clear, you can not do this. If you are unkind, your fellow citizens will ostracize you and try to coerce you to cease. This is a societal norm, not an expression of the law. One must always be careful if a certain behavior is not allowed by law or is outside what a majority of citizens accepts as reasonable behavior.

Society serves our needs and wants. The government's role is to make sure we do not injure or kill ourselves in the process. It is true enough that wants and needs should be easily expressed but laws demand laborious effort and input with maximum attention to our ability to reason and observe, and use past experience.

Yet we know we can not totally dismiss those who express themselves in such disruptive and sometimes dangerous ways. They predict how a law, just in its nascency, may play out once it is enacted. We depend on the expertise of our legislators to take this into account or be prepared for controlling any uncivil action. When the Civil Rights Laws were brought to the floor for voting, some senators tried to filibuster the bills. It was very trying but it gave a heads up of the kind of resistance that was in store after passage. Although we each think we know how to fashion a perfect world, the truth is we live with others who have a different view. Even if there is some tense moments in making law, in the end we must all live together. Going too far out on a limb with our disgust or making your counter point feel humiliated will bring us to a dangerous place.

In the end it must be clearly shown how the suffering of a group affects the whole. Reason must be pre-eminent over belief. Without such a commitment from both sides of a conflicting rights battle, the nation will be lost.

Finally the quote in the title is from Thomas Paine written over 230 years ago. It appeared in his treatise "Common Sense" that argued for the creation of this great nation. He knew however that there would be resistance, but eloquently pleaded for studied reason to prevail. Times have not changed very much in that regard as we continue to fashion our laws.

Who Are the Uninsured?

It is interesting how those opposed to government intervention in health care reform start to blame those who do not have insurance. About 80% of these folks qualify for assistance programs in the form of Medicaid or other such state programs but have not applied for one reason or another. The rest are between the 200% and 300% of poverty level of income. It is this latter group that needs clarification. This group makes up about 15% of the uninsured and is labeled as having the ability to pay but choose not to do so. Are they really the pikers some of their fellow Americans believe? So what is 300% of poverty level. For an individual it is $45,000 and a family of four it is $72,000. On its face it seems these people should be able to purchase insurance for themselves. However any venture into the available market place shows that a bare bones plan for an individual is $6000 and for a family plan the freight is $12,000. Both these plans still come with co-payments and deductibles.



Six thousand dollars is 13% of an individual's income and for the family of four it is 17% of their income. Those who are trying to solve this problem of cost to these people feel 6% is a maximum number to get health insurance and not be an undue burden for individuals or families. As you can see this is at least double for those in the group dubbed "capable of paying." Anyone can budget out what disposable income will be left once such a high expense is entered into the equation. These fellow citizens are not gaming the system. They are making hard choices between what necessities of life they are going to let go and those they will pay for. Numbers that look like they should be adequate to afford insurance is an illusion. It is time to move on to fixing this problem and not get hung up on people who feel someone is out to steal their self determined rights of letting other people suffer. By not addressing the problem, the law of unintended consequence will rear its head. Who wants to wake up and wonder: "How the hell did this happen.?"

Critique of "Medical Waste Article"

The following is my take on an article on eliminating waste in health care with the hope of reducing costs. It has major flaws:

This list is a bit problematic. It disregards some facts of medical economics and puts far too much onus of cost reduction on the ill making it confrontational, interfering with the doctor-patient relationship. My critique is as follows:

Overtesting: The costs for testing are relatively fixed. It costs no more for a lab to do 1000 tests versus 2000 tests except for the small expense for materials and upkeep of equipment. Personnel is any service's major outlay and changes little because the technology can handle doubled loads without adding to personnel. In fact most hospital's labs are under utilized and seek to have outlying labs or pick up from doctors' offices. If this revenue disappeared the hospital would have to find some new source of income to pay for other services like inpatient care. No savings here.

Processing Claims: This is probably is a true assessment but hints to a better solution. Under a Single Payer Plan there would be double the savings or more as billing departments would be reduced to a fraction of what they are now. This is a biggy.

Ignoring Doctors Orders: Better interviewing techniques on the part of the physician would be a bigger help here. Making the patient the enemy is never a good idea. Educating the doctor is always the preferred route. Also preventive care adds to costs. It does not reduce it. It requires more personnel to care for patients to accomplish this and also people will live longer. Although a goal we desire, old age care is our largest medical outlay. Medicare accounts for 50% of nation's health expenditure. No savings here either.

Ineffective Use of Technology: Medicine is at its best when there is excellent personal care. The technology is suppose to enhance this by removing time consuming tasks. This would allow more nursing care and hence increase the health care budget. Nurses have always fought for smaller patient to doctor ratios. Good attention to infection control calls for single patient rooms, again adding to the expenses for good reason, but again making care more costly. Again, no savings here.

Hospital Readmissions: This depends and is a conclusion reached from being too far away from the ground level. If patients are frailer and sicker they will be admitted and readmitted more often. Further hospitals, because of reimbursement rules, push patients out by cook book guidelines, even if their physician wants them to stay longer. The waste here is the marching orders, forums by hospital management, and the poor use of case managers' time. This once more goes to the fixed cost argument. For a particular insurance company it may reduce cost but overall no savings since the hospital now has extra administrative costs. The claims receivable loss to the hospital will have to made up somewhere. Again no savings to the overall health care bill.

Unnecessary ER Visits: The same economics holds here. The hospital will be out of cash if these patients don't show up. So the cost will have to replaced for the same reasons given under the lab above. The expense for the ER is pretty much fixed within a wide range of services. Sorry no savings.

Hospital Acquired Infection: No strong issue here. This can be a savings in time and expense of medications. However the research to bring this about and the extra time and personnel to accomplish this will offset any real savings. The advantage is in saved human lives.

This piecemeal approach to an inefficient health care system is leading us to Rube Goldberg solutions. It is the payment system that is mostly at fault here. It drives resources to where a buck can be made when the underlying nature of health care is a fairly fixed cost system. It is the addition of personnel and real estate that adds to the bill. This can not all be stopped nor should it be , but a single payer by budgeting hospitals so they do more careful planning for their services and allowing people to visit their doctors in their offices would help greatly. However, by far, the most benefit to the nation is controlling administrative costs. Single payer's biggest strength is just that and it has a proven 44 year record with Medicare with a 3% overhead.

For Tim Reed From letstalkhealthcare.org

If you reach my blog Tim, here are my answers to your questions:

Tim: ‘The greatest expense in health insurance is administration in the private sector, about 11% in this state and up to 30% elsewhere.

I have heard this argument a lot from people in favor of nationalized health-care, but the numbers don’t really add up. If 11-30% (and I think your 30% figure is way too high) of the health-care dollars go to administration, then isn’t it fair to say the vast majority (70-90%) is going to pay for actual medical claims / services?

OETKB: What insurance companies pay for actual services is called the benefit loss ration. For private insurers it ranges from 70%(for profits) to 89%(for non profits). For Medicare it is 97% and this covers 50% of the health care bill in this country. The private insurers account for 15%. The rest is out of pocket.

Tim: I also question your logic on the following:

‘The choice to have a national insurance actually encourages a more robust free market since companies, state, and municipal institutions would be free to use this money for something else. ‘

How will insuring 50 million people who were previously uninsured actually bring down costs for anyone? I think this is especially true given the ideas floated around for how to finance this expansion of coverage (ie taxes on employers, taxes on the wealthy, taxes on insurance companies that would be passed along to employers).
and the fact that the vast majority of the health care cost trend is driven by provider payments rather than administration.

OETKB: We already pay for the uninsured when they show up in ERs, doctor's offices, or are hospitalized. A large part of the funding comes from state coffers called FREE CARE POOLS. By the way, private insurers kick in 3% from premiums as an obligation to help pay for the Free Care Pool. So we are already paying for this group of people. By giving them health insurance and also having them be responsible for some payment through a global tax system it has been estimated that this would be less expensive and far more humane and efficient.

It is true that the health cost trend is upward because health care is a growth industry. Insurance will not solve this problem. It will take fair appraisal of what should be covered and to work on redundant care. Hospitals compete by "market share" and duplicate things like mammography, outpatient surgery, and radiation therapy. Each of these units is a cost sink for hospitals because when there are several in an area, the only way they can pay for the service is to raise the unit cost since they are all under utilized. It will take regional planning and cooperation to deal with this. These are dirty words to the hospitals involved who regard each other as the enemy. Under a central payment system and quite frankly being rolled out by the major insurers, there would be a global budget. The theory here is there would be no reason to keep up with the Jones's since payment is already given to you monthly for the services you provide. This is an automatic under single payer and with one payment source this would do away with the current billing mess we now have. Just ask your doctor or someone in the hospital billing department what they go through to get paid.

To pay for all this there would have to be some fair tax that would max out at 6% of a household income. This could come from an expanded Medicare tax to cover an additional 25% of health care expense, the rest being out of pocket. Any amount chosen for this tax would be far less than anyone is paying in now for insurance. At a maximum of 6%, ahousehold with a $75,000 income would be paying $4500 for a comprehensive plan with no co-payments or deductible. This comes about because there is a $400 billion dollar a year savings by eliminating the expense around billing and marketing mentioned above. Employers would then have extra funds to give productive employees and fund other things such as pensions. Maybe even create new jobs. GM imploded because of their ballooning medical expense to current and retired employees. Governments, local and state, would have more funds available since this is a major expense. You might even see your property taxes lowered!

Tim: One thing we do seem to agree on is that everyone should have access to quality, affordable health care. However, by saying people should have ‘access’ I’m not also saying that the government should be in charge / pay for it for everyone. I think the U.S government is wasteful, inefficient and already in way too much debt. Nationalizing health care could be the straw that breaks our backs.

OETKB: It is understandable that there is this distrust in government. However it is really dependent on who is in charge. Also there are many programs that work well: Social Security, Medicare(see below), Our National Parks, other service agencies. There are hard working dedicated people who want to do a good job. I think it does a disservice to them by painting all of government as corrupt or inefficient. It will however always be a work in progress.

Medicare was born in the 60s by an act of Congress and so were HMOs in the 70s. The latter was suppose to curb costs by emphasizing preventive care and having your PCP be a gate keeper. They forgot to tell the insurance plans not to do this with an ever ballooning bureacracy. Over the past 25 years private health insurance administration has grown a wopping 1500%, not so with actual medical services .

Medicare is the most successful program as assessed by its users, has the lowest administrative costs, has the most covered services, and again picks up 50% of the health care bill, the largest share any single insurance and, in fact, more than all of them combined. So which American invention are we going to go with. One has certainly seen more success than the other. It has lifted many seniors out of poverty and avoided medical bankruptcy, not a legacy of private health insurers.

If you don't trust government, why trust insurance companies who trying not to pay the bill when you are sick. As for end of life care I have been in sessions where private insurers(Medicare HMOs-Medicare Advantage Plans) try to push hospice care to help the bottom line, instead of relying on the judgment of a doctor and his patient.

Thanks again, Tim for your civil inquiries.

Update: Here's an article outlining "waste" in our health care system. Notice the $200+ billion for streamlining billing. This doubles if it goes away under Single Payer: http://money.cnn.com/2009/08/10/news/economy/healthcare_money_wasters/index.htm?section=money_news_eco

Recreating the Tower of Babel

"I don't want government interfering in health care and don't touch my Medicare."

"The government made bankers give out bad loans and also made them sell them to others."

"Socialism is evil. It will cause you to wait in the ER and make you the victim of medical mistakes."

"I don't trust the government to do anything right."

The upshot of these emotional thoughts is you will get what you pay for. It is asking for chaos. The language of our thoughts has become prehistoric. It took us tens of thousands of years to break down our clannish nature and now a noisy small group wants to resurrect it again. Why? The most obvious answer: They are afraid. I believe they actually fear themselves. If they give in to change, I am guessing, their comfortable old clothes lifestyle will be lost. And you know what? No one can promise them that it won't. Without some reassurance they will continue in the anarchism business. They have been told government is the cause of all their problems when their stubbornness for change has never allowed a fully satisfactory collective solution. This is where the socialism argument comes in. All that is necessary next is to bring up some Cold War scenario and voila we have impassioned protest. Since the logic of the two camps must now take a fighting stance, language is developed that becomes code for these fears. They threaten the opponent, much as any animal does when they feel cornered.

However their actions will create conditions for the opposite of what they wish to preserve. Without some form of effective communication and cooperation all lifestyles will be in peril. It will be our undoing if each side dismisses the concerns of the other. We know they are suffering. Most of these people come from states who receive more tax dollars than they put in. Without it, their ability to sustain themselves would vanish.

Unfortunately the methods chosen to preserve their fragile daily lifestyles are violent. Peace means war. Inclusion means exclusion. Assistance means servitude. Governement means anarchism.

As an aside, our president, and I voted for him, has added to this michigas. He states he is for health reform but neglects to say exactly what it is, his reasons for it, how it is going to benefit each one in the electorate, and how it is going to be paid for. It is time to take a firm stand on what he wants for the people. Citizens can then more rationally decide if they will support it or not.

On the other hand, the specifics we don't need is Congress detailing which general problems should be paid for. There should be a framework of services, like an office visit or counselling session. It becomes a disaster when you start saying you are going to pay for a specific disease or condition. This is what has caused the uproar against private insurance firms. Research is a different matter, of course.

So we are unknowingly building our political Tower of Babel higher and higher. Our language has become a tool to divide us with resulting ugly behaviors. Taking down this human created edifice is hard work. Communication that addresses fears must be found. Those who would use public speech to promote violence need to be marginalized, but still assured survival. The basic understanding, I hope, is that we do share this country together. It is time to start talking like we know it.

Posts on other sites

dailykos: http://www.dailykos.com/story/2008/6/15/536305/-The-Electronic-Medical-Record-(EMR):The-Hype-and-The-Cautions

letstalkhealthcare.org: July 1st to August 4th, 2009 commentaries

A letter to Ellen Goodman, August 7, 2009

This is my response to Ellen Goodman's article(http://www.boston.com/bostonglobe/editorial_opinion/oped/articles/2009/08/07/in_a_wing_nut_world_granny_is_toast/) in the Boston Globe today.

Dear Ms. Goodman,

Everything you say in your article is true except there is a concern still lingering. As usual technocrats in Washington murder to dissect. Wouldn't any counseling between a patient and a physician be a valuable interchange? It should be coded as such for billing purposes. By having to label it "End of Life Discussion" it is an intrusion that is a ready opening to many outside sources among which are government and insurance companies. This is one of the sympathetic cords these off the beam fellow citizens react to. They do not want their most personal wishes telegraphed. They have zero trust in government authority. This feeds into it and continues the frenzy. The privacy of this moment must be well protected. If someone wishes to study or investigate such conversations then they should get the proper permissions on counseled patients. With identities protected, then do whatever investigation some review deems of value. It should not be an automatic that such data or, in fact, any data be available without safeguards. Of course, after this conversation between doctor and patient has occurred in private, the patient then becomes more comfortable in asserting their status when asked in the appropriate setting. They can even be asked if they talked this over with their physician. The problem described in your article is that these protesters may have had a point but it got lost in their destructive, disruptive undemocratic behavior. A doctor sitting with their patient hears many interesting notions people believe in, but in that setting it becomes a teachable, empathetic moment not a mob scene. It is proper to eschew their methods in certain forums but not their sentiments. They do have real fears that need to be assuaged. My biggest concern is preserving the doctor-patient realationship. Would it be a moment of comfort for you if a doctor suggests: "Next time we'lll schedule your end of life discussion." EDITED FROM ORIGINAL FOR CLARITY

My Right Versus Yours

We all have rights. However I want to exert my right to a National Health Plan over those who want to have the right to private health insurance. Who prevails ultimately will be decided through the legislative process. In the meantime support or non-support will depend on the facts, our experience, and how we are emotionally wired. So I accept the challenge to win over those who don't want Government Health Insurance. So let's cut to the chase and try to answer the question: "What's in it for me?" The answer: A lot more than meets the eye:

Your Income: A national plan reduces cost to your employer or to him or herself and would stabilize their ability to keep employees or hire new ones.
Public Services: Your government worker would have their insurance paid by all eliminating one of the largest expense states and municipalities in their annual budgets.
Your Job: Wouldn't be great to pick a job that suits you rather than for needed health insurance?
Your Mental Health: If you lose your job having health insurance will reduce some of the stress as you try to get back to work.

Your Choice of Doctor: This will be more available under a National Plan than the restrictive panels private insurers provide, causing patients to change physicians even after long relationships.

The Doctor Patient Relationship: Private insurers pay differently and have more restrictive rules than Medicare. This can cause a rift in a doctor's attempt to take care of their patient as they see fit. Doctors prefer to change their habits through education not fiat.

Premium Cost: It has been calculated there will be a 400 billion dollar per year savings by eliminating the need for complicated billing because of multiple payers and getting rid of excessive marketing. If you don't believe this one, just ask your doctor what he goes through to get paid. Multiply this process for hospitals.

Other benefits: Improved pensions, slower rise of medical inflation, lower drug costs, and improved medical research.

This is not an exhaustive list. Hey, we have time to explore those. More next time on lowering cost and how we pay for a National Health Plan.