A New President and His Legacy
Well, it looks like there is a new President coming on board. In reality, he is neither a Democrat or Republican. Let’s see what he can do to fix our healthcare system because is it totally unaffordable. You want a legacy, Donald? This one is staring at you in the face.
If one reviews the regulatory options that are available, and those that have already been tried and failed, then there is a conclusion to be be drawn. If both universal coverage and cost control are to be achieved, there is no other option but single payer. While you may be repelled by the notion of single payer, failure to design a system that way sacrifices either or both of the attributes of universal coverage and cost control. Everything else is a footnote.
So, what to do now in the face of a primal scream from so many troglodyte-Americans? I think that continued efforts at reason and persuasion are pointless. My hope is that physicians with progressive tendencies will work to pressure our largest and most-over-valued health institutions. This pressure should come from actions and not rhetoric.
How do physicians pressure such large corporations? Based on my experience with efforts to resist awful, exclusive practices of large hospitals in one-hospital towns who became real estate giants on the backs of the community by forcing bankruptcies and seizing homes, I can report that physicians who document medical needs of indigent patients in free clinics, issue summary reports to these patients that define urgent medical needs, and direct them to EMTALA-bound hospital providers can bring enormous financial pressure to bear on these institutions. These days, social media represent another lever of people power in these struggles as local newspapers are almost always co-opted by local hospital money. Giving away medical care is one of the most destabilizing actions a physician can take and doing so in organized free clinics amplifies the political pressure exerted by such actions.
These clinics operate out of store fronts, empty commercial space, and church basements, employing volunteer staff, identifying and re-cycling expired medications and DME, and exert force by dint of physician compassion and the creation of medical narratives. If moral distress is killing you as you try to be a physician, then this is a way to fight back that is quite effective and not at all symbolic.
In semi-retirement I’m working in 2 free clinics for no pay. Malpractice insurance is $100/year. I teach a course in pharmacology to nursing students. Never been happier.
Tom, your assertions for cost control and universal coverage as mandatory goals belie the presumption of a right to health care. I reject that. You can have your “progressive” (was there ever a more dishonestly used word?) tilt at windmills, so here is mine: try to find ways to reduce federal involvement in health care at all levels, and restore some economic creativity to an industrial-compassion complex that threatens our entire economy, even as it ruins medicine. Sneer all you want at people who are tired of being bossed around, even as you progressives empower more costs, more regulatory sclerosis, more legal threats to those who, struggling more to survive under your mandatory goodness, you now ask to give away free care as a way to fight one evil (insurance / hospital corp’s) while delivering even more power to a greater evil (big gov’t care). You want to leverage others with EMTALA when you should seek to reform or even rescind that godawful law that allows you to show your goodness by picking others’ pockets.
Give, volunteer, and aid all you like, but using that in the context of working for single-payer deliberately ignores that what you and every other rose-shaded proglodyte are advocating is the use of more force against some for the benefit of others. And I say to hell with that.
I’ll say it again here, as I’ve said before, capitalism without control of greed (a normal human failing) is no better than communism. Socialism is not communism. The socialistic countries with nationalized health insurance are often measurably healthier than we Americans (Danes are even taller!). Imagine that if LBJ hadn’t started Medicare in 1965 and if the government hadn’t sought to limit smoking, Americans would probably still be living just to retirement age (65). Our present system is not working because it’s controlled by profit-motivated insurance companies, who will always have skin in the game. Yes, I know people need to take better care of themselves; many people will still need financial help to put money into HSAs (which of course already exist as an option) if that becomes the bulwark of Trump’s healthcare proposal. If it were an easy problem to fix, it would have been fixed. Too many factors involved, from the high cost of technology in medicine to the (still prevalent) problem of smoking damage to health, injuries from automobiles, the workplace, and firearms, etc., etc. But still a government-based option can be studied. In our current America, where at least half of its citizens still seem to think they’re living in the Wild West, that’ll be tough. And Pat, look at recent history: Trickle-down economics, which you seem to espouse, has been shown not to work. Give the rich a break and they buy Bentleys, islands, and move jobs offshore to make even more money while the poor and middle class hurt more.
Bill, I respectfully disagree with your description of capitalism in that it is not the function of government to be in charge of subjective human frailties such as greed. You think that someone buying a Bentley may represent greed; I think that a family insisting on keeping a demented, contracted nursing home patient alive at all costs to the taxpayer is greed. It was never the place of the federal gov’t to worry about the daily provision of health care, and now by trying to make guarantees to old folks, they have threatened health care, and autonomy for patients and physicians, for everyone of all ages. Life expectancy was already on the rise before Medicare, which had no foresight or ability to restrain demand. That led to ridiculous price spikes, a lot of physician greed, and a worsening cycle making more inevitable the demand for even more gov’t involvement.
Recent history? Tax reform and economic growth led to record federal revenues, which were only squandered in bipartisan fashion. But the lack of spending discipline in no way invalidates supply-side reforms. We certainly agree that the problems with reform are very real, and very complex, and almost insurmountable in terms of politics. History records that FDR first skewed the health care market by wage/price controls, causing companies to offer health insurance in lieu of wages, thus skewing the market. Recent history shows that any federal government option – like Medicare/Medicaid – has been shown to weaken any chance of market improvement, even as it provides cover for the crony corporatism we are now witnessing. And it wasn’t the private insurance companies that forced ICD-10’s, EHR’s , MACRA, ACO’s, and all the other garbage, but they have been happy to follow Uncle Sugar’s lead as and exploit the situation. I just can’t see how more of this causative agent will improve things.
Pat, good evening! I’m no Marxist, but I doubt there’s a cure or control for cronyism except by government intervention (despite our government being alternatively controlled by two crony factions). Speaking only of health care, anything besides office care is unaffordable except through insurance companies, who are essentially given carte blanche to charge what they want to. And once a cost is established, it seems darn near impossible to ratchet it back through any means. After 40+ years in medicine, I certainly haven’t discovered a solution to the ethical dilemma of triage, not in a nation where even fetuses have value to some that outweighs the mother’s wishes. (But that’s another topic that has no easy solution except through government intervention.) In socialized systems, like Canada (where I have relatives) or England (where I partly trained) a patient or family is simply told “You can’t get that” or “You’ll have to wait for it.” There’s still a small functioning private system in both countries, which is likely what we’d get here. Glad I have Medicare although I dislike being old. A hernia operation I had in April has so far cost me only $7.75. My wife, being 63 today, is paying >$850/mo for BCBS and it’s going up by over $200 early in 2017. Of course, it can be argued that my Medicare is not a handout because I put into the system since 1973 out of payrolls!
Well Pat, if you read what I wrote, I conditioned an argument for single payer on accepting the goals of universal coverage and cost control. If those goals are repugnant, then we don’t have much to talk about. I don’t plan to convince you and only hope to out-number you.
All the freedom, liberty, and choice you claim to crave have not been delivered to you by the hordes of administrators, predatory MBA’s, and corporate investors that have plagued US healthcare since 1990. Healthcare sector employment has doubled since 1990 and 95% of the growth has been in administrative positions. It is physicians like you who praise “choice” and “freedom” who have been the natural allies of this corporate horde in every hospital I have seen.
So, I DO hope to kill this trend in healthcare with kindness and EMTALA. The time for debate is over. I have no interest in convincing you. That is what battles are for.
No Tom, you clearly do not have an interest in convincing me, or anyone else. I carefully read what you wrote, including your insults toward those who won’t follow your prescription. After writing on this site for years, I challenge you to find any occasion where I have been carrying water for Big Insurance or Big Hospital. What you will find is my consistent warning against the use of government force, which is clearly your preference rather than persuasion.
I do indeed reject “universal coverage” and “cost control” when administered by the federal government, which has shown itself unfit to operate something for which it was not philosophically equipped. I too despise the growth of private health sector administrators, but giving them the powers and efficiency of the DMV – or worse – is not going to fix anything. You can achieve universal coverage quickly; cost control will only ever come via rationing, which will be administered by the same kindly auditors that presently have private physicians hiding in fear and blowing millions on compliance in order not to be further punished.
You hope to “kill this trend in healthcare with kindness and EMTALA.” EMTALA forces every ER nationwide to deal with a bunch of non-emergent BS, exposing the staff and hospital to greater liability, more uncompensated costs, and gumming up the works for those who really need care. Moreover your precious EMTALA works as a disincentive to spend money on primary care or even catastrophic coverage-plans, admittedly dwindled in number by the ACA.
Your kindness is based on a willingness to use preferential force against some for the benefit of others (and yourself), which is no kindness at all. I am not willing to call for the use of force to do good; you are. Own it.
To rescind is not to reform, nor rewind to the original. The horror began long before Obama. The same bottom-feeders that crept into Obamacare after ClintonCare will be creeping into the system, steering it in the direction of more awful crap. It’s time to be more vigilant.
I hated to agree with anything Trump or that dunce Ben Carson espoused, but the idea of Health Savings Accounts may be one option for health care costs in the U.S. Wonder how the several million people who got insurance through ACA will feel about losing it? I know my health will improve…I’m too nauseated to eat since last night (and not just from the money I lost on the stock market). All the enemies of progress won last night…the NRA, the anti-science lobby, the evangelicals, all the fearmongers. Good luck to us.
Cheer up, the market is already stabilizing, and gun maker stocks are down. The millions that “got” coverage under the ACA didn’t get more care, and were only sold a pipe-dream with an intentionally short half-life. The tough thing will be to try to excise this crap from the larger insurance market, again a design feature that was “progress” we were better off without.