Saturday, August 15, 2009


People sit outdoors as they wait to receive medical treatment during the Remote Area Medical (RAM) health clinic at the Forum in Inglewood, California August 14, 2009. The Remote Area Medical Volunteer Corp (RAM) is a non-profit organization that provides free health care, dental care and eye care in remote areas of the United States and the world since 1985 and was available in the Los Angeles area from August 11 to 18.

The fascinating fact about the "debate" on health care is that there isn't one- at least not in the one place where debate would be both necessary and useful, which is among the lawmakers who will decide whether or how we will fix our eminently dysfunctional system for providing medical services. A true debate would address four essential objectives:

(1) providing some kind of coverage for the 50 million uninsured;

(2) cutting costs to the government;

(3) cutting costs and unnecessary overhead to medical providers; and

(4) improving the overall health of Americans.

The Remote Area Medical clinic, providing free eye and dental care, set up at the fairgrounds in Wise, Virginia, last July. Republicans (and Glenn Beck) argue that Americans have the best health care in the world and that individuals can choose whether or not to purchase health insurance. In the real world, insurance companies refuse to sell policies to sick people, routinely deny any coverage for "pre-existing conditions," and have caps on benefits which cause people who had what they thought was decent coverage to file for bankruptcy when their lifetime benefits run out.

The one benefit to the lunatic fringe's bogus attacks on reform is that they highlight the fact that Democrats' proposals are so fuzzy and incoherent that no one can explain them, let alone defend them. Someone needs to get the message to our communicator in chief that his party's present tactics aren't working, and that even his supporters can't identify what his proposals are or how they will be funded without further busting a budget with record deficits.

So far, President Obama has not endorsed any bill that would truly provide universal coverage- no plan which would cover every uninsured American will make it to a vote in Congress. As to cutting costs to the government, the President has missed the boat entirely by his refusal to consider any plan that doesn't allow HMO's and private insurers a large piece of the three trillion dollar pie.

Meanwhile, the Republicans offer nothing other than the absurd claim that the present system isn't broken. That certainly explains their failure to propose legislation, let alone pass any, to cover even one of the millions of uninsured during their control of Congress from 1995 to 2007. Nor did they ever attempt to rein in exploding costs, instead passing a Medicare Prescription Drug Bill in 2003 which was a huge boon to the bottom line of the pharmaceutical giants who give millions of dollars to members of Congress on both sides of the aisle. Instead of attacking the deficit and runaway drug expenses for seniors, the law increased the federal deficit and raised the overall costs to consumers by placing obstacles in the way of states or companies with health plans and preventing them from negotiating lower drug prices or shopping in Canada for cheaper generic drugs.

It's not as if there aren't excellent ideas out there- they just haven't made it inside the halls of power in our nation's capital. A single payer government funded universal catastrophic health insurance plan-- for example, a plan that would cover ever American family's expenses over $3,600 annually- $300 a month- would solve the first issue of universal coverage.

Replacing Medicare and Medicaid with a single payer plan would also help resolve the second issue of reducing the federal deficit by immediately shaving hundreds of billions of dollars annually from the federal budget. This would remove the cloud of the projected bankruptcies those programs will face in the next 10 or 20 years.

There are some simple- and cost free (to the government) solutions for immediately putting the brakes on the increase in overall health care costs, which have far outstripped inflation in recent years. One suggestion is to subject hospitals, physicians, and other medical providers to federal anti-trust laws. There is no question that overall costs have been driven up in recent years by anti-competitive practices among hospitals and physicians. The trend has been to keep prices artificially high by creating monopolies, either through the legislative process (the most pernicious being the requirement that a hospital obtain a "certificate of need" in order to buy certain equipment or perform such routine medical procedures as delivering babies) or through economic power (buying up local hospitals and clinics has been a favorite tactic of our local "public" hospital in Albany, Georgia, and many local physicians groups deal with lone competitors simply by bringing them into their large practices).

If you've ever walked a city street where restaurants post their menus and prices next to their entrance, then you would recognize the simplicity- and effectiveness- of another cost free method of keeping prices low while encouraging informed consumer/patient shopping for medical services. Hospitals and physicians should be required to publicly post their fees for all services and products, both next to their front doors and on the internet. Consumers have no problem shopping for the lowest gasoline prices- note how two gas stations across the street from each other, or even just in the same town, allow informed shopping. And the fact that they would be subject to anti-trust laws would eliminate overt price fixing.

The Obama Administration needs to include some sweeteners to make these proposals attractive to the health care providers. Far and away the biggest- also cost free to the government- would be the elimination of all medical malpractice lawsuits and replacing lawsuits requiring proof of negligent acts under the current tort system with a no-fault system similar to the Workers' Compensation programs each state has in place. The pool of funds available to compensate patients and consumers injured, regardless of fault or negligence, would be funded by a modest two percent sales tax on all medical services and products, which are presently untaxed. That two percent would be instantly recouped by the billions in savings in overhead by medical providers no longer paying malpractice insurance premiums or practicing unnecessary defensive medicine to avoid lawsuits.

A check on bad doctors (which the current tort system does not do at all) would be to publicly post all no fault awards for patients on the internet, with privacy protected by removing all identifiers except for the name of the hospital or physician, the procedure performed or product provided, the date, and the amount awarded. Even good doctors and hospitals occasionally have bad outcomes, but currently prospective patients have no way of determining who the truly bad doctors are. A large number of negative outcomes for a physician performing a particular procedure (i.e. hysterectomies) compared to other physicians performing the same procedures would certainly be a red flag to patients while providing a genuine incentive for the medical industry to reform itself.

The biggest fans of a single payer system should be hospitals and doctors, since such a system would cut their administrative overhead by billions while eliminating no pay and slow pay patients and insurers. Currently medical providers have to deal with Medicare, Medicaid, a welter of private insurers, and uncovered patients, with a multi-tiered pricing system that charges wildly disparate fees for routine services and products.

One other advantages of a single payer system is that if it is funded by a national sales tax on all goods and all services, then every person in America, including illegal immigrants. would pay. And just like gasoline taxes that pay for road maintenance and other transportation expenses, we each would pay as much or as little as our pocketbooks would allow. By switching to a single payer, government funded program, cash strapped American employers currently providing some form of medical benefits to employees would be freed from that expense in their overhead. Those billions of dollars could go to paying their current employees more and towards hiring more employees. American companies would also be free to compete on equal footing with foreign companies which have national health insurance and no medical costs included in the price of their products.

There are many ideas currently being floated to achieve issue number 4, improving the overall health of Americans and reduce their need for medical care to treat easily preventable diseases. If we can do that, then it would, not incidentally, also result in cost savings at every phase of the system. One proposal whose cost would easily be recouped in following years is for the government to provide or fund free annual checkups for every American. Catching diseases while they are treatable, or treatable at much lower cost, will result in huge savings both in the pocketbook and in human costs.

Another approach is to attack the products and lifestyles which are killing us- or at least slowing us down. W should heavily tax every toxic product, not just cigarettes and alcohol, which presently burden the system with costs for treating patients their products are slowly killing with cancer, lung diseases, heart disease , and stroke. We need to outlaw all forms of advertising for products which have no value and which are proven links to disease. And we need to strictly enforce the laws against underage consumption of cigarettes and alcohol, which would result in huge long term savings from the damage inflicted on our country by those substances.

So the ideas are there, and many of them are cost free except for the paper on which to write the laws to enact them. Without question a lot of large insurance companies' oxes would be gored, and they will stop at almost nothing to prevent true reform from being enacted. But under our present circumstances, we have nothing to lose by boldly going forward.


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