White Coat Underground

Health care reform—what, me worry?

I’ve got a lot of patients who are worried about health care reform. Most of it is expressed in right-wing radio talking points. They quite literally believe that they will no longer be able to choose their doctor, or that other doom and gloom events are imminent.

Have they no experience with government? Health care reform isn’t going to happen quickly. When it does, it will likely have an American character. While socialized medicine works very well in some other countries, Americans just aren’t into it, even if it were to work. Whatever I may think about it, it’s a non-starter.

But what should we really fear about health care reform? The answer of course depends on your position and ideology. I of course hope that something is done about reimbursement for primary care physicians, but that’s one issue of many. Leaving aside for a moment the cost containment elephant in the room, what ideologic fears might we have?

It seems unlikely, given American culture, that any plan will significantly limit choice of primary care physicians. Very few plans place significant limitations. In fact, Medicare, the largest health plan (which is “socialized”) places no limits on what doctor you can see. There is little reason to do so. The closest idea to this would be doctor quality control. If doctors are not practicing according to some (mythical) set of quality guidelines, they could be “punished” either financially, or by being cut from some (mythical) list. If current trends hold, doctors who fail to follow evidence-based guidelines will be punished financially rather than having patients plucked away. This has it’s own pluses and minuses, of course.

Access is certainly a problem, but not in the way the fear-mongers would have you believe. The largest problem with access is lack of insurance (either total or partial). Some other less spoken of problems (which are actually being proposed) are conscience clauses, which would allow doctors to refuse to render certain care; limits on abortion; limits on birth control, and other “moral” issues. The theocratic right knows health care reform is coming one way or the other, and they want in. Since they might not get the economic concessions, they hope to insert their religious agenda, and anyone who thinks this will not affect them is fooling themselves.

Health care is an inconceivably large and complex system. No single issue is likely to dominate the reform effort. When educating yourself, try to avoid the hype, and look to the real issues.


  1. #1 The Science Pundit
    July 14, 2009

    While socialized medicine works very well in some other countries, Americans just aren’t into it, even if it were to work. Whatever I may think about it, it’s a non-starter.

    If they aren’t into it, that’s because they don’t understand it, not because it’s antithetical in any way to “the American character”. The right has been much better at framing the issue than the progressives have. One of the inherent problems with fighting for change is that those who stand to lose the most from the change, will almost always have more money and resources than those looking to change the system. Most Americans who “can’t stomach socialized medicine” are either ignorant of what it’s really like, or don’t understand that the Medicare that they like is in fact a form of “socialized medicine.”

    My apologies if I misunderstood you; the rest of your post would suggest that you pretty much agree with me. That’s why that one sentence seemed so out of place. The way I see it, “Americans just aren’t into it” is just another misleading right-wing talking point.

  2. #2 Donna B.
    July 14, 2009

    Limits on birth control are just plain silly, but when accompanied by limits on abortion they are dangerously so. (I’m personally against abortion, but I don’t want it made illegal.)

    I’m not sure I agree that lack of insurance is the cause of lack of access. I say that as one with excellent insurance who has difficulty at times with access. I also think that more people (even those on medicare) are subject to limited physician choice.

    The biggest problem I see as a patient are the massive layers on top of layers of superfluous bureaucratic bullshit. I’m betting that as a doctor you are privy to several layers I don’t see.

    In all my life, I’ve never seen government intervention simplify anything, so I’m suspicious about claims that any government reforms to healthcare will make it cheaper, more accessible, or pay doctors adequately.

  3. #3 Kate
    July 14, 2009

    You know what? My chief worries about the reforms are the things no one is publicly addressing. Yeah, sure, some paranoid few out on the fringes of the debate think that this is going to lead to communism, yeah some nutbag Senators are trying to get fakemed added to the bill (I refuse to believe that it’s only Harkin behind that) and yeah, others are trying to water it down as much as possible so that it stays “American”…

    …So the hell what?

    The questions I most want answered are will it have dental, will it have vision, will it cover mental health adequately, and will it cover addiction services. Healthcare is more than insulin, well-baby visits and chemo for your various growths and tumors.

  4. #4 a little night musing
    July 14, 2009

    They quite literally believe that they will no longer be able to choose their doctor, or that other doom and gloom events are imminent.

    Your patients can choose their doctors? Because I can’t – not really.I can pick from the menu my HMO provides me, which includes NONE of the doctors I know or know about. Most of the people I know are in the same position, and we’re the “lucky” ones with health insurance through our employers.

    And my mother complains that her PCPs keep leaving her plan, but it is their policy that doctors cannot make recommendations about other PCPs when they leave. This is choice?

  5. #5 PalMD
    July 14, 2009

    Part of that depends on the penetrance of HMOs in a particular market, but remember, HMOs are part of the “free market” model of medicine. The “socialized” bit (Medicare) does not limit choice.

    HMO’s have lost much of their power in most of the country, and panels have expanded to include many more PCPs. That being said, I don’t take HMO patients because I can’t afford to hire the staff to do the paperwork.

    Still, having access to a panel of PCPs is better than having access to NO PCPs.

  6. #6 a little night musing
    July 14, 2009

    PalMD, I’m not worried about “socialized medicine”. I’d welcome it. But you asked what our concerns are.

    PCPs leave my (and my mother’s) plan for the reason you state for yourself, among others. Yes, having access to some docs is better than none, I guess, but I’m reduced to having to guess who would be any good when my PCP is no longer available.

    Another thing I’m extremely concerned about (other than things like dental and vision, thanks for mentioning it Kate, the version of the Senate bill I’ve seen does not seem to cover those except maybe dental for children) –

    Denial of coverage.

  7. #7 a little night musing
    July 14, 2009

    Oops, hit “post” too soon. To be clear, I’m talking about denial of coverage by the private insurers, not the public option.

    There seem to be some provisions to address this in the Senate bill we’ve seen, but it is very far from clear to me that they would control this problem.

  8. #8 PalMD
    July 14, 2009

    Any plan that is rational and sustainable will limit access to doctors, procedures, etc for some. Our current plan rations based on income—if you don’t have enough, you don’t get insured.

    One way to cover the uninsured would be with a bare-bones plan, similar to medicaid. Yes, compared to private insurance it sucks but it’s a helluva lot better than nothing. Choice is always limited. It depends on what is limited and whom it affects.

  9. #9 a little night musing
    July 14, 2009

    PalMD, that’s not what I’m talking about.

    Right now, my son AND his doctor (who is in-network) are fighting to get the insurer to reimburse for something the insurer’s customer service rep told the doctor’s office WOULD be covered, and my son made it clear that he could not afford it unless it were covered, and then the insurer refused to pay.

    I head stories like this every day. And I live in a state which has pretty strong insurance regs.

    My son is paying a pretty hefty part of the premium for this insurance. Under the version of the bill I’ve seen, people who get insurance through their employers (as he does) would not have the option to switch to the “affordable” options made available through the Gateways (exchanges), because these are not available to those with employer-provided insurance unless their premiums exceed a certain percentage of their incomes.

    Sorry, I really did not mean to derail this comment thread. I do think it is important that people find out what is in the actual bill (or bills), as you say, to be educated in the issues. I have spent quite a few hours with the Senate HELP bill and these are concerns that remain.

  10. #10 Colin
    July 14, 2009

    Some vague concerns/points in no order:

    1) Let’s go back several decades when insurance was for unforseeables. Getting a physical: not covered. Getting a flu shot: not covered. Getting a mammogram: not covered. Broke your leg: covered. Smash your teeth falling of a bike: covered. Tumor removal: covered.

    Why involve a middle man to shovel money around when it’s not necessary? Unless you can find me someone who is 120% efficient then you are guaranteed to reduce the efficiency of the system and costs go up to cover the middle man.

    2) No advertising of drugs to consumers. How can you expect the inflicted to reasonably judge heavily-biased advertising?

    3) Patents are their own discussion but it’s sad when one comes out with a viagra and other companies have to “me too” and find their own method because it’s cheaper than patent licensing. IP law is horribly broken.

    4) If a state-licensed physician, nurse, etc. prescribes something then insurance would have zero recourse. Insurance companies best interest are in direct opposition to the interests of the patient. I have no problem with a company making a profit though.

    5) Malpractice costs and over-testing/over-prescribing to CYA.

    6) Philosophy. There’s a reason Mayo is near the top in quality but not in cost.

    7) Physician-owned hospitals and performance metrics. It’s the same issue as with insurance companies. When a physician’s income is tied to the treatment of a patient (or how many they see) they are no longer impartial.


    The most important person in the whole scheme is the patient. Anything that contradicts this should be questioned, especially those that are in direct conflict with the patient’s interests. This is, of course, not to say a patient can walk in and demand care. Resources are still limited but the way things stand the patient is on the losing end.

    I don’t believe socialization solves any of these issues, it merely redirects the costs. Treat the problem (the “whats” that raise the costs) and not the symptoms (uninsured children).

  11. #11 Colin
    July 14, 2009

    Oh yeah:

    8) Let’s disconnect employment from insurance. It wasn’t always this way (I believe prior to the HMO Act of 1973).

  12. #12 Mu
    July 14, 2009

    What most people don’t realize, US health insurance is comparably speaking cheap, compared to some other systems that run it as a tax/percentage of income. The problem is, it doesn’t have guaranteed access, and it’s not mandatory. And, in my opinion, both these “features” bite us in the butt.
    The ability of insurance to deny coverage for “existing conditions” (or flatly refuse to insure you) ruins many a middle income family with crippling bills in case of serious illness. The lack of mandatory insurance leads to those idiotic bills you see being presented by the hospital demanding three times as much from the uninsured as they charge the insurance company, since they are trying to recover the charges left unpaid by others.
    A mandatory insurance coverage, and even if it’s basic HMO style, would greatly help to bring some balance to the force system. But THAT would be really un-American.

  13. #13 Donna B.
    July 14, 2009

    Colin: you need to go back more than several decades. Health insurance (resembling what we know today) began when wages were frozen in WWII, but benefits were not.

    I was in our living room when my parents purchased their first health insurance policy from a New York Life representative in the 60s. They bought two separate policies, one for hospitalization and one for doctor’s visits. (They also bought life insurance.)

    Advertising direct to consumers… I’m not quite sure how I feel about that. If the drug companies are not going to be allowed to advertise directly to doctors, who else is there? (btw, even though I have excellent prescription coverage, I love getting samples when changing medications.)

    I have read that patent lawyers don’t understand patents, so I agree that it’s probably a “broken” system.

    Yes, I too tire of being given two or three generic drugs to replace one brand name combo… sometimes. It really should be left to the doctor and patient to determine what works best.

    Malpractice – what is the alternative to getting rid of bad doctors (and they are out there)? Attempts in other professions to police themselves haven’t worked out that well. This is an interesting related discussion in the NYT:

    Some over-testing is certainly due to CYA, but some is also due to the one area where doctor impartiality comes into play. When the doc is part-owner of a free-standing CT facility, for example. That doc may well be tempted to order more CT scans depending on his personal ethics. Then again, he may just be making a good investment. It’s difficult to know.

    That brings me to physician-owned hospitals and performance metrics… Performance metrics will always be with us. Even if there were no health insurance involved, a doctor will be paid based on the number of patients seen.

    Are there any physician-owned hospitals left? This is a serious questions, as I don’t know of any. Personally, I like the idea over a corporate (or even non-profit corporate) hospital. I’m torn between loving and hating hospitalists. My Dad recently got a hospitalist who was horribly inept. My own experience (different town) has been to get the same hospitalist every time I’ve been admitted over a period of 12 years. I love the guy and consider him “mine”.

    I return to my original statement that superfluous bureaucratic bullshit is the most costly part of our current health system and my suspicion that any government-directed reform measure will only increase that cost. Doctors and patients will both lose.

  14. #14 military wife
    July 14, 2009

    We use a “free” government health care system, and our provider choices are quite limited because most physicians don’t accept the insurance. Often only one specialist will take tri-care in a metropolitan area, so we have to wait months to get an appointment. Most Americans aren’t used to those kinds of wait lists, so single payer will be pretty unpopular. I also expect the press to publish many stories criticizing any government “bare bones” program when its enrollees face the kinds of access issues that we military families deal with all the time. An expansion of Medicaid will only make the wait times longer as more people enroll in a program that physicans don’t want to accept because of low reimbursement and high bureaucratic harassment.

  15. #15 PalMD
    July 14, 2009

    Wow. I know my part of the country is very different, but i didn’t realize how much. EVERYONE i know takes TriCare.

  16. #16 Donna B.
    July 14, 2009

    Pal, I have TriCare and my story is similar to military wife’s. But you’ll notice I’ve referred to it several times as excellent coverage.

    I live in a mid-size city with both a medical school and an AF base. There is a large community of military retirees in the area and lots of doctors. The more specialized the specialty, the harder it is to find a doctor who accepts TriCare, especially TriCare Prime. There are a few specialties that are covered by only one group or clinic. Urology is one.

    But I discovered (when my son was in a serious accident, hospitalized for 7 months) that TriCare (or Champus as it was called at the time) has a wonderful feature – there is no maximum except on out-of-pocket expenses. A friend of mine, a physician, had a daughter hospitalized with MRSA pneumonia. She nearly died several times and was in the ICU for 6 weeks. He had to take out a second mortgage on his house to pay for her bills after his (also excellent) insurance paid its yearly maximum. She was also a 1000 miles away from home and he could not take time off to visit her more than once.

    I don’t envy doctors the amount of time they must put into their jobs or what they get paid for it. Cutting the pay a doctor gets seems counter-intuitive to receiving good health care. Of course, I consider myself a capitalist fiscal conservative, so maybe you will find one or the other hard to believe.

  17. #17 eddie
    July 15, 2009

    The major issues as far as I can see, with any healthcare system, regardless of how its financed, are that a patient’s idea of what makes a good physician is dominated by subjective, emotional relationships, so that popular docs get overwhelmed with demand and their ability to provide is stretched, hence the earlier comments on choice of carer. With all primary carers in the same system, will patient choice be wider?
    Also, the way drugs are developed and marketed in the present setup has led to a glut of viagralikes and anti-depressants and the complete lack of a malaria cure. Changing to a system where pharma development is rewarded on the basis of medical need will be revolutionary.
    Lastly, I have been following the debate over francis collins and the nih. Will he be in charge of this reform?

  18. #18 katydid13
    July 15, 2009

    I worry about the right and conscience clauses.

    I worry about the overuse of specialists. Sometimes I feel like my primary care doctor’s only plan is to send me to a specialist. My mother diagnosed eczema on my foot using a baby care book, but I had to wait several months to see a dermatologist, who barely closed the door on the exam room before she said “that’s eczema.”

    I’ve had several orthopedist visits where I was told exactly what I was told in the ER right before they told me to follow-up with an orthopedist. Both times it amounted to just let it heal and call us if it doesn’t get better.

    I also worry that we are going to get some kind of malpractice fix that is anything but a fix.

  19. #19 Colin
    July 15, 2009

    Donna: the whole insurance thing starting was before my time but I think my point still stands. Insurance shouldn’t be for expected/routine stuff. Should your car insurance pay for gas or oil changes? Should your home/rental insurance pay for painting walls? I see absolutely no benefit to routing “expecteds” through the hands of insurance.

    From what I understand the US is the only country in the world that permits advertising to consumers. (Advertising to the prescribers is another thing because I wouldn’t call them “consumers”.)

    Is malpractice *really* about getting rid of bad doctors or just a way for patients to sue for results they don’t like? Suing anyone for anything is also a larger societal problem.

    To my knowledge Mayo doctors aren’t paid based on performance metrics so it seems it’s not a foregone conclusion that pay based on volume will always be here. It seems antagonistic to the patient’s best interests.

  20. #20 Colin
    July 15, 2009

    Can anyone explain why medications are the only thing that are priced based on what you purchase alone, and not how much you purchase? If I get 10 pills/month vs. 30 pills/month of the same thing then it costs the same to me.

    Seems rather absurd. I wouldn’t want to go to the gas station and pay the same price whether I filled my car or gas container for a lawnmower.

  21. #21 catgirl
    July 15, 2009

    While socialized medicine works very well in some other countries, Americans just aren’t into it

    Actually, I’m American and I’m into it.

    I’ve only heard several arguments against government-run health care. However, they are all issues that already exist with our current system. If the government is in charge instead of private insurance companies, at least I would have slightly more power to vote for new politicians. As it is, I have absolutely no options when it comes to health care unless I leave my job and find a different one.

  22. #22 Colin
    July 15, 2009

    Socialism gives you choice? I’ve honestly never heard those two words together before. 🙂

    With politics it’s win or lose. You have no third option. Didn’t want Obama? Too bad. I consider that considerably less choice than switching jobs.

    And you do have an option. You can absolutely get insurance not tied to your employer so “absolutely no options” is about as wrong as you can get.

    Give me the choice between picking jobs [with different health insurance] and picking a politician and I’ll gladly take the former because there are plenty more jobs to choose from than politicians.

  23. #23 catgirl
    July 15, 2009

    Colin, you clearly live in a delusional world. It’s not an option for most people to just quit their jobs and find a new one. It’s wonderful if you can, but most people can’t. I can not afford to buy other insurance that is not tied to my employer, just like most people. It’s wonderful if you’re rich enough to buy it separately, but most people can’t. It’s just not an option for most people. It sounds like your solution is that if people can’t afford something else, they should just STFU and tolerate the inadequate stuff they already have. Be realistic. It’s just not an option for most people. And of course, anyone with a pre-existing condition has no options, even if they have extra money. Do you care about those people at all? In fact, even people who have insurance through their employer can get kicked off their insurance just by costing too much to care for, and then no other company will insure them even they can afford. Do you really think those people have options? What if that happened to you? Would you be so glad to have no government protection then?

    PR matters more for politicians than for private companies. Our democracy is not perfect, but at least I have some chance of changing who is in power through voting. There are more politician choices than job choices for most people, especially in this economy. If you really think that everyone has multiple choices for jobs and that they can pick a job based on benefits, then you’re living in a fantasy.

  24. #24 Donna B.
    July 15, 2009

    Colin, are you being purposely obtuse? I explained how medical insurance became tied to jobs. I suggested you might want to educate yourself on how and why it has grown/expanded to where it is today.

    If it’s your goal to only have insurance that covers the unexpected, buy that for yourself, but don’t propose limits on what can be offered to and bought by others.

    Insurance probably is the wrong word for routine care, as it’s more pre-paid medical care. But comparing it to car insurance covering gas and oil is silly, as that is comparable to medical insurance paying for food.

    As for advertising, there’s been a lot in the news lately about preventing drug companies from advertising to doctors, or had you missed that?

    Malpractice is what it is. There’s a lot of ‘mythology’ out there about lawsuits in general and most are not as frivolous as we are popularly led to believe. You really can’t sue anyone for anything.

    Mayo doctors may not be paid based on performance metrics as in seeing X number of patients per day, but they keep their jobs based on their performance measured by whatever metrics Mayo sets up for them, possibly patient satisfaction is one.

    Without patient volume, Mayo would close its doors.

    If medications are not priced per pill, that’s news to me. Are you confusing your co-pay with the price of the medication?

  25. #25 PalMD
    July 15, 2009

    Socialism gives you choice? I’ve honestly never heard those two words together before. 🙂

    A single payer system actually decreases choice at one level and increases it at another. You would not be able to choose an insurer/payer, but you would be able to choose doctors and hospitals, since with single payer system, everyone is a participant.

  26. #26 daedalus2u
    July 15, 2009

    The only choice that I want is to be able to choose among good options. I don’t want the option to choose bad options. Current health insurance practices give the illusion of choice; lots of complication, lots of fine print that is subject to interpretation at the insurance company’s whim. Wording designed to trick participants into choosing the option that brings the insurance company more profit, not better health care for the participant.

    Why is socialism ok for providing roads, police protection, fire protection and military defense of the country, but not ok for health care?

  27. #27 Donna B.
    July 15, 2009

    daedalus – all the things you mention fall under providing for the common good, e.g. things that benefit all fairly equally and cost much less when provided once, preventing duplication/overlap of services.

    For healthcare, there’s no question that immunizations, sanitation, and communicable disease prevention activities fall under the same.

    However, I’m not sure that individual health care does. In fact, I think with an even more socialistic system, we’ll find that it surely does not.

  28. #28 Colin
    July 15, 2009

    Boy do I love being called names! Obtuse, delusional: it’s awesome. [sarcasm]Your parents would be proud.[/sarcasm]

    catgirl: It’s funny that every time I discuss this with someone who is socialist that it is *GUARANTEED* to come up that I’m some heartless heathen with no soul and who is morally bankrupt. Congratulations: you’ve continued my streak.

    I have yet to hear a convincing argument that creating a monopsony is the best option and that it will solve *any* of the cost problems that created the base of uninsured that the solution is trying to solve!

  29. #29 Colin
    July 15, 2009

    Donna: How is getting a physical really not analogous to an oil change? It’s something you should do. It’s preventative maintenance. It costs you money. (Thanks for playing the straw man by arguing the gas part and therefore dismissing my point.) Do you honestly believe that passing money around through a 3rd party ultimately makes things cheaper than if you paid directly? Keep in mind this 3rd party is the evil, despicable insurance companies that everyone seems to hate who’s sole purpose is to rob you of your premiums while trying to not pay anything.

    Regarding prescription costs. Did you miss “…it costs the same to me.”? I fully cop that I didn’t state I have insurance with prescription drug copayments but you also didn’t ask before assuming I’m an obtuse confused moron. No, I did *not* confuse them. I repeat: “If I get 10 pills/month vs. 30 pills/month of the same thing then it costs the same to me.” Plus you didn’t answer my question. If you’re telling me to educate myself then I’d expect you can answer this, yes?

  30. #30 Colin
    July 15, 2009

    Pal: Thanks for the answer.

    I can certainly understand the advantage of choosing my doctor and care facility. So let me ask you this: why do/should insurance companies even get to make that decision? If an insurer was legally obligated to pay, and legally precluded from restricting, for care from any licensed care provider & facility then how does this not solve the same problem of creating a monopsony? Why must the government become the single payer to give the participant choice of care?

  31. #31 Donna B.
    July 15, 2009

    Colin – I asked you a question, not called you name. Since I’ve not argued FOR a monopsony, not finding a convincing one in my comments would be a given.

    You haven’t pointed out any ways to solve any of the cost problems either, except to limit to the types of insurance or pre-paid health plans.

    I have offered one suggestion and that is removing a few layers of costly bureaucratic BS that appears to come mostly from government regulations.

  32. #32 PalMD
    July 15, 2009

    Once again, we rub up against the whole free market vs regulation issue. These type of regs are (some would argue) an unwelcome intrusion into the free market. It limits plans ability to negotiate with providers for fees, etc.

  33. #33 Donna B.
    July 15, 2009

    Actually Pal, I’m talking about bureaucratic bullshit which government (no matter how free-market friendly it is) is infamous for proliferating.

    “Best practices” often aren’t 1000 miles away from where they were designed and this is not limited to medicine.

    I’ve had some recent experience in an ER and they were doing one thing that made so much sense I wondered why everyone wasn’t doing it. People with injuries that needed immediate attention, but didn’t need a bed were treated in hallway stations on relatively comfortable chairs with one available for a friend or relative accompanying them. The got their wounds cleaned, stitched, and antibiotics or pain pills prescribed quickly and most importantly – comfortably.

    While I don’t know the cost of an ER “bed” I do know that I’ve seen ordinary comfortable recliners fitted onto platforms to raise the height and with wheels for rolling them to one room to another. I’m sure this wouldn’t be appropriate for all ER patients, but it certainly would for some, especially the elderly.

    I don’t think hospitals and hospital equipment is designed with either patient comfort or nurse and physician ease of treatment/examination.

    The same sort of thinking applies to health insurance — it’s now an evolutionary result of something designed 60 years ago that isn’t working now. It really isn’t a matter of free market vs. regulation. Neither are going to come up with the best. That takes thinking about something altogether different which must take on entrenched interests on both sides.

  34. #34 military wife
    July 16, 2009

    PalMD–some places we’ve had access to excellent physician choice and availability with Tri-Care, and some places it’s been awful. It’s pretty frustrating because there doesn’t seem to be any way to predict which cities will have lots of docs who accept Tri-Care and which don’t. I do think Tri-Care is a bit better now than it was a few years ago, and hopefully more docs will give it another look…reimbursement isn’t as low as it used to be, and they have paid my family’s bills really quickly for the last couple of years.

  35. #35 daedalus2u
    July 16, 2009

    Virtually all of the “cost” of an ER bed is the cost of the infrastructure that supports it, the MDs, nurses, staff, labs, x-ray, MRIs, ECGs, ORs, pharmacy, inventory of supplies.

    Having an ER is a “common good”. No one knows when they will be in an acute trauma situation and need access to an ER. All the costs of having an ER have to be paid before that ER has a single patient.

    It isn’t a stretch to acknowledge that having a “health care industry” is also a “common good”. A good that has to exist before it can be accessed. A good that has to be paid for before it can be used.

    There are some rare events that are unpredictable that can enormously increase the demand for health care faster than capabilities can be developed, such as pandemic flu. There is no “surge capacity” in the ER system because of how it is paid for. Payment is only made when capabilities are utilized, not when they are held at the ready. In the race to the bottom of the cost structure, those who estimate and plan for a lower ER demand have a lower cost than those who estimate and plan for a higher demand. The race to the bottom is driving that surge capacity ever smaller.

    Why do we spend so much to have a “surge capacity” in the ability to wage war and so little to have a surge capacity to treat ill health?

    The main reason there isn’t a surge capacity for health care is because the major cost is labor, people to do the work, MDs, nurses and other staff. You can’t buy such expertise and then put it on a shelf in storage the way you can supplies such as drugs. People resources require active use to remain proficient. If you want to have a surge capacity in health care you have to train the MDs, nurses and other staff and keep them proficient, which means keep them active at delivering health care.

    One way to do this would be to have those “excess” health care providers actually providing health care to uninsured people. Then when the nation “needs” a surge capacity in health care, as in a flu pandemic, the uninsured could simply be dumped in the gutter and allowed to die while the insured were cared for [/sarcasm].

  36. #36 James Pannozzi
    July 18, 2009

    @Colin: Well said, on numerous points. The satisfied users of TriCare live in one of the few remaining pockets of equilibrium – it cannot last. President Obama said it best, something to the effect that current rates of cost explosion are “unsustainable”.

    That a middleman group of health care parasite businesses has been allowed to hijack, infest, and bleed our health care dollars to satisfy their nematodian thirst for profit is unacceptable. That the relationship is, thanks to the politicians, a symbiotic one, disgraceful. That nearly 50 million people have been left to fend for themselves while the skyrocketing costs of the consequences of that fact are sublimely ignored, is unconscionable.

    Reform is inevitable, despite the most determined obstructionism, misinformation and obstinacy. Too many people are on to them now.

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