Revolutionary medicine

One of the premier and earliest flu bloggers and co-founder of Flu Wiki, DemFromCT is also a doctor. Not a young doctor, either, although somewhat younger than I am (most people seem to be, these days). In our young professional days, the American Medical Association was a real political power. When it spoke, politicians listened. Hell, everyone listened. Now? Well, who cares? Dem has a really excellent post up at DailyKos looking at the AMA's opposition to the "public option" in the Obama health care plan. I'm not so crazy about a public option either. If there's an option, it should be a "private option." I want a public system. But that's not what this post is about. I want to add some personal observations about the AMA to Dem's post.

I've lived through two periods of medicine in this country. The earlier one, before 1964 and third party payers like Medicare and Blue Cross, was quite different than the one most of us are familiar with. My father was a "physician and surgeon" in those days and in his best year never made more then $10,000 dollars. He went to the office 7 days a week (the Sunday visit I suspect was to get some peace and quiet and do paper work), rounded at the hospital every day, made house calls, took out appendixes, delivered babies, treated diabetes, sewed up the lacerations of the cook at White Towers at 3 am, etc. I used to go to the office with him and he would let me go in the dark room with him while he developed the x-ray he just took, or I watched him make a sputum smear, stain it and then look at it through his microscope (which now sits on a chest in my dining room under a bell jar). His patients paid him a buck or two if they had it; if they didn't we got a present of some kind at Christmas time. For some reason bottles of booze were popular. We had a very well stocked liquor closet for a family who didn't drink. No one had insurance, to speak of. So he, and many other doctors, worked hard and made an OK, but not a great, living. He died in 1957, shortly after making a house call. I remember him saying the person tried to push some money on him he wouldn't take. A couple hours after that he was dead. Seven years later, when I was a second year medical student, Medicare came on the scene, bitterly opposed by organized medicine. And the result? Doctors got rich.

The AMA started in 1847 as a small group of doctors intent on improving the economic condition of medicine. In the 19th century there were all sorts of practitioners -- Thomsonian Botanicalists, homeopaths, bleeders and purgers )those were the regular practitioners -- and lots of ways you could become a doctor. You could go to a medical school, of course. There were lots of them and they made money. Or you could apprentice to a practicing doctor. After two years or so you could hang out your own shingle. Licensing? Nope. The result was ruinous competition. The founders of the AMA hoped to do something about it. They didn't. For over 50 years hardly anyone belonged to the AMA. It was an irrelevant social club for a few. But in 1900 in re-organized politically and began an era of spectacular growth and success. The AMA didn't focus on a national organization but a grassroots one. The basic unit was the country medical society. The county society belonged to a state society and the states to the national AMA. Every legislator had a doctor and therefore a personal lobbyist. The first objective was licensing laws and brining medical education to heel. The Flexner Report (1907) about medical school reform was part and parcel of the effort to both bring standards to the profession and stop anybody and his brother from starting a medical school. Country societies brought pressure on hospitals not to let a doctor have hospital privileges unless they were a member, and if you were a member of the country society you were automatically a member of the state and national AMA. Membership grew rapidly. By the end of the progressive era the AMA had an iron grip on medical education and licensing in almost every state. And also effective opponents of any government health insurance as a form of contract medicine.

The AME was bitterly opposed to any form of contract medicine because they had found that companies that offered free or very low cost health care benefits to employees did it at the expense of doctors, paying them very little per capita and providing a new kind of competition to the newly organized AMA rank and file. This opposition to anything but fee-for-service was a consequence of the effort to control low cost competition and became a reflex of AMA policy. For all of my father's life as a doctor the AMA was a major political power, and it was doctors like my father that were its main beneficiaries (although he was a member, I don't think he cared much about it. He just paid dues and was a member of the country society like most doctors.). While Medicare and private health insurers made doctors rich beyond their wildest dreams, the AMA understood it would eventually threaten its power. Doctors would become proletarianized. As salaried workers they are very well paid, but they are salaried workers nonetheless, and the AMA has little to offer them except the usual guild-like behavior of fighting for higher reimbursements. As Dem points out, most doctors don't even belong to it anymore. The AMA represents less than one in five practitioners.

So now we are rapidly moving into a new era of medical practice. No one is quite sure what is on the other side of this transitional period, but whatever it is and however long it takes, it won't be the same as before, just as the last 50 years were very different than the days when my father practiced (days which no one remembers any more). Like the revolution at the turn of the 20th century and the next one in the 1960s the change came because the old ways were broken, unsustainable.

That's where we are again. Welcome to the revolution.

More like this

by revere, cross-posted from Effect Measure One of the premier and earliest flu bloggers and co-founder of Flu Wiki, DemFromCT is also a doctor. Not a young doctor, either, although somewhat younger than I am (most people seem to be, these days). In our young professional days, the American…
My public health colleague DemFromCT continues his public health interview series on the front page of DailyKos today, talking to Dr. Georges Benjamin, Executive Director of the American Public Health Association (APHA). Dem clearly likes Dr. Benjamin, which is not a surprise. He is a very likable…
My father was an old fashioned "physician and surgeon," something we don't have today. He did everything: delivered you, took out your appendix or tonsils, treated your parents' heart disease, your childhood diseases, your broken bones, your kids' childhood diseases, the diabetes you got later in…
Lawmakers and the public in general have no idea how the business and practice of medicine operates. None. When you read statements from many representatives, you see such simplistic, anhistoric thinking that pessimism about health care reform is the only logical response. Or so it seems from…

In the 1950-60's the USA and Canadian system were identical.

When Tommy Douglas, a premier in Saskatchewan, a province of Canada, decided to impose nationalized free hospital care, one of the main opposers was the AMA.

Everything under the sun was tried by Canadian and American Medical Associations to derail the attempt. The AMA was involved because this was a beachhead for North America.

Recently, Tommy Douglas, a preacher and former head of the a 'socialist' party, was voted Canada's most respected citizen ever.

Our medical system is our most treasured advance of the last century.

Please don't be dissuaded from the peace of mind and proven efficiences that come from such a system.

No matter the cost of the initial can give no greater gift to the country and your children and grandchildren...just ask a Canadian.

thanks, Tom DVM. Canada is often unfairly portrayed in a deliberately deceptive attempt to scare people about socialized medicine.

When I hear of the AMA's position on this, the first thought I had was that they are getting to be like to RNC: smaller, more extreme, less innovative, and more at risk of irrelevance.

The Flexner Report, âMedical Education in the U.S. and Canadaâ was published in 1910. It ended many good models of medicine along with the scurrilous ones. It closed most of the black medical schools, if not all.

There was a reason why other medical models became so prevalent at that time. Why people wanted something better. Conventional doctors in the early 1800s used nasty nostrums and bled and purged people.

The Eclectic Physicians came out of that âmedical reformersâ movement in the early 19th century. Dr. Quinn, Medicine Woman would have been an Eclectic physician. She would have been using herbs not mercury and opium. Women weren't allowed to attend medical school until 1851 (one woman managed to get a degree in 1849 but the school didn't allow any others).

The Flexner Report ended all competition. It killed the Eclectic Medical Schools. The last one to close was in 1930. The Lloyd Library and Museum in Cincinnati holds their legacy.

The Eclectics were around for the 1918 Influenza. John Uri Lloyd and John M. Scudder, Harvey W. Felter, John King and Finley Ellingwood. They used herbs and many herbalists today find them just as efficacious.

By phytosleuth (not verified) on 15 Jun 2009 #permalink

Just because public health care works in Canada doesn't mean it will work for Americans. We are culturally different from Americans. I would even go so far as to say that the difference in the sort of people Canada has attracted as immigrants over the last century vs. the sort of people the U.S. has attracted is large enough that we are genetically different.

I want my 'brothers' and 'sisters' to have the same peace of mind that I and my familly have...thanks to my father and his generation.

It wasn't very long ago in Canada that farms and houses were lost and famillies were made penniless just because someone was unlucky enough to get sick.

It is quite a simple concept really...

...1000 people buy a lottery ticket for 10 each per year.

The unfortunate winner of the lottery gets advanced healthcare, in a reasonably timely manner, for ten bucks!

If lottery's are good...then publically funded healthcare is good too!!

...and it is good that it is funded by taxes.

The only improvement I would make is that I would have the patient pay ten dollars to the doctor per visit... father was a general practioner-coroner etc. who worked seven days a week and twenty-four hours a day... was he who said that the only way you will effective treatment from the medical system is if dollars change hands...he said it didn't matter how much and it was more for the doctors frame of mind then the patients.

Our parents generation were bold.

They gave us pasteurized milk, brucellosis and tb programs, in a few months they pretty much eradicated Polio with a publically funded, publically owned vaccine laboratory (Connaught in Toronto)...

...and Dr's Banting and Best gave the propriatary benefit to the world...and put in a contract that the discovery could not be used for profit...and I assume Dr. Saulk did the same.

...also all plant breeding was publically funded at universities and provided to the world at no charge as well.

What has our generation done?

The bulk of Americans will accept socialized/nationalized healthcare until they realize that there are restrictions ie you don't get a script for MRI on your first, or second visit with a complaint of a sore joint. We are a nation of 'entitled people' albeit it rich, poor, or middle class.

I'd love to some something modeled along the lines of the L.I.F.E. (Living Independently For Elders) programs-which should be the national model for care of ALL elders. Their dedicated staff keep down costs while keeping this at-high risk group in their homes instead of nursing homes.

A LIFE program in West Philly,not a well-to-do area at all:

Medicine is a mess right now. I have been practicing medicine for only 15 years and every year I grow even more disheartened. The metrics that my boss uses to assess me does not consider how many people I saved, or helped but rather how many relative value units per hour (measurement of financial productivity in medicine) I generate. Do I get protected time to do other things like make follow up calls to pts? Absolutely not--it doesn't generate money. I blame the business suits who, like the financial sector, have ruined medicine. How screwed up is the payment system? As an example, I make more money taking wax out of someone's ear than intubating a kid who is comatose after a severe head injury. I have recently had insurance companies deny my bill because I forgot to include a family history in the documentation--never mind that I saved the man from a massive heart attack. Educate a diabetic on diet? Sorry it does'nt pay enough to be worth my time. This is why doctors dont talk to pts any more and only want to address a single problem during a visit--because the insurance companies in trying to make more money are paying less to doctors. To make up for the loss we are forced to squeeze even more pts into the office or clinic. Its volume not quality that matters in medicine right now. Most docs I know would leave medicine in a heartbeat if they could financially.

This health care reform better address the doctors unhappiness, and it better start breaking the news to the public that we are going to need to ration care. Yes that means we dont offer any more chemo in advanced metastatic cancer and no we are not going to pay for a shoulder MRI because your shoulder has hurt for the past 48 hours. I may sound sarcastic about this but this is what the pubic wants. Rationing or withholding tests, treatment etc only pertains to the other guy not my family member or me--I want everything done or so help me doctor I will sue the pants off you--I hear these sentiments several times a month in the ER. They are right. The public has spoken loud a clear on this: they dont want any tort reform and want everything done. So the gov't better get busy downgrading this expectation or reform will never work.

By BostonERDoc (not verified) on 15 Jun 2009 #permalink

DemFromCT is right about the misrepresentation of our Health System in Canada. They make it sound like something dreadful. We watch this and marvel because actually we consider ourselves greatly blessed with our system which may not be totally perfect but is pretty darned good. (Canadians do have greater life expectancy, for some reason.) Nobody here goes bankrupt over health problems. Nobody is uninsured, because everybody is ensured: single-payer system. Revere put it so well. Better a "private option" than a public one. Actually I have a private option on top of my basic one, for dental and prescription coverage, for 97 dollars per month. But all kids up to seventeen get free dental. (in Ontario, maybe elsewhere)

The U.S. system is shocking. No other civilized country in the world...

Hillary Clinton well said that Women's rights are Human rights. Yes, and maybe the same could be said for health care rights.

It never occurred to me that the AMA did not represent the vast majority of physicians out there. I suddenly like 80% of physicians even more than I thought I did!

But in light of this information, I now have to ask about the AMA the same question that I have been asking about Americaâs healthcare insurance companies--how is it that they have become deserving of such a prominent place at the healthcare reform table? Are we asking for their permission to reform our healthcare system? Are we asking for their blessing as we reform our healthcare system?

A (very close) former relative of mine has worked in the healthcare insurance industry for more than 20 years, and is currently an executive with Kaiser Permanente. Even twenty years ago, as a young college graduate with only an undergraduate degree in economics, he was earning significantly more than the average family practitioner or pediatrician. He used to make the observation that, sooner or later, Americans would realize that the healthcare insurance industry was getting an unnecessary slice of the âhealthcare dollar pie.â

I admit that I am still a bit skittish when it comes to perceiving arrogant posturing on the part of huge monopolistic corporations who run rough shot over public debate and policy. Indeed, I find myself still feeling quite traumatized by the investment banks who basically just held our entire financial system hostage until Uncle Sam had no other option than to pay their ransom. (Would anyoneâs 401k out there like to see what a real âfree market correctionâ feels like?) But the only detectable argument I am hearing for keeping Americaâs healthcare insurance companies involved in our public policy debate at this point is that we can only trust the shareholders of huge conglomerations (and not âthe governmentâ) to do what is in the best interest of our country. Really?

The 20% of physicians who make up the AMA along with Americaâs healthcare insurance companies are more than welcome to partner with each other--as free marketers do--and come up with a phenomenal healthcare delivery product for those who donât trust government--and can afford not to. But I do not want to subsidize any more insurance companies right now. If Blue Cross/Blue Shield, Aetna, Cigna, Kaiser, etc. are worthy of staying in business--they can venture out into the big free market and find their own customers. Then, they will do what healthcare insurance companies do when those customers get sick--they will care for them. And then they will do what healthcare insurance companies do when those customers get really sick--theyâll dump them on âthe government.â

And you know what? Iâm okay with that. I donât have a problem with providing healthcare for people who need it.

But thatâs just meâ¦

Ditto melbren: I, too, am thrilled to find out that the AMA does not speak for most physicians anymore.

A few years behind Revere's father, mine was a small town gp/surgeon in the late 50's-60's. We were solidly middle class-- nothing more. But we were inundated with home grown vegetables every summer, and I was treated like a princess wherever I was recognized as my father's daughter.

He left private practice in the early 70's to return to the USPHS, partly because he had no stomach or aptitude for "business" as it was then evolving.

Medicine has been corporatized to benefit those who run the corporations. John Ehrlichman laid it all out during a discussion about Kaiser Permanente on one of the Nixon tapes: "all the incentives are toward less medical care, because the less care they give them, the more money they make."

I'm pretty sure the AMA, the health insurance industry, PHARMA, and possibly even the US Congress, will NEVER put their avarice aside for even a second to do what's in the best interest of the American people, unless and until Congress is hit with about ten times the pressure brought to bear by the electorate this past fall during debate of the bailout (it passed, remember?).

Revere, I hope you are right and that the revolution has begun.

By Catherine Isobe (not verified) on 15 Jun 2009 #permalink

I happened to be looking at some old articles and came across this one from 1921.…

Which talked about doctors forming group practices not so much to increase their income but to make it more stable over time. Many of the issues then still hold today.

Medical practice has passed in two decades from the jog trot era of the horse and buggy to the frenzied era of the high-speed motor car and the aeroplane. Increase in scientific details and in cost and complexity of equipment has been proportionate to increased rate of transportation. The doctor of twenty years ago was hard worked. His mental capacity was heavily taxed. Medical men of today are as well endowed mentally and physically as their predecessors, but the capacity of the human brain has not changed. Doctors are not today equal to seeing several times as many patients, considering twice as many details on each case, and covering at least five times as much literature as their fathers did in the same number of hours. They become too jaded to cerebrate. Mechanical routinism is the natural outcome.

The concluding paragraph:

Group formation is' the first step toward efficient stable adjustment of medical service. Organization of patient clientele is logically and unavoidably the next step. Machinery must and will be evolved whereby the man of moderate means may, by the regular payment of a modest due or premium, be able to protect himself and those dependent upon him against the catastrophe of serious illness with its attendant curtailment of earning capacity and its overwhelming expenses. When in his emergency a costly service must be rendered to the patient, no one will seriously contest the doctor's privilege or undertake his responsibility. What type of agency do you choose to have make the terms upon which you will deliver such service? Shall it be service organizations of medical men themselves, carefully planning and unselfishly working with the wisdom of special training and experience toward an end which will conserve the health of the public and the highest ideals of our profession? Shall it be great insurance corporations, organized for profit? or shall it be departments of government, mayhap, controlled by men untrained and unlearned in the profession whose services they seek to direct?

The Great One announced today while addressing the AMA that "putting limits on malpractice would hurt pts". That old adage is right: Once a lawyer...always a lawyer. Nice job Mr. President you just summed up why health care reform aint gonna happen in the USA-no malpractice reform--I just keep ordering to save my butt.

By bostonERDoc (not verified) on 15 Jun 2009 #permalink

You can give no greater gift to you children? Yep, its called taking from someone and giving it to another. So we make it legal to take someone elses money and give it to whom in the US?

Sorry, but the welfare state is broke and I am not just talking about California. If they are dumb enough to raise taxes and then force all of America onto this bullshit healthcare program then you better prepare for war. This is a cash flow scheme and thats all it is. The absolute second it goes in, the clock begins to tick. No more money for any other program other than healthcare. That is... Healthcare at all costs. The idea is that you pay for me and I pay for you isnt legal for starts, and then there is that equal protection clause under the Constitution. That also could be reversed to force the issue. That being that you had better goddamn pay for me to have a hip replacement at 75 and not as an in line scenario. It means that bozo in Chicago at 25 doesnt get one before you do if you are on the list.

States are also going to balk at this. California in particular..Yes the great welfare state is going to collapse on July 22nd and cut out ALL welfare as government shuts down. It will be the best thing that ever happened to them. It will remove the possibility of revolution from that state and force the closure of the "rotten boroughs."

Their biggest problem is the illegal aliens that we and they the taxpayers have been forced to take care of. We can go around and around but forcing employers to provide healthcare ensure that the Obamagasm ends even more quickly. You might have healthcare, but you wont be able to eat. Shit, it will hasten the shutdown of the US of A. I spoke of revolution.... What do you think this state sovereignty thing is? Its a legalized revolt against DC and their welfare based programs that will permanently keep people poor and put millions out of work. Thus, they get to ensure that we move to socialist/communism/marxism.

Tom...FREE healthcare? Sorry Dad but that just aint true. You pay a huge amount of money for your healthcare up there and the costs are rising just as fast as they are here.

Dont get me wrong but its a fundamental issue. Healthcare isnt a right. Absolutely isnt a right. Think not? What if a country goes broke trying to provide care? Suddenly it cant pay for it? Is it a RIGHT or is it a service? Didnt have this or the suggestion of it until this past century folks and was based in socialism. Those socialist programs are failing all around the world even now. Oz is underfunded by 8 Billion,

Nursing shortages-

Hey, how about Daniel Inouye's socialist utopia... Hawaii…

Or we can post from the state run media…

My point is VERY simple. Its not free. Joe the Plumber got it in the shorts from Obama and accused John McCain of trying to take from the guys that were working to pay "for the guy behind you."

Well today Captain Amerika said that he was going to tax existing healthcare benefits as if they were income to pay for his goddamn healthcare. So, the employers are going to cut it completely and then everyone will be on it because there will be NO place else to go. So now everyone will get that same shitty care that forces people from the UK to make Orlando a medical Mecca on Virgin Atlantic. They have to save and scrimp and fly to America to get procedures done. Why? Because healthcare is rationed to those who are paying for it. The fallacy of this system is that the bar is set so that really only the people working pay the bills. Those people pay for everyone, not you pay for me and I pay for you. It will also increase the size of those that live in poverty because when you are in, you get to decide that.

People that are too dumb to understand what this really means might not understand too that the threat of revolution is in the wind. Secession is still legal and frankly I think us guys down south with our guns and religion would just as soon bail on this great nation and form a new one than go to war. The bottom line is that there isnt a state out there that can afford their damned portion of Medicare and Medicaid, nor can anyone afford their own deductions any longer. This new application against employers will drive more people out of work and THIS is healthcare at all costs.

The real question is whether the few northern liberal states want to break up this union for healthcare. It will get to that so quickly that none of us will believe it happened.

Its not a rant. I want someone to tell me as it has been stated in the EU Parliament how we can continue to spend when there simply is no more money TOO spend. Its someone elses money and this last bond auction fell apart like a two dollar watch. The interest rate jumped AS PREDICTED 180 days ago by 1/4th of a point. In six months it will jump 2-3 percent and that my friends is going to shut this economy completely down. Cant deficit spend any longer. Healthcare... shit. Last time it was "renewable clean energy sources" and .38 cents a gallon. Tax and spend just to put it into a box in 75 years? Not if you want to be around as a country in a 3rd of that time.

Melbren.. I agree. I want laws to enforce that the insurance companies CANNOT use the premiums to enter into other ventures such as the stock market. AIG was one of the worst. Its a crap shoot with our money and Obama is going to go after everything in sight now to pay for his programs...With our money.. You know, the people who work for it. Well, mid terms are going to go poorly for him and he is already a lame duck. Blood in the water.

By M. Randolph Kruger (not verified) on 15 Jun 2009 #permalink

Is past prologue? What are the Brits willing to do to make it work out? There are 60 million Brits, do the math on 15 billion and tell me how a population that will be more than 60% over the age of 40, 35% over the age of 60 is going to be able to pay this money just to bring it up to solvency? 25 pounds right? Uh, hum.. Only 34% of the population is working at any given time. Doesnt say how they'll clear it other than to not permit surgeries, or hospital visits and those old people who are causing all the problems, and paid all the bills arent going to get shit for their efforts.

You cannot pay for healthcare with deficits. Its not possible and the greatest thing you can give to your children is not a bill when you die.

Wednesday, June 10, 2009
Coming to America: UK Health Care System Faces 15 Billion Pound Shortfall
Posted by: chris field at 8:23 AM
An American friend living in the UK sent this Guardian piece to me this morning. Like so many who have been through government-run health care, he warns that this is where the U.S. is headed.

The health service faces an "unprecedented" 15bn Pound shortfall which is likely to trigger job losses and service reorganisation as it is forced to get to grips with the "most severe contraction in finances it is ever likely to face," NHS leaders will warn tomorrow.

The NHS Confederation, which represents trusts and health authorities as well as independent health providers, calls for "hard decisions" if the NHS is to remain true to its founding principles and provide care free at the point of need over the next few years. ... The NHS Confederation's chief executive, Steve Barnett, will tomorrow challenge the NHS to "prepare itself for real-terms reductions."

He will tell the confederation's annual conference in Liverpool that the NHS must "make hard decisions about which programmes to fund, how to reward staff and how to reorganise services now." ...

The restrictions will start to bite at a time when extra demands will emerge from an ageing population and the "negative health effects of recession in areas such as mental health and alcohol."

The report adds: "Public spending will be dominated by the need to service debt and so NHS and social care spending will not follow renewed growth in the economy." Simple savings programmes used in the past should be avoided, the study urges. Letting waiting lists grow, cutting training or allowing a hospital maintenance backlog to develop will all lead to serious problems.

By M. Randolph Kruger (not verified) on 15 Jun 2009 #permalink

As an employee of a major US city's health department, I first want to thank the Reveres for bringing light to the plight of public health in this nation. While this message of thanks may seem off-topic, hopefully by the end of this comment I'll be able to tie everything together.

I'm about to invoke a word that is anathema to the medical insurance industry - prevention. The system, as it's designed right now, provides more incentive to treat conditions than it does to prevent them - and it is my belief that this is the key contributor to the "broken-ness" of health care.

Prior to my current post, I worked with an HIV clinic in Washington, DC - a city with an incidence of HIV so high it ranks with many sub-Saharan nations. During my tenure at the clinic, I survived two massive reorganizations. Each time, HIV prevention and education services were slashed - in one instance, the division was eliminated altogether. At best, the extent of outreach provided by this clinic at this time centers on testing and referral into services, not simple prevention messages.

I don't want to make it sound as though senior leadership were callous to the needs of the community. Unfortunately, funding for prevention became nearly non-existent. Ryan White funding covers the needs of folks who are HIV+, not the folks who may become HIV+. Medical assistance does not provide for prevention, and neither do insurance companies.

In other words, the only way for the clinic to stay solvent was to enroll more patients with HIV. A successful prevention message makes that more difficult. The current reimbursement system provides a perverse incentive to medical centers to "let" people get sick.

On the flip side, the prevailing attitude among people middle-class or under (the vast majority of the population, lest we forget), is that we see the doctor only when we're sick. We can't afford to see the doctor to keep us well. The current insurance system provides a perverse incentive to people to "keep" themselves from staying well.

Caught in the middle are the doctors, who (I would hope) wanted to get into the field because they felt a desire to help people get and stay healthy. Any doctor worth his/her salt knows that a little preventive medicine early on can save a family from needing a lot of treatment later; however, doctors won't get reimbursed as well for keeping someone from getting sick, and patients are trained to think that if they are feeling well, they don't need to see the doctor.

Insurance companies get more money for more sick people.
Doctors have to see more people to make the same amount of money.
And it's nigh impossible to get patients to change their behaviors.

Is it any wonder that there is so much disillusionment and vitriol in the medical community?

I'm concerned about the "outcome-based" aspect of proposed health care reform. I have a friend who has been a type 1 diabetic since childhood - 30 years now. She is not going to get better, the best she can hope for is to keep her numbers pretty much stable. She is already getting refused by doctors, who tell her that the insurance companies pay them to make diabetic numbers better. They tell her to go to a different practice, that she makes them "look bad." (This is in Ohio, if that makes a difference.) If we go to "outcomes-based" payment, what will happen to people like her? I'm not a specialist in this field - have I misunderstood something?

Repost: Simple Health Care System

Here is my simple health care plan for the U.S.:

* Each person is required to put 15% of his or her income into a health savings account.
* All health care spending comes from this account using a debit-like card.
* If you do not have enough money in your account to pay for a charge, then your account balance goes negative. However, the health care provider is paid the full amount. You can think of this situation as a personal federal health care loan that is provided instantly.
* When your account balance is negative, 20% of your income is deducted from your income until your account balance is positive again.
* The money in this account is your money. When you die, any positive balance is passed on in your estate. When you die with a negative balance, your assets must first pay off any negative balance in your health care account.
* If you have insufficient assets to pay off your negative balance at death, then the balance is "written off" (paid for by general tax revenues).

Additional points:
* This program replaces all government health care programs, including Medicare and Medicaid. The taxes for these programs would be eliminated.
* Most employers would probably stop offering health insurance as a benefit. This would free every private employer of this costly and complex burden. This would make U.S. businesses more competitive.
* The payment for health care services would be immediate and swift--like using a credit card at Wal-Mart. However, providers would be required to retain records about the transaction for a period of time to allow audits for fraud.
* People would largely be spending their own money, and thus, they will be more careful about how it is spent. (With today's insurance model of financing, there is little reason for the consumer to make sure they are getting their money's worth.)
* Doctors might get tired of answering the question "How much does this cost?" but the question will be coming from their patient, right in front of them, rather than some nameless guy at an insurance company.
* Cost shifting already happens when non-insured/indigent go to a hospital for treatment. This plan simply makes it very transparent. These people will carry a negative balance funded by all of us. The hospitals would not not have to cost shift, and so their prices should become more reasonable immediately.
* The health savings account would be for legitimate health care spending only. Fraud would be very strictly punished--both on the side of the provider and consumer.
* Health care products and services typically covered by an employer-sponsored plan would be elligible.
* Dependents would be paid for out of their guardian's accounts.
* 15% would be a minimum. You could deduct more if you want.
* There would be a maximum account balance per dependent. For example, the account balance might be limited to $150,000 per person covered by the account.
* Funds would be deposited in FDIC/NCUA insured bank accounts. You would get to pick the institution. I would likely pick a local credit union.

Other points:
* I think we should probably include in this plan some general tax to pay for indigent care (those who die with negative balance). This tax should cover whatever our generation is predicted to cost in indigent care. It might be 1-5% of income.
* Private health insurance would be largely eliminated. However, insurance companies might provide "negative balance" insurance. That is, they would kick in and pay when your balance is negative. Or, another type of policy might payoff a negative balance at death. This would avoid an asset sale when the spouse dies first, for example.
* The numbers 15% and 20% are example numbers based on the statistic that 17% of the GDP is spent on health care. The actual payroll deductions required might be smaller.

jeff: How about a similar system for police , fire and schools. And let's cap the salaries of docs and profits of drug companies because there is no way in the world an ordinary person could put away enough money to pay medical bills if they get really sick in this country. Better yet, let's do all that and call it "taxes."

Taxes. Yes, that's the ticket. Lots of countries do that. Works well.

'Better yet, let's do all that and call it "taxes."'

I don't think a traditional Canada-style single-payer approach is politically feasible in this country. The plan I outlined is designed to strike a balance between those who feel health care is a right that must be provided by the government and those who want to retain a more free-market, privately-run health care system.

Would you feel comfortable with the plan I outlined? Do you think people would be more or less inclined to take better care of themselves? Do you think it would be acceptable to the doctors in private practice you are familiar with?

o.jeff, it wasn't politically feasible in Canada, either...
until we asked Canadians and found out it was.

Indeed, when care-providers are given a choice between billing individuals and billing government, they overwhelmingly prefer the latter.

Today, despite concerted government sabotage, media slander, and foreign disinformation campaigns, it remanins politically infeasible to dismantle medicare in Canada, or apparently anywhere else.

We need you to ask real American persons what is actually politically feasible and then to get on with it, so that we can leave off fighting propaganda and devote our resources to solving real problems.

I guess it comes down to...what kind of society you want to pass on to your children vs. what kind of society you can afford.

Humans have always chosen to be in collectives. We have collectivized many services and those services are paid for with taxes.

Randolph, I am happy to pay taxes because they are the only real differences to civilization 200 yrs. ago or 500 years ago or 5 million years ago.

I assume the prison system and the armed forces are collectivized...paid for through it seems to logically follow that the pattern is already historically in place and proven to be the most effective way to protect personal freedoms.

I assume that no one is against the concept of a lottery where one person ends up winning millions of dollars etc...

...Disease-influenza-cancer etc. are very much a lottery...if you fundamentally accept lotteries then you should logically accept collectivized healthcare...

...and finally, you will save money by using this form because almost all western countries have been using this system for decades.

...and one added benefit...pharmaceutical companies have not been much better then those in the financial-stock sectors in the past twenty-five years... or in other words, there are real potential savings to all and poor!

I would greatly appreciate collectivized negotiation of drug prices so that ethics is finally forced down their throats.

That doesn't make me a socialist or a liberal...that makes me a humanist... I said before, the 'hippy' generation has done nothing but pick at the bones of is time to rectify the situation and pass something meaningful onto our children...

...public healthcare in many ways will make up for our disgusting behavior of the past fifty years.

Salutations Reveres,

Lately, I have been mobilize in a Communication Junction of High Outrage, High Impacts as Sandmand and Lanard would denominate it

I was doing my best in contributing to 'Deal" with the Social Impacts of the Genetic Predisposition interpretation, how it was heading in MSM in some countries, and How Fukuda with firm Hands on the Environment Field of his mandate drove the issues with such fine tuning, almost chirurgically.

This Comment is very relevant of this thread as you will see.

First Thing First


Some First Nations Reserves in some Regions, with almost inexistant Health Care Services, slow if none of help from the Federal or Provincial GovernMentals, no running water, overcrowed houses and of course not in Good Health, substance abuse, violences, etc.., the reserve presented in this pandemic more morbidity.

The First conclusion would be the reasons for such an increase in morbidity are obvious from the above.

But here something else, some reserve are doing well with the pandemic, it is not as mild in some Urban or well served Communities but it could qualify as moderate but certainly not severe as St-Theresa, Manitoba for example.

But in a 'coucours de circonstances', the Genetic Predisposition of the First Nations in all the American Hemisphere became the object of speculations.

Still Focus on the asymetrical severity impacts of the pandemic between reserves in the same Infrastructures, behaviors, etc.. we noticed something relevant to One Specificity of Regional Life.

I will post in in two part if it is OK

Case Sensitive

Few 'case sensitives informations'
(from the point of view of the Federal pandemic Preparedness Guidance) in relation to First Nations reserves are not issues related to 'genetic predisposition' of First Nations,

but more so of few common factors for all Regionals and many Rural sites and that is relevant to all indigenous behaviors and all around the World.

There is of course a lack of proper quality drinking and cooking water, poor housing quality, promiscuity (too many people living in one house,
but mostly a common behavior with the environment.

People living in Rural areas, Regions or Reserves, drink and feed more on elements coming out of their environmental regions than from Industrial complex production like people of Urban Areas.

And of course, because of such difficult living conditions, there are more what is now called underlaying health conditions, bodies resistance and poor immune response capacity are well below the one living in big cities that manage to have a minimum of quality of living related to water, food and shelters.

Indeed, People in Regions, harvest, fish and hunt on elements that have grown, evolute and feed on their surrounding area.

This reality (the majority of people of this planet not yet full customers but still have some autonomy and autarchic behaviors) inherit some specific Health impacts that are not part of the urban reality.

Regionals are more expose to their surrounding undesirable toxic elements found in their water, their vegetables/fruits, fishes and wild meat.

Rather than to focus on genetic causes, analytical people seems to voluntary excluded studies on specific environmental conditions that exacerbate morbidity and mortality. (Mainly because of the economical impacts on Federal and Commercial Establishment) of some eventual potential imputability that would be directed to them for polluting the environment of Regional Environment with their activities and thus contribute to the raise of morbidity, mortality, Health Care costs, etc...

Mercury in Fishes, Mines activities toxics leftovers, other sources of pollution's residues present in the daily Life of Regional do indeed contribute to the difficulties for the People of Regions to Individually Cope with viruses and bacteria's.

When you look at the industrial contribution of toxic elements dumped in Regions one cannot denied the Health impacts of such behaviors.

That is why, in trying to reduce the effects of such poisons in Regional Individuals we must consider on how to reduce the Health impacts, the increase predisposition of weak bodies, to cope with a disease like an influenza.

We already know that we do have in many Regions of the world a lack of Selenium intakes because of its low presence in our environments.

Selenium is well known to contribute to the elimination of toxic elements such as arsenic from one's body.
It is known that an high level of arsenic as of mercury within one's body will concurred to rise the levels of morbidity and mortality when facing a new virus or new bacterias (MRSA).

For instance we already have identify regions that has higher levels of arsenic within them.

There are Natural Causes of such high levels of Arsenic and their bad effects on bodies, but there are more Man made causes that has contributed to the raise of arsenic in the environment. One has to think about the mining activities.
Around gold mines, for instance, we are aware that geological evolution that leads to gold has an essential surrounding element, arsenic.

Just as we know that Forest Industry and transformation generates a lot of toxics elements in the industrial process, mong it huge amount of arsenic not so well treated.... etc..

These two activities are not happening in large Urban areas, they are stored in Regions and become part of the Food chain and Health changes.

We are aware that coal mining and coal uses contributes to the weakening of the capacity of the lungs to Cope with respiratory diseases, thus reducing the capacity of bodies to Cope with infections.

These observations lead to an obvious conclusions, industrial activities in Regions raise the levels of toxic elements present in the vegetation's, animals that feeds on it and humans feeding on free wild animals and vegetations in their Regions.

But which government would dare to open an inquiry into the Pandora box of industrial activities that have contribute to the toxics omnipresence of poisons that contribute to the raise of morbidity and mortality in Regions.

If such effects would be proved, thousand of people who have inherited the financial privileges of blind exploitation of Regional Resources would become object of imputability and compensation.

Just as in the Cigarettes Industries.

Those (most of the time) multinationals would then become in the same position as the cigarette industries and force to compensate for the nefast Public Health Effects of their industrial activities.

Those industries would indeed prefer that some genetics reasons are the causes of the rise in morbidity and mortality in specific Regions.

I would like to express my respect to Grattan W. (known as the Doctor) an old timer in the Flublogia to have reach out and disregard his prejudices concerning genetic predisposition and I sincerely wish that he takes a look at these elements.

One part left Reveres


The Tobacco Industry (I am Ojibwa Metis, tobacco is a Sacred Plant), should Boldly and Swiftly order thousands of ventilators, respirators, contribute in lowering the cost of Asthma and related medicines, thousands became very rich, Noblesse Oblige.

Miners Family and big Corps should Boldly and Swiftly contribute in Public Health Human Resources and Equipments and research to start to fix the environmental Public Health Imapcts provoqued by mines, gold, carbon alikes.

Establishing Equitable Imputability is a win-win situation, instead of a confrontation with Present and Past Industries and subsequent Family Generational Priviledges, or spending huge amount of money in lawyers, etc.. they should invest Now in give back to give a hand to the Public Health around the World that are now trying to Cope with the Public Health crisis that they have cause.

When the Multinationals Swiftly and Boldly contribute to Public Health Needs the will put their shoulder at the wheel and thus reducing morbidity and mortality leading to the maturation of economic activity.

Thank You

Snowy Owl

jeff: How about a similar system for police , fire and schools. And let's cap the salaries of docs and profits of drug companies because there is no way in the world an ordinary person could put away enough money to pay medical bills if they get really sick in this country. Better yet, let's do all that and call it "taxes."

But taxation is tyranny! (Unlike crippling levels of medical debt.)

I'm sure my mother could've handled her $750K hospital bill with no problem, if she'd just started saving up for it a couple of decades earlier....

Randy, the empirical facts on the ground say you're dead wrong, period. As for UKers coming to Florida to have nose jobs and boob jobs, fine, whatever. And as for illegal immigrants, by now you ought to know enough about public health to know that an untreated population is a reservoir of disease and contagion.

As for "politically unfeasible," they said that about the skinny black guy who wanted to be President. How'bout we introduce a bill to strip Congress of their socialist medical coverage?

Or how'bout this nice little one-liner of a bill: "Congress shall have the same type and degree of medical coverage as provided to 51% of Americans, calculated yearly."

Randy #16 - actually thats the problem, you don' understand what you are reading. The UK system has suffered a similar infestation of suits and businessmen over the last 15 years or so, as part of a deliberate gvt policy to involve private companies. Guess what, they cost more, thus more money gets spent. Add this to an expensive method of hospital building, which is such a poor method that it should be illegal, and a gvt throwing money at a system which doesn't work well (I know a few people who work in the NHS) and yes, it seems awfully expensive. But we could save that £15 billion right off if we sorted the things the gvt has done wrong.

Randy #16 - actually thats the problem, you don' understand what you are reading. The UK system has suffered a similar infestation of suits and businessmen over the last 15 years or so, as part of a deliberate gvt policy to involve private companies. Guess what, they cost more, thus more money gets spent. Add this to an expensive method of hospital building, which is such a poor method that it should be illegal, and a gvt throwing money at a system which doesn't work well (I know a few people who work in the NHS) and yes, it seems awfully expensive. But we could save that £15 billion right off if we sorted the things the gvt has done wrong.

@ BostonERDoc:

I don't understand your issue with Obama's statement that capping malpractice hurts patients. Plain and simple, it would. IANAL, but it's my understanding that the whole idea behind malpractice compensation is that it is a punishment for negligence committed, and a deterrent for future negligence. I have no problem (even as an aspiring doc) with malpractice going uncapped.

I do, however, have a problem with the way malpractice suits are decided. So long as juries of uninformed laypeople decide points of medical and scientific minutiae, then malpractice will always be problematic, as a sympathetic plaintiff will usually win the day, medical expert opinion be damned. Capping damages doesn't fix the problem, it just controls the bleeding.

I'm in favor of a case review process that actually involves seasoned medical professionals for determining cases of medical malpractice.

When it comes to argument about health care being a right, and how that relates to need to pay for it with taxation, all I can say is that driving on roads is not a right, but you bet those roads are paid with taxes.

The bulk of Americans will accept socialized/nationalized healthcare until they realize that there are restrictions

do you mean to imply that our current system doesn't have restrictions? because i'm seeing one huge big restriction on it, from where i'm looking. a restriction with a dollar sign painted on, you might say.

By Nomen Nescio (not verified) on 20 Jun 2009 #permalink

It seems to me that malpractice suits have two sensible goals that could be met more efficiently in cheaper and less destructive ways:

a. I want my doctor to have a strong incentive to treat me as well as he can. I don't want him taking unreasonable risks with my life to save money. Similarly, I want incompetent doctors weeded out.

b. I'd like some kind of help, if a medical procedure goes south and I'm screwed over somehow--say, paralyzed or something.

It seems like malpractice lawsuits are a lousy way to accomplish either of these goals. A jury of non-experts isn't going to do a good job evaluating the competence of a doctor, because they don't know enough. And I'd like some kind of help if I'm paralyzed during a medical procedure, whether this was the result of negligence or bad luck. I keep thinking the right answer would be some kind of no-fault insurance for bad outcomes, plus an expert review of bad outcomes, with the reviewers having the power to discipline negligent doctors, maybe all the way up to revoking their license.

By albatross (not verified) on 22 Jun 2009 #permalink