Tuesday, August 11, 2009

Hooray... A Good Start!

Thanks for bringing us back to a PROPER starting point: establishing the GOALS *before* we get wrapped up in HOW to do things. Excellent.

A few general comments - just to keep the conflict in our positions alive and well...

BTW - Just what definition of "universal" are you using, anyway? As a synonym for "FREE"? (TANSTAAFL.)

"there are some activities which private citizens, either in groups or individually, cannot be expected to perform in the fair and comprehensive ways which government can."
- C'mon, Chris. This is a sound bite. "Fair?" Who Decides what is 'fair'? "Comprehensive?" Who decides how far to go and what happens when you reach that Real World limitation? And how do you guarantee government will actually DO what they are supposed to do? I'll put the Education Establishment up as an example of government not getting CLOSE to 'reasonable expectations' for performance. What makes one think they will do better with Health Care (1/7th of the economy)?

"You can take all the blather about government controlling 'who lives or dies', roll it in a ball and drop it off a cliff for all I care."
- Sure. And I wholeheartedly agree... As long as government doesn't try to make and enforce those very decisions you're talking about. Some of the policies being proposed do NOT require a Huge Leap to get to that point, IMHO. As an aside, it would appear you trust the 'inherent goodness' of a powerful bureaucracy NOT to do something that... I think their historical performance warrants a reasonable distrust of ANYONE holding such power, regardless of their stated 'intentions'. BTW, why does it seem like you generally see some aspect of 'Good Intentions' as ALWAYS residing in the deeds of bureaucrats, but NOT being present in similarly-motivated actions of private individuals? Question: Is the U.S. a Great Country because of the actions of its Government, or because of the actions of its citizens? (No, the answer is not BOTH - Hint: who "derives" their power from who?) Hmmmm.

"...disadvantaged citizens being universally referred to as deadbeats and social parasites."
- People generalize, frequently when they shouldn't. (I just did so, above. ;-) ) Please continue to be gracious and seek to understand the principle behind the comment instead of focusing on the inaccuracies of the generalization and use that inaccuracy to discard the comment as a whole. I know very few people that consider the Truly Disadvantaged to be 'deadbeats'. I, and most others (even well-known arch-conservatives!), will not hesitate when it is appropriate and possible to give a hand up to someone trying to better themselves or their situation. However, it is the people who make - and continue to make - poor decisions and expect OTHERS to assume the (financial) burden resulting from those Bad Decisions that are 'Parasites'. Give me another equally descriptive adjective, and I'll use it. But changing the label doesn't change who/what they are. This goes DIRECTLY to my point about "The demand for a Free Good or Service is UNLIMITED". Sorry.

"I see no reason to humiliate, through a system of odious penalties, those who lack the ability to pay their fair share. But why not offer them some honest and honorable means to do so?"
- Sure. I proposed it - it's called Public Service, usually doing an otherwise distasteful task or position. It's only 'humiliation' if one accepts it as such. It is just as accurate to see it as a means to show your appreciation for the (undeserved? unearned?) help you received when you were in need. It's all about Perspective. And there *is* a Real Cost for such a program: what is ethically wrong with asking those who are reasonably deemed capable of paying for the services received to be legally obligated to do so after the fact? There is a HUGE difference between honest acknowledgment of receiving charity and the claim - as your 'RIGHT' - to goods services which must be provided by another through their direct efforts. 'Rights' are granted by God and are typically intangible things. Accepting the philosophy of being "my brother's keeper" is by MY CHOICE and does not - repeat *NOT* - confer or grant a 'RIGHT' to 'my brother' to make DEMANDS upon me as HE sees fit. Any government that seeks to FORCE adherence to a arbitrary standard of 'providing for others' is WRONG.

"America spends at least twice as much per capita on health care as any other industrialized nation, and yet by no objective measure do we outperform these other countries."
- *SIGH* --- I'd *really* like to see an honest, unbiased evaluation of world programs that hold EACH system to the EXACT same criteria, including: Quality of Life, Life expectancy, Available treatments, treatment scheduling, patient/doctor satisfaction. In-country education training. Bureaucracy compliance costs (bookkeeping overhead). Birth survival rates. Access to the latest medical procedures and equipment. Extent and length of Real Rationing (whether by bureaucratic fiat or by private company policy). Taxpayer costs and function of GDP. Health care costs as function of Tax revenue. Etc., etc., etc... I'm not saying that study is not out there, but I haven't found it (yet). It seems like every 'study' starts with a desired result in mind and manipulates the available data to fit the pre-ordained opinion. And either side can 'prove' anything by cherry-picking the statistics which support a particular position... Sorta like the AGW argument. [zing!] +:-)

"It follows that we have the resources to provide universal health care, but the system we have is not particularly good at distributing them."
- Careful... That same logic could indicate we should not supply foodstock to other countries as long as one person is "going hungry at home". I could point out you're making the same kind of far-reaching generalization you complained about earlier in a different context. "Provide"? Sure, theoretically. But WHO will pay for it? So... I must respectfully disagree. I think we 'distribute' care pretty well, all things considered. The complaint is that no one wants to pay for it. (We can agree that costs are somewhat out of control, too... That's what we're trying to fix, by changing carefully targeted aspects of the system operates.)

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OK, Now that we've got that out of the way (indulging my narrow-minded viewpoint; I feel better!)... Let's set most of the ideology aside and get back on the right track...
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I like your list! Let's use it as our new starting point. Naturally, I have a few more points to add. Maybe some editing, too. There are some caveats (sub-points) we need to put in place as we head toward developing proposals to actually DO these things. Remember: TANSTAAFL! My comments, point-by-point...

1. Provide a reasonable level of health care for every American citizen.
- Sorry, this is just a Sound Bite. The key question is WHO DECIDES what is "reasonable"? [Cue the slippery slope.] This is where we will get in trouble: WHO decides what is "available" and what must be "provided" (and paid-for by WHO). If we're going to seriously keep this bullet point on the list, let's think HARD about what it *really* means. Seriously. Otherwise, its just a 'feel-good' statement without true meaning.

2. Develop a health maintenance program with built in incentives to encourage healthy lifestyles.
- Sure. (But almost a pure Sound Bite, however.) The inherent Incentives exist anyway. It's forcing or "mandating" adherence to those a program (defined by "WHO"?) that concerns me. Is it in one's Best Interest to take actions to stay healthy? Of course. But I dislike using FORCE to insure compliance. You know that I dislike giving bureaucrats the authority to insist on a particular practice or procedure "for your own good". Supposedly, systems like Canada has many options and incentives – which are not used – either because of Real World availability (waiting lists, rationing) or the simple desire to just NOT DO IT.

3. Allow for private options.
- 100% agreement. My biggest concern is 'limitations' or 'requirements' (generally defined and enforced by state and local agencies) that mandate specific coverages, etc. My sub-points: (a) insurance policies are attached to the individual, not the employer, (b) any company may offer a policy to anyone, regardless of
previous medical condition or residence, etc. (c) no 'required' or mandated coverages of ANY kind. CHOICE prevails. See my original notes - More to come, I'm sure.

4. Protect all citizens from the high cost of catastrophic illness or accidents.
- Sound Bite. WHO DECIDES how much 'protection' is provided and what services are required? We have high-deductible policies available now for this very purpose. They seem to work just fine; they just have to be paid for. I don't see how complete government coverage is going to work, especially since this is where huge costs exist, by definition. A good place for personal CHOICE and accountability.
Again: Actions (or inactions) have consequences - and that means the consequences might be dire on a personal level. Good Risk management evaluation can be taught to those who recognize the value, but cannot be forced into existence.

5. Reform the health industry "from the ground up" to increase the number and and quality of health care professionals.
- Sound Bite. You don't fire everyone at General Electric and start over because the secretarial pool is getting thin... As for increasing available staff professionals - this is an "education and training" issue. I proposed government financing of training being 'paid back' by a period of public service. Start there. What else can we do, anyway?

6. Engineer a universal system of electronic patient record keeping.
- Agreed. It's been suggested for years. Why isn't this a key (STARTING) component of any legislation? Treat it as a properly run DOD project (rare, but they exist).
Open it to bid with no pre-conditions (union labor, racial makeup of company ownership, etc.). Penalities for cost overruns to bidder, not taxpayer - build it and get out: this isn't a long-term funding project.

7. Engineer an accessible system of computer based diagnostics.
- See #6. Obviously part of record keeping system.

8. Review and reform tort law with the following goals:
A: No citizen is denied legal remedy for injuries from malpractice.
B: Lawyers who pursue cases deemed to be frivolous are liable for
censure, penalties and court costs.
C: Allow for actual damages but restrict "punitive" damages.
D: Criminalize certain acts of malpractice and negligence which are
presently the subject of civil suits only.
- I made a few proposals in my original note, and I really like the details you've provided here. But I think we're still leaving some things out. A good start. Let's keep working on this one.

9. Provide universal access to low cost, generic medicines.
- Sound bite. You cannot FORCE a business to supply any product to government at a lower cost than is available to private (FAIRNESS). Also - Cannot mandate/ dictate price (value) of a product, especially when FDA makes it so hard to approve a new drug. see #10.

10. Allow the federal government to shop - and bargain for - the lowest cost prescription treatments.
- same as #9, They already can, and do. But price controls DO NOT WORK. Remember how market forces operate in the Real World (e.g., Adam Smith).

11. The cost of elective treatments, i.e., cosmetic surgery, will be paid entirely by private citizens.
- A Very Good idea, and while I agree on the surface, WHO DECIDES what procedures are considered 'elective'? What about new drugs and treatments? for cancer, et.al.? What about Abortion? (a *real* sticky issue) What happens when a psychaitrist insists that a young girl's "sense of self and her self-image" requires she get a nose job? Or this exotic dancer needs a boob job to enhance her career? Once you establish a specific class of medical procedures as being NOT COVERED, you open up a Pandora's Box. "Here Be Dragons..." That's why we *MUST* limit government-supplied services to legitmate critical care for those truly in need; not "universal care" for whoever wants it (or can convince a bureaucrat its a good idea). Let the private system cover ALL private issues from the beginning.
Seriously, I *do* like this point, but it WILL end up being trickier than it looks...

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12. After receiving treatments at government expense, reasonable processes to recover those costs must be made via payroll deductions, etc. If necessary, mandated 'public service' to recover expenses. TANSTAAFL.

13. Care is intended for U.S. citizens FIRST. Reasonable steps taken to recover costs and/or expell non-citizens who receive care at U.S. facilities. See my proposals: Harsh? Take care of your own first.

14. Immediate (drastic) improvements in FDA procedures and policies to speed-up the process of clinical trials and other costs associated with bringing new drugs and treatments to market. Obvious.

15. Massive paperwork changes (simplification and standardization?) of record keeping requirements required for government programs: Medicare/Medicaid (see #6).

16. *All* government employees and electied officals *must* participate in this system. Any "special programs" or "special consideration" for non-=critical care (especially for elected officals) are hereby abolished. Possible Exception: Executive branch; but let's think about it.

17. Yes, I'm going to bring up the Sterilization Issue again for government-funded birth and abortion expenses. Yes, it's harsh [shudder}. Honestly, I don't like it. But it seems necessary to prevent abuse of the system. Again: Actions have consequences, and you know them ahead of time. Sorry.

(BTW, let's consider combining 6+7 and 9+10. Maybe add 15 as a sub-point to 6+7. Yes, I know 12, 13, and 17 are serious, tricky, and marginally-offensive to some, but I think they are important in principle and should be tracked separately. Think about it and let's review later.)

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I still believe a better approach is to have the Government become a provider of SERVICES instead of being a source of FUNDING. Please re-review my approach to expanding (fixing) the VA hospital system. (If government cannot fix that, which they already control, can they fix anything?) Competition is a Good Thing, and government can meet the legitimate health care needs by being an alternative provider. This concept has a possibility of reducing over-all system costs by moving (non-critical) indigent care - we need another adjective - out of the private system. It should help prevents RATIONING (which *is* a serious issue) from affecting those who properly provide for their own coverage costs.

More to come... we're off to a good start.

- Steve

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