Friday, October 30, 2009

Re: Arrangement of Parts

Adding more parts to the equation is certainly a Good Idea. We've both said that in our own way. Therefore, I not only empathize with your point; I agree 100% that it's reasonably valid. In some obvious and egotistical way, I am reminded that providing actual SERVICES - not just changing who writes the checks and where they get the funding - is indeed such a simple solution (proposed, as you will remember, by the child-like mind of yours truly).

That said, and as you continue to work on this most challenging subject, I would caution you to remember that (IMHO) the leadership of BOTH political parties in the U.S. have (apparently) failed to understand that business in America is run by actual People... those strange creatures called Human Beings. They fail to realize that constantly calling such individuals 'evil' and 'immoral' and calling their integrity into question (no matter one might justify it) is not an effective method to encourage voluntary changes in how they operate under a given set of conditions (especially when such conditions are dictated and controlled by those self-same politicians).

And lest we forget the ultimate responsibility rightfully assigned to the U.S. voting public --- it has been said that Vox Populi, Vox Dei can be translated as "My God, How did we get in THIS mess?"

Keep in mind that all Human Beings suffer from a natural condition where, under certain difficult circumstances, they may become disheartened. When this happens they *will* take ACTION eventually. First and foremost, they may decide to pack it in, go elsewhere, do something else or just quit what used to be called the rat race. (It might as well be called that again since the government seems to think they’re all rats anyway.)

By-and-large capitalistic creatures - or anyone with an admitted self-interest - are *NOT* high-achieving robots who will obey whatever commands the currently elected political class and their friends in the bureaucracy may choose to issue. Regardless of one's desires or Good Intentions, you cannot 'mandate' or 'implement' or FORCE INTO EXISTENCE a willing slave; at least not for long. He will rebel or he will be worthless. And you cannot force someone to "think of an answer" at the point of a gun. These are truths, obvious to all but those within the beltway.

A government bureaucracy is concerned - first and only - with protecting ITSELF; not with actually accomplishing a specific goal. In fact, far too many see the world as being an expanded zero-sum game, where the size of the pie is fixed and cannot be altered. Adding more pieces (or even baking a new pie) is such a radical concept, they cannot accept it, and therefore It Must Be Bad. The only acceptable solution is to TAKE CONTROL OF THE PIE. Egad, save us from the machinations of the well-intentioned...

I agree that a 'simple child' with an obvious(?) solution to our problems would be most welcome. But, I don't think (a) he exists, or (b) the current ruling class would tolerate or accept ANY 'simple solution' which would limit their personal pursuit of why they got into politics in the first place: the accumulation of Power over Others. *sigh* And so it goes.

If you haven't already, a careful re-read of "Atlas Shrugged" by Ayn Rand is recommended. Caution: Take it in small bites as the subject will distress you mightily; trust me on this. Be aware that you don't have to drink the kool-aid of the story therein, but do follow the logical series of events presented and contrast against current proposals being run up the flagpole. [shudder]

- Steve

Wednesday, October 28, 2009

Arrangement of Parts


Suppose a hungry man looks in his larder and sees he has nothing more to eat than a crust of bread and a stick of carrot. What possible difference can it make what order he eats them in? He's still going to go hungry because he just plain doesn't have enough food. It only makes sense that instead of wasting his time trying to decide whether to eat first the carrot or the crust, he should be out looking for more food.

That to me in a nutshell is the problem with today's debate over health care. In essence, what we are talking about is how best to arrange the parts and everyone has an opinion. Some say the machine will work better if we arrange the parts this way, others say that way - and still others think we ought to just leave it alone. But lost in all this back and forth is the first and fundamental truth that we just don't have enough parts to work with, no matter how we arrange them.

Now the dirty word which always crops up is rationing. But people who throw this word around in the manner of criticism are missing the point. All products, from aspirin to zucchini, are rationed in one way or another. And it is their relative abundance which ultimately dictates what we pay for them.

How many ways and times is this parable repeated in all cultures: a group of learned men are debating complicated solutions to a problem when up walks a child who uncovers the perfect solution by merely pointing out the obvious. When it comes to health care and all our raging, passionate debates, I don't think we ever more needed just such a child.

And that's where I'm come'in from...


Tuesday, October 27, 2009


Thank you for responding to my request. I am inclined to recommend that neither of you consider a career switch to fireman, since I fear the house would have burned down and the fire moved off to the rest of the neighborhood while you dither as to which end of the hose should be connected to the fire hydrant. In short, each of you are living tributes to the awesome power of the Blarney Stone.

I promised you a judgement, so here you shall have it.

Mr. Green, the points you gained for timeliness you promptly threw away by calculatingly incorporating an acronym of my creation into your title. I frown on that strategy. I found your remarks to be disorganized, but refreshingly direct, at least when juxtaposed against the episode of Mr. Rhetts' meandering post. If you are going to make any further headway, I suggest you study the art of conciliation. Always bear in mind that no pill, however efficacious, will ever cure a sickness so long as the patient cannot be persuaded to take it. Work on your delivery.

Now Mr. Rhetts. The next time I am accosted by muggers, I assure you your name will immediately come to mind as my champion, since you would have no trouble talking them to death. I found myself rubbing my eyes repeatedly as I slogged through your post. While Mr. Green is working on his tact, use the time to study Haiku, which is nothing more than recognizing Nature's breathtaking simplicity. Shorter next time Mr. Rhetts... and more direct.

Overall you both have good ideas and have therefore earned the right to continue posting your thoughts in my domain. Sort through what you have offered and weld it all together into a coherent plan. I think you are close.




What we have going on today in Congress is debate over a bill, the primary goal of which is to make health care affordable and accessible to average, working Americans. It won't.

Now don't get me wrong. The bill itself is filled with great, common sense ideas which all ought to be put into practice. Even the dreaded public option and insurance exchanges should have a positive effect. The bill also proposes some other cost saving ideas, from the creation of better electronic patient record keeping to the search, by experts, for more standardized tests and treatments.

Yet stepping back from the problem, I think its fair to say this bill virtually ignores the most significant issue, the basics of which are taught in every first level high school economics class. Bluntly, the problems we are experiencing in health care all go back to the elementary principles of supply and demand. And this pretty much goes against the accepted model of American economics. We have been taught that in all cases, when demand goes up, private industry responds by increasing supply. But for some reason, when it comes to health care, this law doesn't seem to be operating. What we have instead is a perpetual seller's market. For all sorts of reasons, this situation cannot, and won't, continue. The unnaturally high cost of health care, (17% of GNP - and climbing), is siphoning off money from the economy which is much needed for investment elsewhere. Sooner or later this is going to catch up to us as American industries continue to lose traction against international competitors. Steve, this goose of ours can only lay so many golden eggs, and we're running out of time.

As I've said so many times before, government and private enterprise can solve this problem by working together towards practical, attainable solutions. Heck, we all know what happened when government and private industry rolled up their sleeves and built the tools we needed to defeat the world's enemies in World War Two. Health care reform is going to be a tough nut to crack, but we can do this.

Before I offer up a plan, I want to break down the problem into smaller pieces:

First, we have the cartel like behavior of suppliers to restrict supply. I've mentioned before that the U.S. has one of the lowest, if not the lowest ratio of doctors to patients among developed countries. This is, frankly, shocking. Doctors in America simply make more on average than doctors in any other country. You don't have to be a rocket scientist to understand how this low ratio drives up the cost of health care. Of secondary importance to the issue of supply is the extraordinary cost of pharmaceuticals. In every case, right down the line, we pay more in this country - on the order of at least double - what consumers in other developed countries pay for the same drugs.

Second, we have what has become an essentially dysfunctional health insurance industry, the most glaring failure of which has been to mask the effect of limited supply, and government is acting as an accomplice. Here's the math. Health insurance companies are essentially pools of individual consumers who share risk. In effect, what happens is that healthy people thereby subsidize the care and treatment of unhealthy people. There's really nothing wrong with this concept, since no healthy person can ever know when he or she might suddenly become seriously ill and incur catastrophic medical bills. But the reality is that we are allowing insurance companies to stack the deck.

Today, health insurance companies insure profits by a two pronged strategy: increasing premiums (or raising deductibles - which is the same thing) and eliminating by one means or another the most costly (in terms of benefits) policy holders. Government acts as an accomplice, first, by providing Medicare for the most costly of potential consumers, and second, by subsidizing emergency medical care to those who are uninsured and cannot pay. Amazingly, Medicare is a non-deductible health insurance premium which young, healthy workers are required to pay for a class of individuals who are largely unemployed and substantially less healthy. Ultimately, Medicare and subsidized emergency care contribute in one way or another to the national debt. Or, to say this in another way, government relieves private health insurance companies of the responsibility for the most costly policy holders by converting the cost of their health care to debt, plain and simple.

So, to summarize this second point, what we have in place in this country is financial mechanism whereby health care suppliers are able to enjoy unnaturally high levels of compensation through 1, Higher premiums for health insurance, 2, government mandated contributions, and 3, debt. This situation cannot go on indefinitely.

Third, the population of the U.S. is growing older. The median age of the U.S. population has grown from about 33 years in 1990 to 37 years in 2008. Four years may not sound like a lot, but in terms of health care it is huge. I've shown in a previous post that older persons quite simply require more health care than younger ones. The increase in average age constitutes a double whammy. It increases demand while at the same time increasing the ratio of non-productive (retired) to productive individuals. Now you can't simply pass a law which magically makes people younger. But any version of reform out at least to account for this significant demographic.

Fourth, I hate to break the news to you, but we are in a recession. Fewer employed persons simply means that fewer people are enrolled in private health care plans, and employer provided health care insurance is the bread and butter of health care providers. It should therefore come as no shock to anyone that private insurance companies are protecting profits by ratcheting up premiums on a dwindling base of employed persons. And we are now beginning to see the self-defeating aspects of this situation. Economic recovery is being delayed in large part because potential employers are faced, not just with higher payrolls, but with the skyrocketing cost of employer funded health insurance.

Now lets consider these problems and see if we can get beyond blind, political ideology to craft a plan which meets them head on.

I think the most important thing we should do is realize that things didn't get this way overnight and any solution is going to require time and patience. There are things we can and should do to provide immediate benefit. Perhaps the best way of looking at it is if the problem is that you don't have enough roads, you probably should start building more roads. But in the meanwhile, you should come up with ways of better utilizing the roads you already have. I've decided to establish 10 years as a suitable time scale for full implementation. This interval is essentially arbitrary and subject to revision, but at least a place to start. Also, I reject, totally, the notion that health care reform will in the long run require any increase of any kind in terms of government expenditure. This country is already spending a minimum of at least twice what other developed countries are spending per capita on health care, and those countries are providing universal care to boot. Any idea that health care reform is going to cost more money is, frankly, absurd. Now to specifics:

The first and primary goal of this plan would be to significantly increase the availability of certain health care resources by 2020. This goal addresses what I now consider to be the biggest obstacle to affordable health care, which are private, institutional policies, the main purpose of which is not to improve service but to restrict supply and therefore increase profits. In my view, government not only has the constitutional right, but the duty to enact legislation which prohibits or counteracts these policies and therefore levels the playing field to allow for fair competition and equal opportunities.

The short term strategy for increasing supply of health care resources would largely consist of better management of existing resources. The long term goal would be the actual increase of resources.

In the area of health care practitioners, I would institute the following short term strategies:

First, I would commission a blue ribbon panel to create a uniform, federal "scope of practice" certification system to replace the various hodgepodge of state boards of certification. The purpose of this would be twofold: 1, to expand the role in health care of certain professional grades currently certified beneath the level recognized as medical doctor, and 2, to allow for maximum "portability" of certification between the various states.

Second, I would legislate a uniform and liberalized system of certification with regards to foreign trained professionals. Currently, about 25% of all doctors who practice in the U.S. were foreign trained, but this figure could be much higher. The public's perception that foreign trained medical professionals are somehow inferior to Americans is simply not true. Doctors and other professionals who have already achieved certification in other countries should be allowed to immigrate to the U.S. and practice medicine with the fewest possible restrictions.

Third, I would create a federal information exchange. This office would be charged with the goals of 1, storing and providing access to detailed patient records, 2. providing immediate access to approved treatment options and regimes and 3. providing detailed, state of the art answers to raw, prompted diagnostic inputs. The importance of this exchange cannot be overstated. I've already noted previously the immense disparity between Medicare outlays in similar communities. Much of this stems from the truly Byzantine nature of the American practice. Doctors routinely specify duplicate and unnecessary tests. Furthermore, important advances in treatments and procedures trickle down through the system willy nilly. Medical professionals need immediate, up to date access to detailed patient histories and the latest treatments.

Long term strategies would include

First, quite simply, make a larger government financial investment in health care education resources.

Second, I would create a streamlined, goal based college curriculum which addresses the reality that medical practitioners should only be required to study and master the courses which are directly related to their professional career choices.

Third, and this is crucial, I would create a standard definition of "hospital" and thence forward require that all hospitals be required to furnish a minimum level of residency training for college graduates.

In the area of pharmaceuticals:

First, the FDA already has in place a perfectly rational and reasonable approval process for new medicines. My guess is that those who carp about how slow the process is, probably haven't carefully reviewed the process itself or made the effort to understand why each step is important and necessary. Literally hundreds of new drugs are submitted for approval every year, yet few are approved - and there are good reasons for this. Furthermore, you don't jump from the lab to human trials without first taking the elementary precautions to insure that a drug is safe enough to warrant this step. The idea that some private outfit could rush effective drugs to the market much faster is a total shibboleth. What exactly are the methods they would employ that the FDA doesn't already use? ESP?

Second, I would revise the laws relating to patent medicines. Rather than start the clock ticking on a patent when a drug is submitted for approval, I would start it on approval, and limit this patent period to a maximum of 5 years. I would also pass legislation designed to prevent drug manufacturers from gaming the system by filing multiple patents on slight variations of the same drug in order to push back the introduction of generics.

Third, I would allow Medicare, and any other provider for that matter, the power to bargain with both domestic and foreign producers to obtain the lowest possible price for prescription drugs.

Fourth, I would use government's already considerable resources to find and make available new drugs to be produced, marketed and paid for on a royalty basis by private companies. We already have billions invested in taxpayer funded universities and other institutions like the CDC. Why not use this resource to make new discoveries at little or no additional cost to the taxpayer?

All of the preceding ideas are pretty much aimed at increasing supply. Now I know that as a result, whole plane loads of doctors and nurses from other countries aren't going to immediately start touching down at airports, schools aren't going to churn out fresh graduates like so many Kewpee Dolls, and miracle drugs aren't going to descend from the heavens on chariots of fire. And even the short term goals won't have any substantial effect overnight. But at least its a start at fixing what amounts to the root of the problem.

Now we turn to private insurance companies.

My purpose here is not to create a laundry list of all the unethical shenanigans which private insurers are being accused of in the news these days. Some of the things they have been doing are unconscionable. But, bless their little black hearts, what they have been doing is only what comes naturally to private enterprise, which is make the most money they possibly can, by any means possible. Like it or not, that's the American Way. How many poor people do you think, ourselves included, dream of hitting the lottery and then buying a Lamborghini or mansion on the beach - instead of donating the money to charity? Everyone of us I think.

So if private insurance companies are a bunch of greedy little bastards, why not see if we can get these little bastards working for us?

First, I would void the exception health insurance companies currently enjoy from the anti-monopoly laws which apply to all other industries.

Second, I would pass legislation which allows for fair competition among health insurance companies across the country.

Third, I would review and strengthen contract law to prevent denial of coverage based on unrelated technicalities.

Fourth, I would created government managed, semi-private insurance pools where small businesses can band together and use the resulting increase in scale to bargain for lower cost and better coverage. Sam's Small Engine Repair, which consists of Sam and a couple of employees, could then enjoy the same bargaining power which companies like General Electric do.

Now we consider "The Public Option".

We've talked about this one before Steve. The public option, as currently envisioned, is something of a club with which government intends to knock some sense into private insurers. I really don't have a problem with that idea. Private health insurance companies have certainly earned a trip to the woodshed. But just getting insurance companies to make less money is a little short sighted. What we really need is private insurance companies to start taking each other to the woodshed, thereby saving us all a lot of sore arm muscles. Wouldn't you just love to see United Health, Wellpoint, Aetna and Humana going after each other hammer and tongs in a four way throw down? I know I would.

If we are successful in passing legislation which results in fair and honest, across the board competition among health insurance companies, the public option becomes rather a mute point, don't you think.

I think we've pretty much agreed that our private option would involve the provision of actual services to citizens who are unable to pay the full price, for whatever reason, for essential medical care. Since this post has run on so long already I won't backtrack at this point and list all the useful ideas we both have come up with to use existing, government managed resources to meet this goal. But in a nutshell, I would simply combine all related government agencies, such as Medicare, Medicaid, SCHIP and others, into one, hopefully streamlined bureaucracy. Level of service would thereafter be dispensed according to level of entitlement and ability on the part of enrollees to compensate government for services received.

Beyond that, you mentioned in your post a lot of rather Draconian policies which I totally reject, but I will hold my tongue until the Professor has certified both of our posts.

Now last, on the graying of America.

First, we need to start looking for better ways to take care of the elderly. The simple truth is that Americans are getting older. Having just crossed over the 60 year mark myself, I'd be lying if I said this issue is not of great personal interest to me. This country owes its elderly (holding up my hand!) the highest possible quality of life we can provide. But somehow, we must engage in a fresh, honest national dialogue on exactly what the nature of that quality of life should be and how we go about attaining it. I have in mind all sorts of ideas. But most all of them begin with the idea that elderly people need to be considered a precious resource rather than a burdensome liability. And all this crap about "death panels" is not only unhelpful, but entirely misses the point. Personally - when I get to the end of my life, I am sure I'd trade 6 years of lying in bed, waiting to die, for 6 months of worthwhile contribution to society. And I rather think most elderly Americans feel the same.

In my home town there is a free clinic which is staffed by volunteers. All the doctors and nurses who work there are individuals who have previously retired. And what a strikingly positive example that is. AARP estimated that in the year 2000 there were in this country 250,000 retired physicians over the age of 55, and this doesn't even count other professionals such as nurses and administrators. Why couldn't we design, as part of our plan for reform, a national service corp of previously retired volunteers to help out with our public option? That's just one idea. And we can use a lot more like it.

Sorry for the length of this post - but you shamed me into it. Enjoy...


Monday, October 19, 2009

The TANSTAAFL Health Care Plan with Individual Accountability

Yeah.. this is a huge post, but you asked for it, Bernardo... It's only bullet points, and some implementation details are not specifically addressed – I had to start somewhere. It's mostly a re-statement of notes from previous posts. I don't *think* this is everything, but it's far more detailed than many proposals floating around... (and I'm not afraid for others to look at it, either.)


= Funding of government supplied health care programs is defined as 15% of previous-year tax revenues. This funding level to apply for the first five (5) years of the program, then *decreases* by 1% per year for the next five years, ending at 10% of tax revenues. No direct taxation of workers (via paycheck withholding) for health care funding (which only documents deductions / credits). Annual budget starts from documented revenue numbers from GAO. Increases in revenue (or reductions) are applied line item basis, e.g., if tax revenues fall by 5%, then *all* budget items funding are reduced by 5% for the next year. No 'borrowing' against projected future revenues. The only way to increase spending is to increase OVERALL tax revenues – no 'targeted' taxation for this (or any) specific spending program.

= BY DEFINITION: Budgetary constraints will, by necessity, generate limited services (i.e. rationing). This rationing only exists in the public system. Budgetary constrictions mean there will be Clearly Defined limits to the products and services to be provided. It is highly likely in some cases that 'care' will be restricted – for cost considerations – to 'reducing pain', not working on individual 'cures'. So be it. That's the risk one takes by relying on the government for your care instead of taking appropriate steps to provide for YOUR OWN CARE.

= No direct government payments to individuals or organizations OTHER than reimbursement for transfer from private to GHFC facility. Government provides Health Care SERVICES, and is not a payment transfer mechanism.


= No governmental restrictions or regulation of private provider-to-consumer health care transactions. Example: There is no - repeat, NO - restrictions based on the idea, "if everyone can't get (afford) that service, no one can." Life is not fair, either; deal with it.

= Eliminate all (state and federal) restrictions (and mandatory coverages) in the purchase of private health care insurance. In other words, anyone can buy any policy, even across state lines. Using of any reasonable 'group rates' formula at discretion of insurance company, but same group rates are to be available to all who meet qualifications. Consumer may pick and choose coverage items (e.g., persons 60+ years old not required to have pregnancy coverage).

= All health care expenditures (including compensation deductibles) are 100% tax-deductible on the individual's tax return, e.g., all HC insurance premiums are also deductible by the individual. Employers are allowed tax deductions *only* for the administration of health care plans, not the actual cost of insurance. All HC insurance costs paid by the employer are considered INCOME to the individual and reported on his annual W2 as such. (As noted, any deductions from salary are 100% deductible to the individual.)

= Insurance is considered a CONTRACT for services between the provider and the individual. Existing Contract Law applies for enforcement. Once a policy is issued, the policy should remain active and in effect with the individual until canceled or modified by mutual consent, regardless of employment status. Thus, “pre-existing conditions” will remain covered, unless new provider clearly discloses new requirements. No penalties greater than one (1) month's total premium charge to shift insurance coverage from one provider to another. Consumer can change coverage provider, or change program/coverage details, on an annual basis at no penalty.

= Failure by the individual to pay premiums allows provider to suspend coverage. Consideration will be provided for short-term delinquency issues, but if account is no more than three (3) months past due, coverage may not be canceled if account brought current within ten (10) days. Once coverage has been 'canceled' , the individual may re-instate coverage , including coverage for pre-existing conditions, by paying a one-time penalty of one (1) years premium cost, plus the first months coverage in advance.

= Personal Health Care Insurance is not required by law. Individuals may choose to be “self-insured” at their own risk. Insurance will have have two components: catastrophic (long-term) and maintenance (short-term). HC-LT will utilize a Medical Savings Account (MSA) approach, controlled by the individual. HC-ST will be a traditional policy to handle short-term and health maintenance costs. Contributions to either account are considered 'pre-tax' income. Contributions to MSA's may be withdrawn for any reason by consumer, but have a 10% taxable income penalty if *not * used for medical / health related expenses. Earnings (from policy investments), may only be used for medical expenses. Upon death, any remaining funding may be assigned (via stipulations in a will) to a beneficiary, but those funds are treated as “earnings” in the new account and may not be withdrawn for non-medical personal use without penalty.

= Emergency Health Care is provided by any/all public or private facilities (as is done currently). However, if non-insured, the patent is transferred to the nearest Government facility as soon as safe. Once transferred from private facility, the facility has no further obligation to the patient (see Tort reform). Transfer costs are assumed by the government at a defined compensation rate scale.

= All insurance policies must clearly state which conditions and/or services are NOT covered. Consumers are always allowed to directly pay for ELECTIVE (or non-covered) procedures. No limits on the number (or responsibilities) of policies held by an individual.


= All current medical programs – VA system, Medicare, Medicaid, drug program, and medical aspects of social Security – are consolidated and absorbed into a single division – Health Care Services (HCS) – which is represented under existing HHS cabinet department. Budget to be consolidated and separate from all other programs/departments....

= ALTERNATIVE IDEA: existing Medicare and Medicaid programs to be privatized under contract to government, with specifically defined requirements and obligations. Open to (re)bid every five (5) years.

= No more than 10% of HCS funding may be used for administration staff at all levels. Suggested breakdown: 50% staff salaries (health care workers), 40% products, services and infrastructure, 10% administration staff.

= Using the existing VA program and infrastructure as a starting point, the government will provide actual services to individuals, at a Government Health Care Facility (GHCF). There is no charge to the recipient, but patients must be released from care as soon as medically appropriate. Details of care to be defined by GHFC staff. Patient has no voice in defining 'what they want', e.g., using the government system puts the government in charge of treatment to be provided. Point: You can't expect to dictate how you will receive 'unlimited access' to any and all 'possible treatments' when YOU are not paying the bill.

= Disband / Eliminate the Food and Drug Administration (FDA), and replace it with an organization managed by the private sector under contract to federal government. As an example, the Underwriter's Laboratory operates appropriately in certifying electrical appliances. This is the model for a privatized version of the FDA.

= Tort reform: (1) defined caps on malpractice amounts; (2) malpractice limited to reasonable standard of care; (3) adoption of 'loser-pays' approach to reduce frivolous suits. Individuals cannot 'sue' government for care (or failure to provide care). Use of the GHCF system, releases liability from care providers. No one is denied legal remedies for actual injuries or damages, but limits (caps) placed on “punitive” damages. Lawyers who pursue frivolous cases are liable for censure, revocation of law license, penalties and court costs. Legal fees capped at 33% of any court award.

= Education: Student loan financing to medical schools and colleges require civil service in GHCF as a contracted employee. One year service per year of financing. Not unlike concept of getting tuition help for military service, but in reverse (training first, then civil service).

= Mandatory (reversible) sterilization after government pays birthing expenses (or abortion expense) for childbirth at GHCF. Reversing sterilization procedure must be paid in cash, in full, in advance by individual. Children of 'Illegals' are assigned to private adoption agencies – parents are not allowed to remain in country.

= Implement program to implement a national, standardized patient record keeping system within 5-years. System to include computer based diagnostics and test results. To be managed by annual contract once in place. Services to be provided by private bid with no pre-conditions (e.g., union labor, racial company ownership, etc.). Bid must include penalties for cost overruns, delays, etc.

= All elected officials are required to participate in GHCF program. Only alternative is direct (and immediate!) cash payment for services in a private facility. (They are allowed to keep / maintain personal MSA accounts for when they leave public service – but while they are drawing a check from taxpayers, they use the GHCF system as their primary provider. Exception: Personal Care at Walter Reed will be provided for first ten persons in executive branch line of succession and in the cabinet (does not include care for their families).

= Persons working for GHCF system (e.g., for tuition reimbursement, or any contracted staff positions - including non-medical personnel) must use the GHCF system while employed in civil service.


= Deregulation: Relax the restrictions on those health care professionals who are not licensed doctors, e.g., nurses, nurse practitioners, medical assistants, etc., for routine procedures, physicals and minor ailments.

= Misrepresentation and demanding NON-EMERGENCY care at an ER (private or public) is immediately subject to severe legal procedures, starting with immediate jail time for not less than 72 hours.

= Private medical professionals and facilities may refuse to provide non-emergency or elective care at their discretion with reasonable notification to the patient. They must use best efforts to immediately assist with transportation to another facility at their cost - shift to another private facility if covered by individual, or to the nearest GHCF location.

= Non-U.S. Residents who rely on public system (not privately insured) – when released from care - must assume a non-paid position as hourly government worker (building roads, janitorial, etc.) until 80% of spending has been recovered.

= 'Illegals' (even those with insurance coverage) are treated – either at private or public facility, based on payment status – however, they are not released. Instead they are transferred to INS and *immediately* shipped to country of origin. Repeat offenders become unpaid permanent staff at correctional facilities (prisons, etc.), and are not allowed access to public. Cost of transportation and maintenance of illegals counts as 'foreign aid' and reduces ALL available funding to those countries accordingly.

= Usage of government health services by individual who remain gainfully employed have 25% of wages automatically garnished until 80% of expenses are recovered. 100% of any income tax 'refunds' are retained.

= Manufacturer pricing of drugs and other medical supplies to private organizations capped at no more than 25% above or 10% below cost paid by GHCF for same item.

= Fraudulent use of GHCF goods and/or services is a felony punishable by not less than 1 year in prison per count if convicted.

= If private insurance does NOT cover a specific procedure, and consumer unwilling to pay, then private facility may transfer case to GHCF, where care follows rules there. Example: if policy specifically doesn't cover CANCER, patient may pay out-of-pocket or be transferred to GHCF.

= Actual costs of ALL medical procedures and services will be clearly stated and must be acknowledged line-by-line by the patient. This is required for both private and GHFC billing. Non-immediate (or elective) procedures must be accurately estimated and acknowledged before treatment begins. Where possible, costs for various options must be presented and consumer chooses which is performed. (NOTE: It is likely treatment options with the greater chance of success will *always* be chosen, but there are frequent situations where the costs of doing things in a particular sequence vary with little/no impact on the expected results – this must be disclosed to the consumer.)

= Voluntary contribution program: individuals may choose to apply a portion of their income tax refund to assist people who have no insurance and rely on GHFC services. (As with election campaign contributions.) Also, tax deduction for those who pay for private coverage for others (direct payments only, not insurance).

* * * * *

Did I miss some things? Highly likely. But you can't say I didn't try...

Yes, dear Professor, the horse is dead and we should dismount.

* * * * *


Pundits and 'Radical Change' proponents begin with the premise that everyone has a fundamental right to have someone else pay for their health care costs, just as everyone has a fundamental right to have someone else pay for their children's education. The result has been a government-run school system that has been clearly proven to be less than optimal by any reasonable standard of measurement. Question - Why do we think government-run Health Care will be any different?

Are the problems we have providing health care services severe enough and common enough to justify fundamental changes in 1/6 of the national economy? It's arguable that, yes, the system is broken. If so, what do we fix first? I ask that simple question because the changes we *know* now will not happen is (a) some modification of the malpractice laws and (b) general tort reform. It's likely there are several more sacred cows that are 'off limits'. Let's be real for a moment – the proposals being batted around (unlike what we discuss on this blog) are not and has never been about addressing the problem – it's about politics: Control and Power over people.

I'd like to point out (again) that Tennessee and Massachusetts have already adopted variations of the current proposals a few years ago. That should give us a picture of how well these proposals will work in the real world. So... Are they working? *THE* major criticism of the present system is that we spend far more, on health care than anyone else; we're not getting our money's worth. This leads to the obvious: let's look at the implementation of government-run Health Care in Tennessee and Massachusetts... Have costs gone down? Hmmm...

Let me ask, one last (?) time, where did this obligation for pay ME to pay for someone else's health care come from? Exactly what objective principle justifies confiscation of one person's property to be used for direct benefit of another individual? (I don't care if we're already doing it for other reasons; it's still wrong!) 'Mandated charity' is NOT charity; it's redistribution (theft).

The argument that “doing this will save money if everyone is put under a health care plan, and the preventive medicine process alone will save huge amounts” is, quite simply, wishful thinking at best. We don't need health care reform to, for example, put a tax on soft drinks - so while we're at it: if 'sugar' is so bad, why not end the sugar protections and subsidies already on the books? (If you think that task is easy, look back upon decades of farm subsidies for tobacco farmers.) Is there any evidence that preventive medicine applied to an entire population lowers health care costs? Cleaning up toxic wells and providing clean water certainly works. But does 'encouraging' people to exercise more and lose weight actually work? It's not going to be one-size-fits-all, no matter how good the intentions are – it's going to be one-size-fits-NONE.

Out the political world, the 'experts' are not even able to tell me what these changes that “must” be included are even going to cost – and seem strangely obsessed with keeping ME from looking at the details of their plan before THEY vote on implementation. Paranoid? I don't think so. After all, all these machinations are because there is an unjustified belief that, somehow – this time, this time – government will prove itself capable of managing Health Care for the entire population within our borders, *better* than it has managed Amtrak, the Post Office, Social Security, Fannie Mae, Freddie Mac, FHA, FDA, the DC public education system, etc., etc., etc...

*THE* reason health care costs so much is the last two years of life. If we could eliminate those two years we would no longer be spending more than other countries. And THAT is where the Real 'Moral Dilemma' exists. We know how to save the money. Have the good grace to die – do it for the good of country! It's your duty to die!

The Real Problem is being able to identify - AHEAD OF TIME - that you're in that "last two years". Sometimes (i.e., with a terminal illness), that analysis is easy; but at other times (treatment just "didn't work") , figuring out you're at the end of the line isn't so simple.

Seriously, the moral dilemma comes when you try to plan out WHO makes these End Of Life health care decisions? And WHO pays pay for them? If the dying person has the resources to pay for all that expensive treatment, should the state step in and prevent that "waste", so the money can be inherited (and subject to inheritance tax)? And WHO speaks for the dying person? Themselves? Can they assign that responsibility to someone else (e.g., a family member)? Who decides if a person is mentally competent to make a life-death decision? Does the interest of 'the country' take precedence over the decisions of the individual?

I personally *start* from the position where the property owner has the right to use that property to preserve every last second of life (or use that property for *any* purpose) - IF THEY SO CHOOSE.

But that's just the beginning ... suppose someone doesn't have the resources – and now 'society' must pay for their end-of-life expenses... WHO is obligated to make that payment? Is it an entitlement for all and an obligation on the public purse - and WHICH public purse are we talking about here: Local? State? Federal? If it's an entitlement, then it could be argued those funds are actually the property of the patient, and therefore, the individual decides whether to spend great sums on staying alive... Circles within circles within circles.

No one wants to be accountable – they don't mind making the decision, they just don't want to be accountable – for deciding exactly when prolonging life at great expense isn't worth the cost. What about a 90+ grandparent needing quadruple by-pass heart surgery so they can have a few more good years (who knows how many)... Now what? If we are going to seriously focus of controlling costs, these are the EXACT questions that need to be discussed by these self-proclaimed decisions makers in Congress. And they WILL NOT DO IT because the political implications are *HUGE*.

If it is all about controlling cost – the 'solution' is obvious, since the massive portion of the cost is spent in the last two years of life. There is only one question: WHO DECIDES?

** CONCLUSION (Yay!) **

On this blog, we've tried to sincerely work on finding and discussing the PROBLEM and what we might be able to do (and live with) to address the Real Issues.

At least, *I* feel better for having tried. Enjoy.

- Steve

Monday, October 12, 2009


By my reckoning, you have over the last two and half months submitted 27 lengthy posts on health care reform, not to mention three amusing cartoons as well as several odd comments... and still you are individually no closer to formulating even the rough draft of a plan, much less one you can agree on.

As I mentioned to Leonard "Lips" Carrigan, upon drawing the club seven to fill my straight flush, "It's time to put up or shut up.", a challenge, by the way, of singularly powerful impact upon a man of Leonard's reputation, who would have wandered the world naked and destitute, for all time, rather shut up (Yet considering the exasperating banality of his discourse, I wish to this day he had folded).

To paraphrase a poet of my liking, I think you have miles to go before you sleep. But I on the other hand need my rest.

Mr Green, I will allow you, if you wish, one more of your confusing diatribes before submitting a workable plan of action. Mr Rhetts, since you have absorbed enough of our attention to details, I expect your next post to answer, directly, my challenge.

Gentlemen, if I haven't made myself clear enough, I challenge you to stop sniping from cover. Come out of your foxholes and attack this issue as men. Give me a plan! I won't promise you a fair, or even equal judgement. But a judgement you shall have.


Sunday, October 11, 2009


I had a problem with your last post on health care. Reading it, I was reminded a little of what started our occasional debates almost a year ago now. This was the video circulated by the RNC at that time which tried to blame the current recession on the Community Reinvestment Act. Interestingly, this same line of attack kicked off a foul smelling lump of propaganda masquerading unconvincingly as journalism on Faux News the other night: "The Truth About Acorn", hosted by Faux's resident glamouroso, Megyn Kelly. Oh and by the way, after watching (most of) the program, I immediately sent a donation to ACORN. No kidding.

What originally struck me then about this profoundly implausible claim was how it seems to have been constructed from the top down. Someone, somewhere looked things over and decided what would resonate among conservative apologists, then pieced together this remarkably lame counter-intuition, and the game was on. Conservatives, not any more than liberals, don't want to believe the policies they accept as gospel could possibly contribute to a financial crisis of this magnitude. I said almost a year ago, and I'll say so today, that the mortgage meltdown was an economic phenomenon which transcends any attempt to define it as the product of a political philosophy. If there ever was a runaway train which left government in its tracks it was this. Liberals and Conservatives just need to man up and stop pointing fingers.

Anyway, back to your post. I get a sense that you've subconsciously taken the same top down approach while trying to determine why supply and demand doesn't work in health care. Since you are in the habit of believing government is always the problem, it wouldn't occur to you that in some industries at least, private enterprise exercises all sorts of strategies to limit supply, and therefore increase profit. Health care is clearly one of those industries. You say:

with the operation of the marketplace. These outside manipulations take many forms: regulatory requirements, limiting growth of supply (restrictions on accepting applicants at medical school and certification of graduates), etc., etc., etc. Attempts to manipulate aspects of the marketplace is a significant contributor in WHY "it doesn't work". And, sadly, a huge portion of that interference has, at its root cause, government action(s). Doesn't matter if the intentions were good, or even necessary, its still interference in the marketplace." (emphasis added).

Actually, government's contribution to "limiting growth of supply" in this case is secondary. The real culprit here is medical licensing, which in this country is directed by the American Medical Association - a private institution. Go here to read a thorough report on the issue: "Medical Licensing, Do Economists Agree?". The Report is more or less a series of excerpts from the works of other economists. Here are a few:

"Restrictive licensing can . . . result in declines in the quality of received services in that there may be (1) self-substitution of inferior products and/or services . . . ; (2) decreases in the average per capita service time rendered; for example, short, hurried, delayed office visits with a harried physicians; (3) differential geographic availability as numbers are reduced and the remaining members of the profession can choose their locations with more discretion, such as doctor shortages in rural areas; and (4) increased waiting time for provision of a service where delay in service entails expense for the buyers. (Carroll and Gaston 1979, 2)"

"...a clear consequence of licensure is to inhibit the production of information concerning the comparative performance of practitioners and hospitals. This in turn reduces the incentive to introduce innovations that would facilitate comparative evaluations and improve quality control. (Benham 1991, 89-90)"


"Economists see state licensing as a source of cartel power among physician groups. Kessel (1958 and 1970) pointed out that licensing requirements increase returns for existing practitioners at consumers’ expense. He was especially concerned that graduation from an American Medical Association-approved medical school was a condition for admission to state licensing exams—allowing organized medicine to control entry to the very market it served (1958, 283)" (emphasis added).


"Economists have, for some time, suspected that occupational licensure operates as a legally sanctioned cartelization device, restricting entry . . . and restraining competition. . . . Excessive limits . . . can result in monopoly rents for members of the profession and higher prices and fewer services for consumers. (Martin 1980, 143-144)"

Now I want to keep this post at least a little shorter than "War and Peace", so I'll just try to summarize to give you something to chew on. While reading through this report, I was reminded of your earlier argument that doctors, indeed, all medical professionals, have every right to charge whatever they want for a skill which they acquired through a large investment in time and money. Well, I couldn't agree more.

But what if the same medical professionals band together in private institutions like the AMA and convince government to undertake regulatory practices which restrict supply and therefore artificially inflate prices? Now it may be government's fault for abetting this undertaking, but significantly, it wasn't government's idea in the first place. To my mind, if government is to be blamed for anything, it is a failure to act in a manner which you yourself apparently dislike: that is, to regulate medical licensing, scope of practice and education for the greater good of all.

This article is a lot shorter, and (to my intense annoyance) something of an unjustified hit piece against Barak Obama and the direction he is taking towards health care reform. But it does nicely sum up the reasons why I am pointing to a dysfunctional market as the root cause of high prices in health care. Have a gander.

I started this post by referencing an earlier exchange we had on the mortgage industry meltdown and my own observation that it was and always has been a phenomenon organic to the general evolution of basic economics in this country and not the consequence of one political misstep or another. I feel the same way about health care.

My view is that the general direction of reform currently being taken in Congress is helpful, necessary and well intentioned. But we aren't going to make any real progress until government wakes up and starts patiently addressing the problem of supply.


Friday, October 9, 2009


Caroline Moore is the 15 year old amateur astronomer who, at age 14, became the youngest person ever to discover a supernova. And not just any supernova. Astronomers believe her star, 2008ha, represents a new category which lies somewhere between a nova and a supernova. If so, this may lead to some interesting new theories about this kind of object. You can read all about it here.

I happened to catch a short interview with Caroline on the Rachael Maddow Show last night. For a 15 year old, this little girl is amazingly smart, energetic and poised. She is exactly the kind of person we need to singling out for our young people in school to follow.

If you go to any of the links in this short post, the one I would want most for you to visit is this one, which features Barak Obama in company with Caroline and another bright young astronomer, Lucas Bolyard, at an event held at the White House in recognition of their work.

I get so discouraged sometimes at the incivility and unreasoning paranoia being directed at our President these days. Watching this video, its hard to imagine he's the same man being called everything from a covert, Muslim terrorist to a reincarnation of Hitler, not to mention an outright liar in the halls of Congress.

Now its fair to argue against the President's ideas. But these incessant - and loathsome - character assassinations are more an indictment of the people who are ignorant and churlish enough to not only believe them, but to repeat them over and over in public - as if repeating a lie somehow makes it true.

I'll admit, I didn't much care for most of the policies and decisions of George W. Bush. But even in my wildest rants against those policies, I never considered him to be anything less than a man who was trying to do what he felt was right for this country.

It strikes me now that some of these noxious allegations against the President are exposing one of the most repugnant sides of human nature. At our worst, we want to believe that anyone who disagrees with us is just plain evil. And this isn't because some people are nasty or selfish, but because they suffer from the more common affliction of being intellectually lazy. Why bother to take the challenging and difficult course of actually educating yourself on the facts, when all you have to do is believe Obama hates white people, or wants to kill old people, or wants to be the next Hitler, or is... well, a liar?


Thursday, October 8, 2009

Health Care & Supply and Demand

Chris, I enjoyed your last post. A wealth of information and comments. And thanks for your compliments. You are a source of knowledge and insight as well...

Yes, there are 'disconnects' with traditional views of "supply and demand" when it comes to Health Care. After all, it is frequently a "life or death" decision. In that situation, you don't CARE what the cost is. If it’s a choice of paying whatever price is demanded or losing your life, you will pay whatever is demanded, even if it utterly impoverishes you.

The problem with areas where Health Care is in high-supply is that with fewer customers per provider, each provider must charge more to get the amount of profit that he desires. Because all of the providers in the area are operating under the same "Money-Or-Your-Life" Rule, they all do this. In this specific case, "normal" competition can’t drive down prices. Further, when the whole industry operates under MOYL Rules, there’s no real driving force for competition. By analogy (a slippery one) an increase in the number of muggers in an certain area does *not* decrease how much money they obtain from each victim.

But back in the real World and away from theory - even with Health Care... With respect to the supply side (i.e., how many professionals are out there working), when faced with an increasing demand and stagnant/decreasing supply the price will increase until supply catches up with demand... exactly according to Supply and Demand principles. Frustrating to find a simple answer.

But when you scrub away all the reasons you gave for WHY Supply and Demand doesn't seem to work, there *was* a common thread... interference with the operation of the marketplace. These outside manipulations take many forms: regulatory requirements, limiting growth of supply (restrictions on accepting applicants at medical school and certification of graduates), etc., etc., etc. Attempts to manipulate aspects of the marketplace is a significant contributor in WHY "it doesn't work". And, sadly, a huge portion of that interference has, at its root cause, government action(s). Doesn't matter if the intentions were good, or even necessary, its still interference in the marketplace.

I note that Paul Krugman (among numerous others) just can't accept that the reason there are "no examples of successful health care based on the principles of the free market", is simply because We The People (via our requests/demands to government) keep sticking our fingers into the machinery. He seems to think that adding more and more Zeros (laws and regulatory bureaucracy) to a sum increases its value.

I admit one serious aspect about health care is that it’s complicated. Many people are unwilling to do the research for real comparison shopping. That’s why doctors are supposed to follow an ethical code, why we expect more from them than from bakers or grocery store owners.

BUT STILL... IMHO, (Re)Introducing the Consumer to exactly WHAT the costs of care ARE (or will be) will do far more to reduce costs (via increased competition) than any 'mandate' or 'bureaucratic decision-making'. Sure, some people won't do it (or do it well), but that should not prevent *ME* from having the option to retain ultimate control of my treatment.

Just more food for thought...

- Steve

Wednesday, October 7, 2009


I'm sorry about what happened with Phil. I wish I was better at moral support - but usually when something bad happens to a friend the best I can do is stand there beside them and bawl. Anyway, maybe this blog will help you take your mind off that while you wait for the next (!!*#%!??!!#%!) court date...

I had started another post while waiting for you to put something up. I'm going to use some of it it this one.

As you know, I sometimes tend to over analyze things. But the more I think about the issue of health care, the simpler it gets. Oh and by the way, in some ways you're a pretty smart guy. It looks to me like you've got your arms around the real problem. More on that later.

While reviewing what I've learned, it struck me forcefully that most efforts at health care reform are about as logical as trying to build a house by starting with the second floor. Forget ideology for a minute and consider this:

It almost doesn't matter how you manage the delivery of health care. One side (mine) justifiably points out the horrible track record of private insurance companies and wants a public option to pound a little sense into these miscreants. The other side (your's, I presume) paints a picture of ham handed government bureaucrats mucking things up, just like they always do. To be fair, I myself conceded this point when I cited this country's bloated military budget a few posts back.

So, pick your poison. Government or private rationing of health care. It's a fool's choice when the real problem is that there isn't enough health care to go around in the first place. Steve, you can only get so many miles out of a mule, no matter how many carrots you dangle in front of it.

Somewhere in my research I recall a statement to the effect that just giving everyone an insurance card isn't going to "reform" health care one bit. What we have in this country is a noticeably smaller supply of providers (relative to demand), across the board, than in just about every other developed country. Given this situation, it seems logical that providers, since they are in short supply, would tend to charge more and therefore drive up health care costs. When viewed from this perspective, it is only reasonable to wonder if indeed the health care delivery systems in other countries work better than ours - not necessarily because they are designed better - but because they have more and less expensive resources to work with.

Now if you are a fool, you can just pass a law which says doctors, pharmacists and hospitals must reduce their charges by half. This isn't going to magically produce more doctors, prescription drugs or hospital beds.

One study I came across indicates that the 2005 median net monthly income for physicians in the U.S. came to about $8200.00, which is far and away the highest in the in the world. The next closest was Taiwan, at $5388.00. Doctors in France averaged $3210.00.

Now if the free market was working properly, one would think this potential for higher income would attract more people to the profession, which would result in more doctors, which would result in a greater supply against demand, which would lower doctor's salaries. To me, this is the way the market is supposed to work. But for some reason it doesn't.

Another study confirms that the U.S. has one of the lowest ratios of doctors per capita among developed nations. France for example has 337 doctors per 100,000 of population, Germany has 337. We have 256.

I wrote about prescription drugs in an earlier post. In this study on antidepressants, the U.S. is at the top of the price scale in every case. The price we pay for this kind of prescription always higher here than in other countries - by an average factor of two to one. I'm quite certain that if you look at any other drug, the relative differential will be the same.

What about hospitals? According to a Kaiser report, despite the fact that aggregate, community hospital profit margins are at an all time high, hospital beds per 100,000 of population have steadily declined - from a whopping 436 per hundred thousand of population in 1975 to 266 in 2007.

It seems to me we ought to be looking at why, despite high demand, the supply remains low. Surely we have enough qualified young people who are interested in a career as a medical professional. Yet according to an OECD study, the number of medical graduates in this country (as of 2007) comes to 6.3 per hundred thousand of population - well below the OECD norm of 9.9. Another interesting number revealed by this study is a little counter-intuitive. Despite the fact that doctors in the U.S. enjoy the world's highest rate of compensation, we seem to be attracting foreign trained doctors at noticeably lower rates than many other countries where compensation is lower.

I think what these numbers are telling us, over and over, is that as an industry, health care in this country simply does not follow the normal principles of supply and demand. With all the money being spent on health care in this country, it is almost incomprehensible that more providers would not be jumping into the market and ramping up competition - thereby lowering costs to the consumer - the same as just about every other industry. Lately, I've begun to believe the answer for this isn't as complicated as we think it is. What if...

Hardly anyone these days actually goes to a doctor, receives a service and then pays for it on the spot (a point you made, thank you). Generally speaking, health care providers are almost always paid by intermediaries, such as private insurance companies or some government program. What if we woke up tomorrow and no such intermediaries existed...

Pretty scary thought, huh? But think it through. Steve Green (or Chris Rhetts) goes to a doctor, finds out he needs battery of tests, followed by some critical surgical procedure, followed by a lengthy schedule of follow-up treatment and medicines. Cost? Oh, say a couple of hundred thou. Now I know I don't have that kind of money laying around (If you do, can I borrow some?). End result: we don't get the treatment because we can't afford it. That, by the way, is precisely the situation which many millions of Americans find themselves in today.

In my research, I was literally flabbergasted to learn that 5% of the population accounts for almost 50% of all health care expenses. Just as amazingly, the lower 50% of spenders account for only 3% of health care expenses. Continuing on with my "what if"...

In health care, what intermediaries do in a nutshell is collect a little money from everyone in order to pay a lot of money on behalf of a very few. But if that didn't happen, what would result is some incredibly radical changes in the health care market. What I mean is, if health care providers had to compete for the individual consumer dollar, just as most other industries must do in a free market, the whole industry would be turned on its ear and costs would drop immediately.

I think now we need to start building this house from the ground up. For the moment, maybe we should realize that although you can relieve traffic congestion by better management of the roads you have, the real solution is that when there are more cars, darn it, you just need more roads.

I'm going to start right now by admitting that this health care crisis (and it is a crisis) we have in this country is not going to be solved overnight by some magic formula which all of the sudden has Dr. Howard or Dr. Fine rushing to my doorstep every time I have a case of the sniffles.

Oh, and the "smart guy" part... I meant it. Turns out this crackpot idea of yours which begins with some dude going to a doctor and actually paying for it, just like I did the Shasta Daisies I bought at WalMart last spring, doesn't seem like such a crackpot idea after all. Stop gloating.


Health Care musings

It's been awhile since I posted anything. Here are a few random comments... In the future, I'll be (hopefully) more organized and (hopefully) more precise with (hopefully) less speaking-off-the-cuff as this missive will prove to be... hopefully...

- There is one thing we could do NOW, do easily and it would have a nearly immediate anc clearly positive impact: Allow individuals to buy (private) policies offered in any state, not just the state where they live. #1 - This will enhance competition. #2 - It will force the state regulators to take a serious look at just how much existing rules and regulations affect competition for insurance dollars... Yet, no one seems to talk about this option. I wonder why buying an insurance policy from the Government (the so-called 'public option') - which is essentially buying a specific policy across state lines - is just fine and dandy, but buying a private policy is somehow Wrong.

- If the driving force for reform is to provide the best possible patient care, let's agree to take any government-controlled "public option" off the table. Whenever it has been tried - repeatedly, and around the world - it has proven to result in long waiting lines to see a doctor, substandard care, and an end to medical discovery (among other things). Caveat: Not that such approaches are 100% totally wrong or inadequate, mind you, but enough to matter when you compare Care against Care. We have no reason to believe it will be different this time, just because OUR government is doing it. There is plenty of time to go down that road LATER... *IF* providing care is the Real Goal. (If that is *not* the Real Goal, it certainly explains a lot about all these proposals, doesn't it?)

- I haven't seen many proposals such as new incentives to purchase low-cost health savings accounts by individuals, providing tax credits for individuals and families buying health policies on their own, and extending subsidies for those who can be reasonably shown to legitimately (and temporarily) need financial help. What is wrong with incremental steps? Oh, no, we need a 'complete overhaul', and we need it RIGHT NOW!... Why? Someone explain why amputation is the only solution for a hangnail...

- What about the right of patients to privately contract with physicians to ensure they have PRECISELY the medical care they want, without penalty—regardless of what the government pays? Today, if a doctor wants to bill a patient for additional payment over the Medicare reimbursement, he has to withdraw from Medicare entirely for two years. A patient who agrees with this arrangement can't receive any Medicare money for that period, either. Why is this particular regulation even in existence? Someone explain to me Who, exactly, is losing in the equation when the money (and the decision) comes out of the consumer's pocket and not the taxpayer's?

- Where is the simple acknowledgment that we need PEOPLE to provide all this medical expertise? If you cut payments going out and increase bureaucracy, it is almost 100% certain fewer individuals will enter the medical field. And that's not even considering finding enough qualified TEACHERS for those programs... Look, every patient wants to have the best possible medical professional on his case, according to HIS judgement. Trust me: a patient with cancer wants to see a doctor who has had years of training in oncology *and* is knowledgeable about the latest ways to beat the cancer. It appears that in HR 3200 - e.g., the 'medical home model' section - physician assistants and nurse practitioners may *NOT* get the authority to make important medical decisions. To say nothing of the PATIENT. What makes a bureaucrat MORE QUALIFIED?

- Discussions on Real Tort Reform with respect to Health Care are (strangely) missing... Statistics from private insurers (and a Justice Department report of 2007), indicate 80+% of malpractice cases are closed without payment. Moreover, when there is a trial, the physician (defendant) wins 89% of the time. What is glossed over is that these lawsuits, even when dismissed or closed without payment, cost doctors time and money, and encourage defensive medicine. This adds billions to the cost of medical care. It also increases malpractice insurance premiums - and you better believe that cost gets passed on to patients. This is so obvious, it make one wonder exactly WHY the topic is not part of the conversation ANYWHERE.

- What I *really* want to see - from EITHER party - is a plan that focuses on the real MEDICAL issues facing patients and doctors, and manages to keep patients in control with doctors as their trusted advisers. Sorry, I just don't see where adding a brand-new, all-powerful bureaucracy HELPS any *any* level.

*** just food for thought...

- Steve