PrintJuly 23, 2009
Healthcare Policy, Social Justice and Thugs
Policy Makers say the only way to achieve social justice is to deliver an equal and adequate amount of health care, directed by a well motivated government central plan. No more crude private system, flawed, uneven, and unfair.
I have a day job as a physician. A great job, a wonderful job, better because I do it in the emergency department at a very big army base, so I can thank soldiers and retired soldiers for their service. I also get to teach, and emergency medicine is a great niche for a physician suited to it.
I did my internship at Harlem Hospital in New York, then was a solo general practitioner in a little Nebraska town, followed by a great variety of practice situations in places big and little. I was a student when Medicare started, knew Medicaid in its early years as a ghetto practitioner, ran an HMO in 1980 and 81 as CEO and Medical Director in the early days of managed care, after I finished law school.
My theory or hope (actually, my illusion) was that managed care would reward an effort to provide efficient and effective care. I am an optimistic person, and managed care taught me about pricing and markets for resources -- the basics of economics and insurance. HMO of Baton Rouge went bankrupt in spite of my efforts to make good on my idea that managed care and managing health care costs would be economically viable. No way we could have succeeded without an effective vice president of rationing.
I will admit that since the bankruptcy of HMO of Baton Rouge, I have no interest in being a "manager" and insurance executive, but, like all physicians, my life is being a doctor, like my dad (a general practitioner), my brother (a general surgeon) and my sister (a neurosurgeon). It therefore gives me great sorrow to watch elites and experts and politicians destroy what I have watched become one of the great achievements of America, a health care system that provides incredibly effective technology and treatments for all kinds of things.
When I started in practice in Elgin, Nebraska, a town of 900, in 1972 there was much less technology available and certainly less than that available to big city patients. Things changed and expectations of patients, resources, and mobility increased, so that rural and city medical care in America is now quite sophisticated.
What we developed in American Healthcare, for various reasons, will soon begin to go away. Soon the budgets and the efforts will be pinched and become mediocre under the new proposed Healthcare Takeover plan. However, I must say I saw the beginning of the death of good American Medicine 35 years ago in the office of the Elgin State Bank, where the banker sold Blue Cross and Blue Shield insurance, the dominant insurance of the day. The price was great, but I knew that people were going into the only hospital in the county for checkups and sometimes older folks were hospitalized for custodial care during family vacations. Blue Cross had a high tolerance for inappropriate use, the premiums started to increase, and people started to complain, but continued to enjoy hospital care when outpatient care meant out of pocket expenses.
My experience with Medicaid, intended as Medicare for the poor, when I returned to the big city in 1974 and took up a practice with poor patients, was scary. I was so desperate that I went to the Nebraska capital, Lincoln, and pleaded my case to Medicaid officials to hurry up their payments for my predominately Medicaid practice. I wasted my time. I was an outlier in the world of medicine, a goofy do-gooder, during the days when physicians were jumping into higher income brackets.
I went to Louisiana after law school in 1979 for the job I thought ideally suited for a physician-lawyer who was interested in health care economics and policy. I became the benefits and patient care referee, CEO, Medical Director, dealing with a limited premium budget and an insatiable demand from patients. Patients paid a "community" premium, level for the program with no underwriting allowed for preexisting conditions -- no protection at all. We had some patients who got open heart surgery the first month they joined the HMO. That's the way it was for federally funded HMOs (Nixon was the author of an elaborate managed care start up and funding plan, imagine that).
I was the manager between people who couldn't understand the word no -- the patients and members of the HMO would wanted Cadillac medical care 24/7 for their community rated premium, and people who couldn't tolerate saying no -- the physicians and board of directors, influenced by federal experts who believed in lavish benefits combined with a level, one size fits all, premium.
The HMO went into bankruptcy, and I was then occasionally asked to make speeches on why HMOs go broke. I saw patients, tried to keep costs down, but I was fighting a losing battle, because the economics were against me. The bankruptcy was a disappointment and took a lot out of me, but taught me many lessons about patients, insurance, and medical care.
In 1983 I retreated to emergency medicine for thrills and predictable hours and because my nurse wife loved emergency medicine too. There is not enough room here to describe everything I did after that, but I ended up in a medium size town in Texas, because Texas was my kind of place. Not bad for starters and I finally had a good lake for working on water skiing.
Now I am too old for a new career, and teach emergency medicine to army neophyte emergency residents at a big base hospital. I am watching the Texas Medical Association, once a proud and independent organization that stood for the physician role in society and for the benefit of patients, along with every other damn medical society and association, delude themselves into accepting socialized health care. These physicians go to college, listen to socialist smart ass professors, come out convinced that the welfare state and Marxism are well meaning and just need more planning and money. They also feel guilty about being privileged and well off -- and they think the rich need to contribute for the benefit of the poor.
We end up with leftist, socialist, welfare state insanity supported by the smartest guys in the healthcare system.
I found out that HMO managed care is insurance writ large, a total package on the promise of a premium that looks good. The trouble is, there is no way to ration care to the over-users who have no incentive to be rational, and have veritably unlimited access. I see the same thing in Military Medicine, but ignore it, since I do believe that Military Medicine is intended to be easy access as a reward and a thank-you.
The health care crisis in America is not about the quality of health care, but about sticker shock to people who believe and have believed in the free lunch. The political theme is the health care system is broken and too expensive -- and that must mean someone is a victim and someone is taking advantage
There is plenty of talk today about the broken medical care system, inefficiency and waste and the prospects of government-planned better quality and how a more accomplished central planning effort and more rules will create better care at a lower price. All the yakking is a distraction. Even the providers, who know the truth, will join the government plan to save, short term, their economic status. Some hope to maneuver a place on the planning committee and receive favorable payment treatment. They also recognize political pressure and know it's a dance; planning doesn't control silly overuse and lack of economic incentives. They know the system will never be sensible until people start paying their own bills for service. However they also aren't inclined to blurt out the truth to guys with an attitude.
Last night I saw patients, just me and the nurses and the patients. No committee; the association executives and insurance people were asleep, and so was the administrator of the hospital. Just me, thanking soldiers for their service and asking patients what the problem was, coordinating with the radiology and lab and nursing staffs, a plan that was in my head. With a ball point pen spending some money, not as much as residents spend because they are under pressure to over achieve, but still spending hundreds of dollars with a stroke of a pen to answer questions of great import to the patients and to their physician, me.
That's the nature of being the decision maker. I have lived a good and rewarding life being a physician, that's why I must say I am very concerned that my profession is allowing the calling to become a matter of servitude to a government entity, and not a service to the person on the exam table. I am concerned about non-physicians and no-longer-physician-chatterers clogging the hallways and forums of state and federal capitals, pretending that they have special knowledge of the health needs of Americans, what will work, and how to pay for it and achieve social justice.
I am saddened when a conservative physician Senator, a fine man from Oklahoma, sponsors a Republican Bill of 1000 pages in response to a Democrat bill of more than 1000 pages, on the theory that there is a lighter version of overreach.
The vast majority of the uninsured do not need care -- they are young and healthy or they would already be in the safety net. There is no uninsured crisis. The cost of uninsured care in the United States is less than 50 billion, much less, because the bill of 120 billion is a bill of lost income, not cost. Cost is half of that-- 40 to 50 billion, and the uninsured pay 40 or 50 billion, so one might call uninsured care a wash. It's not forbidden to pay for healthcare with cash money, is it?
So the cost of uninsured care is 2 percent of the total cost of American health care. The studies show that they don't suffer ill health because of lack of insurance -- that is another shibboleth put out by the left. Lack of insurance is not a disease I know.
To address another obsession of the public and politicians, encouraged by my whining emergency physician colleagues, the uninsured who go to the emergency department are not that big a problem. In fact the total cost for emergency care in America uninsured, and insured, is 120 million visits at a cost of less than 1000 dollars per visit. That is well less than 5 % of the 2 trillion plus total cost of healthcare in the US. So the crisis is?
So two phony crises are enough to take down the whole system and reconstruct it, and put it in the hands of the organization that gave us the FBI, the CIA, the State Department, the VA, the Post Office, the Department of Education, or the EPA and the Department of Energy and the Department of Commerce. Is there a czar of national healthcare?
The premium cost and affordability that irritates the devil out of the common man and makes it impossible to find real catastrophic, cheap health insurance, could be fixed on Monday next if the state and federal mandates were removed and insurance companies could get down and compete. My cheap-as-possible catastrophic policy with a 10,000 dollar deductible (yes you read that right, that's the way big boys buy their insurance) would cost me a lot less than 4500 dollars a year, since I have never, ever filed a health insurance claim in my life (I am not unique, some people, even doctors, don't use health insurance to pay their medical bills).
So the problem is that the federal government proposes in its Healthcare Highjack Bill that they will fix the cost of health care and make it cheap and high quality when they caused the problem? The same outfit that made healthcare insurance premiums too expensive and restricted competition across the country says they are the solution?
We need to start over and ditch the guys from Chicago, they're always on the take and acting like thugs.
John Dale Dunn MD JD is an emergency physician living in Brownwood, Texas. contact him at jddmdjd@web-access.net. He works for his wife Patty, 4 dogs, and 4 horses.
