Thursday, August 29, 2013

World Health...and Closer to Home.

Personal History...Not the Other Kind:
America's Medical/Industrial Complex

President Lyndon Johnson signing the Title IX amendment
to Medicare, July 1965.

"In the United States, Medicare is a national social insurance program, administered by the U.S. federal government since 1965, that guarantees access to health insurance for Americans aged 65 and older and younger people with disabilities as well as people with end stage renal disease (, 2012) and persons with Lou Gehrig’s disease. As a social insurance program, Medicare spreads the financial risk associated with illness across society to protect everyone, and thus has a somewhat different social role from for-profit private insurers, which manage their risk portfolio by adjusting their pricing according to perceived risk."

"In 1965, Congress created Medicare under Title XVIII of the Social Security Act to provide health insurance to people age 65 and older, regardless of income or medical history. Before Medicare's creation, only half of older adults had health insurance, with coverage often unavailable or unaffordable to the other half, because older adults had half as much income as younger people and paid nearly three times as much for health insurance. Medicare also spurred the racial integration of thousands of waiting rooms, hospital floors, and physician practices by making payments to health care providers conditional on desegregation."  Wikipedia
Health Care in America should really be named after Christopher Columbus, for it is indeed, a voyage of discovery.  And not the overly pleasant kind, for in this business, the Earth is flat and you can sail off the edge.  In my lifetime, that has occurred three times...working on my fourth as I speak.  You know the drill: mystery 'caps,' pre-existing conditions, trying to ascertain which deductible level will still allow you to eat...though being either sick or in the deeper valleys of economic depression might make food less than palatable -- if still affordable.  And of course, if you happen to be self-employed, engaged in something more strenuous than day-trading commodities, you are bound to have a long list of pre-existing, unplanned and future conditions.  I believe the last time I applied for a health insurance policy (while I was still playing with horses), the company finally agreed that they could insure my left ear and most of my right leg -- below the knee.  Medical records are a lot like a parolee's rap sheet -- they follow you everywhere.
And yes, I'm still whining about that new ball-joint I need on the left hip.  But now it has turned into something else -- a fool's crusade maybe; Don Quixote confronting another malevolent windmill.  And in the background is the happy/unhappy news that I might qualify for Medicare in October.  Well, not so fast.  Sure, the selfish shit in me says, "Whoopee!"  The other part, you know the one I mean: the conscience, the pragmatist, the childless man that still tries to consider the costs to all the children down the road -- a path that seems to be collecting more potholes by the hour. That little portion of my soul.  Which is beginning to make me think that kids should be allowed to vote. Because every idiotic thing us adults dream up...they are going to pay for sooner or later.  
Let me run the numbers -- on second thought, you already know them because we are all living them.  The demographics alone argue against anything short of insolvency -- sooner, than later.  And no, Medicare is not an entitlement. Free congressional health care however is.  Medicare is the nation's largest insurance company, one that works for us -- the taxpayers -- not a group of stockholders that wouldn't know a spleen from cantaloupe. And for a quasi-government agency with more paperwork than the IRS, they do manage to do a remarkable, if not impossible job.  So why not take it one step further.  Give this shark the teeth to swim with all the sharks. Yes, let Medicare go toe to toe against all the insurance conglomerates, corporate medicine peddlers and the rest of the Medical/Industrial Complex...including the pharmaceutical companies.  And at the same time...force the FDA to re-instate the ban on advertising prescription drugs directly to the consumer. Just like veterinary medicine, more and more the 'doctor' is prescribing via patient pressure, not the parameters of medicine...and right behind them, those 1.5 million attorneys that ply (plow) America's courtrooms. And yes, there are twice as many lawyers in this country as doctors.  Another demographic you might want to chew on.
"Agh!!" You scream.  Sounds like nationalizing health care!  Well, guess what?  With the aging population, the economy incapable of producing real jobs (as in full-time, living wage type) -- not just brokering the efforts of others or simply exporting them; the young in this country will be incapable of supporting the health care needs of the old, through the conventional sources: income-generated taxes.  Math 101: what goes in must pay for what goes out. (An idea grown stale in this society.)  And since we are so good at 'bailing out' the corporate sector, how about bailing out the elderly?  Yes, rhetorical question, but it will come to that point in very short order.  And if you would like an analogy (I do!), look to China.  Mao's one-child policy was good as a short-term remedial action for a social/state burden almost unimaginable here; now, decades later with a hot economy, an exploding middle-class and severe labor shortages due to that one-child policy, men cannot find wives and the elderly are left with no children to support them in old age. Fair comparison?  Yes and no. The lesson is that nothing stays the same and both government and the private sector must develop the agility to change with a shifting social dynamic, while embracing the type of forward-thinking that extends beyond next week, the next election cycle or Congresses constant need for 'vacations.'
So along comes a few Republican senators spouting the notion that Medicare is broken and the solution is a voucher system.  Well gosh, wouldn't the insurance cartels just love that idea! But actually, I like the voucher system -- trouble is the Republicans have got it all wrong.  But first, a brief opposing argument -- no, not by
Kenneth Davis, President & CEO, Mt. Sinai Medical Center. Exerted from his blog, 10/08/12.
"Turning Medicare into a voucher-based system is not a solution for our seniors or what ails our health care system in this country. With over 100,000 visits to Mount Sinai last year by Medicare beneficiaries, I am acutely aware and concerned about the changes that are being proposed to the Medicare system. The voucher model -- which essentially gives seniors a check and sends them off into the private marketplace -- is based on the notion that competition, facilitated by a free market, will bring down the cost of health care. Putting private insurers into the ring with traditional Medicare, it is presumed, will change the trajectory of overall health care costs, and solve our cost crisis. Unfortunately, the answer is not so simple.

There are three major reasons why private insurance simply cannot -- and should not -- compete with traditional Medicare. First, private insurance is fundamentally more expensive than the Medicare program. Private plans have significant overhead costs that the Medicare system does not, including stockholder profits, administrative costs, and marketing expenses. Medicare does not have these additional costs. Further, while reforms are still needed, the fact remains that the single payer Medicare system is extremely efficient. Indeed, 97 cents of every Medicare dollar goes to medical care. In contrast, only 80 cents on every dollar goes to medical care in the individual insurance market, where seniors would be taking their vouchers. Prior to the new health care reform law, the number was even lower.

The second major problem with the voucher-based system, and perhaps most concerning, is that it hurts those seniors who are already hurting the most. We must recognize that the voucher system is a fixed benefit plan. It is designed to control the government's contribution to Medicare. If health care costs continue to grow -- driven by numerous factors including the aging of the baby boom generation -- Medicare costs will inevitably grow at a rate taxpayers cannot afford. However simply setting the share that the government will pay through a fixed benefit voucher is one of the least humane ways to save the system. With this approach, the fixed voucher will simply "buy" less and less in the private marketplace.

As a result, the wealthy will supplement their vouchers to buy adequate insurance, while the average senior living on social security and perhaps a modest pension will likely not have the resources to purchase today's level of coverage. Lower-income seniors will find themselves with unaffordable copays and the inability to afford comprehensive health care. At Mount Sinai, we will see the effect first hand. Our hospital is located between the most and least affluent communities in New York City, and while many patients from the Upper East Side may be able to budget for these increased costs, those visiting us from lower-income neighborhoods will not be able to afford the care. This simply is not right. Medicare was never intended to provide two levels of care. Medicare was created to provide reliable, affordable, comprehensive care for our grandparents and parents after retirement. It was a safety net for all. Under a voucher system, that safety net may only catch a handful of seniors -- it is no longer provides piece of mind that we will all have healthcare in our golden years. With so many of our seniors already trying to make ends meet on Medicare and Social Security, we should not be dumping our debt on the most vulnerable."


Now sure, Medical Directors of large medical institutions have their own fish to fry in this conglomerate we so euphemistically call 'health care,' but his point mirrors many other opinions both inside and outside the medical loop.  And contrary to political musings (from both sides of the aisle), Medicare is NOT broken, but certainly headed for a funding crisis...a condition that will accelerate as more and more Americans reach retirement age.  And let's see...can health care options possibly get more confusing?  Particularly for a vulnerable population?  Just more fish food for those emaciated sharks out there in fine-print land. If I can't figure it out, a 70-year old guy with cataracts certainly can't either.  And of course, it is here where the lawyers and bean-counters thrive, for the details of health-care are written for and by the lawyers.  Why? Because America is the land of litigation and the house that punitive damages built. Everybody screws up.  Life is tenuous at best.  100 years ago, appendicitis was 100% fatal. If I shod every horse like it was a lawsuit waiting to happen -- well, there would be lot more barefoot horses walking around. Both patients and medical professionals need to sober up -- quit hard-selling expectations to yourself or others and lock out this public-sector pandering by the various drug peddlers and spare parts sales people that undermine the doctor/patient relationship. Look around. Every new 'miracle drug' advertised is followed by 6 commercials for class-action lawsuits generated by 'side-effects' already printed on the box. The doctor knows, the patient you sue when you get what was already a given risk to your health?      

However, as I stated earlier, a limited voucher system could produce some interesting fall-out in the marketplace. Returning to my hip for a moment. Now here in this country, a hip replacement would run between $80-120,000.00 -- truth is nobody really knows. It would take 3 lawyers a week to answer that simple question.  France or Belgium, $13-15,000. all-inclusive. No mystery charges, no 'whoops' stuff. Further, no lawyering up if things don't go well. Which is fine -- waking up every morning is risky.  Oh...forgot, the $80-120,000 is only 80% of whatever the list price actually is, so I would have to pony up the rest. So, why not negotiate? Medicare can give me (or anyone else that wants to go shopping), a voucher for $15,000 and I'll go to France. Save Uncle Sam $100,000 in the process and probably receive better care than here. (Noting that health care quality is ranked #1 and #3 in those European countries -- #34 in America; CDC Estimates.) 
But you see, this is NOT the kind of free enterprise and market competition these voucher exponents want. They want instead for Americans to compete for the insurance, not the product.  Meanwhile, the insurance executives, the lawyers and the drug companies continue to run the show...not the doctors, the health care professionals and certainly not the patients.              
The idea is fairly simple. A hip joint is a lot like buying tires for the SUV. You don't buy the first set that comes along, or the set the car dealer or the bank that holds the note demands.  No, you shop around because it is your damn hip...SUV, I mean.  And instead of an absurd bill (like the one on the right), you are not billed for renting an operating room, or every Band-Aid and enema you did or did not get. Some hospitals must have at least a half-dozen nurses just manning the cash know, like check-out time at Safeway.
The theory is fairly simple overall.  If medicine is going to be a business (course, there is already something wrong here), then truly make it an open, free-market system where competition is lively, real and unhampered by this cartel of private insurers. Make the hospitals, the incorporated medical centers...even the doctors, compete for the customer.  Medicine may be considered a higher calling by some, but if we are going to define it here as for-profit -- well, then it is just another service-sector endeavor that may or may not kill you. 

Another area of abuse is centered around the 'compartmentalization' of medicine. As journalist Elisabeth Rosen [New York Times], pointed out and the above medical statement shows, medicine in this country is conducted by many disconnected segments. As a Belgium hospital administrator pointed out: "How can you can charge an operating room fee? Where else would we operate?" Good question. And oddly, it is the doctor that is charged for that and passed on to the consumer. Unless the doctor happens to be a 'rock star cardiologist' - a term I didn't coin, but the CEO of a well-known American hospital did. Side deals...professional courtesy based on profit margins, the idea of a doctor's reputation being a selling point for a hospital that needs to fill beds.  You billable hours.  In reality, today's doctors are more like corporate plumbers.  They only show up to 'fix' the pipes.  The rest of the medical process has been sub-contracted out to a myriad of independents who in many cases operate no differently than the local 7-11.  

How this came to be is a story of how Wal-Mart came to be. There is money in selling crap to humans and there is money in selling health care repairs -- not prevention. No profit in telling somebody to eat more Kale...unless you happen to be a Kale farmer. The motivation was two-fold: profit and risk sharing.  But the result was added expense to the consumer and a huge replication of services tied directly to the price of real estate...i.e., geography = money.

As an example: I lived for about ten years on the peninsula below San Francisco. Normally, a somewhat affluent area mixed with a large immigrant population; Asian, Hispanic. Within 20-miles of my residence, I counted 6 major hospitals, including Stanford Medical Center and the regional County Hospital. All offering the same services, same so-called specialties -- many owned by (ha, ha.) overriding corporate entities spouting religious affiliations or non-profit status. Sure, some mystery foundation may be non-profit, but the hospital certainly is not. So instead of focusing on medicine, all these institutions are engaged in a mad-cap competition for fill beds, to keep the operating theaters running 24/7, ad nauseum. And yet, in the spirit of this false-competition, prices rise -- they do not fall.  And they love Medicare!  Because they have a lock on it.  Guaranteed profits at our children's expense.

So why not globalize medicine?  Take the experiment one more step into the unknown. Medicare, as an agency of the Federal Government (and a faux non-profit) has the power to level the playing field. With the government's backing, they can be the 'big stick' in negotiating reasonable costs. And Congress? Go around this body of herd-bound steers and force the change through a public plebiscite. Or simply send the recalcitrant 'my party or my life' bunch to the unemployment line.  Better yet, abolish their free health-care ride altogether. Let them swim with the sharks before they allowed to dictate policy to the other fish. Free rides do not create free thinking or any form of affirmative action.  Never has.

Love this photo. Mostly because I was younger, more dashing...yeah, yeah.  China, just post-Tiannemenn. Before the great capitalist surge in the world's most populous state.  You notice it doesn't say "GREAT," just good. And no, I am not advocating blatant socialism -- merely saying that all democracies (and other fairly benevolent forms of government), must have a social conscience as an adjunct to their political lip-service. Particularly here, where we tend to wave it around like a gym sock that doesn't smell. At least to some of us.

Of course, everybody will scream about government control, blah, blah, blah. Sure, less would be better, but sadly governments were and are formed, maintained and accepted because humans are incapable of being accountable to themselves or other humans, animals, bushes...pretty much everything below our overblown status on this planet. So we bitch about the constraints placed upon our ability to run amuck; conversely, refuse to be a part of constructive change because opinion is more fun than logic. Why people spend hours on Facebook and have never even read something as fundamental as "The Federalist Papers."  (One critique of perhaps many that formed the basic tenets of this nation's troubled founding.)

Lastly, a little patient responsibility. Learn how to say, "No!" Be a consumer, not a lemming. Turn down ridiculous tests, learn to negotiate personally on fees, shop around or as many have done, take your business overseas and leave your lawyer at home. Most indicators have actually shown a greater quality in health services, extremely competitive prices and fewer risks.  Sure, a procedure can go badly in can a favorite recipe you've made a 100 times. As I said, life is risky.  And poverty makes it even more so. We have a fundamental right to medical care.  But not at the price of everything else.  

And no, I don't necessarily know what in the hell I'm talking about. However, I have worked inside and outside the Medical/Industrial Complex and have personally (and painfully) experienced, as many others have, just how cruel and how financially devastating the current system can be.