Health reform repeal will lead to single payer, Medicare for all

In a guest post last year, physician-author Richard Reece commented that the individual mandate may collapse health reform.

Those words came to mind as Judge Vinson not only ruled the individual mandate unconstitutional, but the entire Affordable Care Act, as well.

Nobody likes to be mandated to do anything, least of all purchase health insurance, and this was always the sticking point with the current iteration of health reform.

So, what next? I don’t pretend to have a crystal ball, but all analyses point to a showdown in the Supreme Court, with Justice Anthony Kennedy being the ultimate decider.

Striking down the Affordable Care Act would be a shame. As a wrote previously, Conservatives shouldn’t be so enthusiastic about the prospects of repeal. If health reform was completely abolished, health premiums would continue rise unabated, along with health costs consuming a larger piece of the GDP. That very likely would lead to an expansion of Medicare and Medicaid — which would be a far worse fate for the those who worry about a government takeover of health care.

There’s a reason why the health insurers haven’t been vocal supporters of repeal. From their end, the Affordable Care Act is a positive outcome.

And for patients, complete repeal of the law would be harmful. According to the ACP’s Bob Doherty,

Repeal, of course, would also eliminate all of the provisions of the ACA, including rules to end discriminatory practices against people with pre-existing condition exclusions, coverage of adult children on their parents’ plans, the new 10% increase in Medicare payments to primary care physicians, the new Medicare wellness examination preventive and other screening procedures now available free of charge to beneficiaries, the phase-out of the Medicare Part D doughnut hole, the requirement that insurers spend more on patient care and less on administration, and much, much more.

I continue to stand against repealing health reform. It is far from perfect, obviously. It doesn’t do nearly enough for primary care, and has only token efforts at reforming our malpractice system. Conservatives would better serve the public if they worked on including their principles in the Act, tort reform and an expansion of health savings accounts for instance, rather than lobbying for repeal.

After experiencing the debacle of constructing the Affordable Care Act, it’s unlikely that either political party would touch health reform for the foreseeable future, should we need to start over.  Thus, we’d be stuck with an unsustainable status quo.

Should Conservatives  succeed in repeal, that, ironically, would be the first steps towards a Medicare for all, single payer system, which would be an infinitely worse proposition for them.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • Jake

    That law was a mishmash of ideas written by college kids on internships. Every day some new nightmare provision is discovered. Most of it was unworkable hence Obama has been handing out exemptions daily.

    The replacement will be written by adults who have had real jobs before in their lives. It will still be a disaster, but it is a disaster we can live with.

    • Brian

      As opposed to… ?

      Look, I admit that I’m a homer for the ACA, but even I can admit that it is far from perfect. What is not in doubt is that the health care system prior to its passage was unsustainable. For the first time, everyone, from providers, to insurance companies, to pharmaceutical companies, etc., agreed that some major changes were in order if American health care were to survive in the long term. Add to that the fact that there were some long-standing, glaring inequities in the system that, IMHO, should have been addressed a long time ago.

      There is no legislation in recent memory that didn’t carry with it some unfortunate unforeseen consequences; this is, of course, no exception. But I do get tired of people prognosticating an unmitigated disaster as a result of the ACA. Are there portions that need to be amended, and other provisions that ought to be added? You bet. But “nightmare” provisions?

  • http://hotmail.com Art

    There isn’t so much wrong with Medicaid and Medicare, except for the fact, well known by the White House and Congress, that $1 out of every $3 spent is for waste, fraud and abuse.

    With our annual healthcare bill at $2.7 trillion, eliminating $900 billion a year “wasted with no benefit” to consumers would pay for Obamacare’s 10 year projected costs! This would even probably pay docs for even better care, while eliminating some bad insurance traits.

    It seems to make more sense to go after these wasted funds which the Justice Department just announced a banner year in recoveries of $4 billion! Just think what we could do if they could recover more than half of one percent, which they proudly proclaim as the best year ever!!

    • pcp

      Going after Medicare fraud is a no-brainer. Unfortunately, speaking of no-brainers, Congress controls the resources for this lucrative activity, and it has been historically under-funded.

      • gzuckier

        what about the FL governor’s recent decision to abort the state’s plan for a database of narcotic prescriptions, to prevent “doctor shopping” for multiple scripts? even though it was to be funded by donations and federal grants, and cost the state nothing?
        “The state’s relaxed laws have allowed hundreds of storefront pain clinics to flourish in recent years with little oversight from state regulators. These clinics attract car-loads of drug buyers and dealers from Kentucky, West Virginia and other states who use bogus injuries to score drugs like oxycodone and resell them back home.
        Broward County has become the nation’s pill-mill capital, with 130 pain clinics now operating. In Broward alone, more than one million oxycodone tablets are prescribed every month, Lamberti said. ”

        http://www.miamiherald.com/2011/02/08/2057033/gov-scott-seeks-to-kill-drug-database.html#ixzz1DUiOwv4C

  • http://fertilityfile.com IVF-MD

    Imagine a world where thousands of smart people (doctors, lawyers, business men, scientists, inventors) passionately work on their own or with the teams they form to invent new drugs, new devices, new ways of delivering medical services etc and are economically rewarded or economically punished based on the INDIVIDUAL VOICES of the people they serve judging whether their product is worthy or not, not based on the political decisions of a central planning committee.

    How robust would the advancements and improvements in healthcare be in that scenario? Compare that to the backwards direction that things have gone in the real world today, as more and more, the system becomes dictated by bureaucrats and the corporations that lobby them.

    Giving more power of healthcare to politicians and insurance companies is not the answer. Giving more power back to the doctors and patients IS the answer.

    The healthcare bill is a huge step in the wrong direction for that very reason.

    I respect that everybody, including politicians and corporate executives naturally want to better their own situation for themselves, but this should be done by voluntary incentives ie (vote for me and I will sacrifice of myself to give you this or that or buy our insurance/service/drug/device and we will sacrifice of ourselves to give you this or that). It should NOT be done by forced means nor coercion. Shouldn’t we respect each other’s freedom as a fundamental right?

    • Jeff Taylor

      ‘INDIVIDUAL VOICES of the people they serve’

      How does an individual judge the safety of a new drug or procedure, the competence of the doctor, etc – and how do they pay for it without insurance, which is a collective?

      • http://fertilityfile.com IVF-MD

        1. What’s to prevent an individual from accessing a variety of information upon which to base his/her decision? He could also take into account the source of his information, meaning he could put more weight on information that comes from someone he already trusts. It’s like asking how can a non-mechanic judge the safety and quality of a car. Again the individual voices, ie the market will reward good providers with positive referrals and repeat business and punish lazy providers by leaving them and giving bad reviews.

        2. Non-catastrophic medical care is paid for the way one pays for anything else. Bear in mind that a office visit for a UTI under a free market will plummet to the leanest that the market will bear. It will definitely not be more expensive than what we have today in our highly regulated system. As for the catastrophic emergencies, that will be covered by COMPETING insurance companies. The key word is “competing”, meaning letting the market free so that good companies are free to compete. As it stands in our current system, the regulations block competition so that the current establishment big corporations have little to fear from good companies competing. The barriers to entry are too great.

        • Jeff Taylor

          From what you write it seems you’re in favor of no government involvement in physician training, drug and product safety, research (eg human genome and cancer), comparative effectiveness, hospital and surgeon standards and so on. I guess you want to see people trying to make buying decisions on the basis on what will be company marketing material. As we know from commercial markets, poor products often do best, and in the drugs market already we see development pursuing profit with vast investment in ‘me toos’ and not patient need.

          And do you really want a race to the bottom for doctors in an unregulated market? Happy to see things like advanced RT machinery overdosing people with no proper regulation, as we’ve seen recently (ref: NYT series on radiotherapy horrors).

          • http://fertilityfile.com IVF-MD

            The recent horrors you speak of are exactly what we got from our CURRENT system. No accountability. Ask yourself this. What happens to a government agency that fails in regulating what they are entrusted to regulate? Do they perhaps stick around and continue to draw salaries on taxpayer money? Or even worse, do they get even MORE money and more resources?

            You are wrong in claiming that I don’t want government INVOLVEMENT. That’s not true at all. Instead, I’m opposed to a government MONOPOLY on the control and regulation of healthcare. In my opinion, monopolies are bad and inherently lead to abuses, lack of accountability and overall bad outcomes. I can live with inefficient first-class-mail delivery, but healthcare is too important to leave in the hands of a bureaucratic monopoly. Wouldn’t you agree? While we’re at it, let’s talk about our children’s education….

          • Jeff Taylor

            Sorry, but you rightos are arguing to take away all regulation (such as the EPA). Don’t tell me you want increased federal oversight on facilities like radiotherapy – surely not.

            As for ‘government monopoly’, that’s just scaremongering as we will aways have a dynamic mix of private and public provision. The way forward though must be to secure decent healthcare for all and not to unravel Medicare, cover for pre-existing conditions etc – that just takes us to the dark ages.

        • Brian

          IVF-MD,

          I find I can always rely upon you to parrot the Rand party line (it is with a great deal of delight that I note thy patron saint quietly enjoyed Social Security and Medicare benefits, her opposition to government entitlement notwithstanding).

          Regarding your first point:
          The naive belief that in a truly free health care market, patients will magically have access to sufficiently accurate information, unclouded by disinformation from other sources, and be able to make responsible decisions about what procedure, device, service, test, etc., is best for them, is, in my opinion, silly. Sure, when the available options were blood-letting or Wizard Oil, it was much easier. But are you really arguing that patients in this day and age will be equipped to leverage the principles of science-based medicine? That they’ll magically find their way behind pay-walls to access the primary information? That somehow, despite the fact that the mathematical competence of the average American isn’t all that impressive, they will nevertheless suddenly grasp the meaning of sensitivity and selectivity?

          As far as sources that patients trust, that’s all well and good if the source they trust is, I dunno, a doctor. But what if they really trust Jenny McCarthy? Or John of God? Or Uncle Bob, who cured his self-diagnosed testicular cancer with a can of Comet? How do you regulate sufficiently to ensure that these patients, newly-liberated from the Evil Cabal of Government Bureaucrats(TM) to make their own health care decisions, aren’t taken in by charlatans or other unqualified nitwits? In fact, if I’m not correct, that was part of the idea in requiring licensure for physicians.

          To say nothing of the fact that in health care, evaluating a “good” versus “bad” provider is a bit trickier than evaluating a car. While a “bad” car may be unsafe, or have bad gas mileage, or is just plain ugly, what makes a “bad” provider? For some, it’s someone who isn’t really nice. For others, it’s a provider who refuses to prescribe antibiotics for every cough and sniffle. For others still, it’s a provider who doesn’t use the Da Vinci robot for their prostatectomy (despite the fact that its current popularity is the result of a marketing campaign, not data).

          Are these measures really what you want to be the deciding factors? To me, this is the surest way to ensure that your so-called “free market” rewards the nicest, most solicitous, most cutting-edge providers, but not necessarily the best. And why is this so? Because patients in general prefer to consider these measures as a proxy to what really matters; it’s an awful lot harder to access and understand the information that would actually help patients determine good vs. bad providers.

          Lastly, do you not realize that our current system rewards insurance company monopolies? If you honestly think that insurance companies put much weight on whether or not they’re a “good” or “bad” insurance company, you’re dreaming. Currently, the biggest insurance company has the biggest patient population, and therefore the greatest leverage in determining rates with hospitals. Since most patients seem to choose their coverage based on price, one can imagine how this might result in a system that rewards the largest companies, to the expense of other perhaps more salient measures.

          • http://Www.twitter.com/alicearobertson Alice

            Brian…..the Rand party line may look similar to IVF…but really…..it is not the same…some similarities. Ayn Rand had to hell with everyone else attitude and loved money. I feel IVF cares about people and the free market can sustain both those who need government assistance, those who need employment to live and receive employer based healthcare (which is about 160,000,000) and pay into the system with taxation (which may be the crux of a settlement over health care reform…instead of a mandated penalty they will bait and switch to something similar to a tax), and the free market just may make someone rich…good on them….there must be incentives and the free market is a huge one that helps much more than it hinders. Let’s face it……the health care bill is a dream that even the free market and progressive over taxation of the people cannot sustain.

            I would not like to be compared to Rand personally or business wise….now Freidman? Much more in line with what I perceive IVF is saying.

    • gzuckier

      sorry, but the need to actually feed myself and my dependents is exactly why i left “a world where thousands of smart people … passionately work on their own or with the teams they form to invent new drugs, new devices, new ways of delivering medical services etc”, otherwise known as academic research, since the local grocery store wouldn’t accept my promissory note backdated to when I win the Nobel Prize. The plain fact is every medical breakthrough is associated with 10 or a hundred failures, for no fault of the investigator; that’s why pharmaceutical companies have to be so big, they basically bet the entire company on each new drug that goes into human trials.

      • http://fertilityfile.com IVF-MD

        Gzuckier, why is the invention of new devices, new drugs, new ways of doing things equated with academic research? Isn’t it the opposite? Look at the advancement in mobile phones. Look at the advances in high tech reproductive medicine. Look at the advances in internet applications. The good ones came about from the private sector with little or no government academics.

        And for the very reason you cite that each success springs from many failed attempts, doesn’t it make sense to allow the market to reward the people who come up with an innovation that the public actually wants?

        • http://Www.twitter.com/alicearobertson Alice

          The plain fact is every medical breakthrough is associated with 10 or a hundred failures, for no fault of the investigator; that’s why pharmaceutical companies have to be so big, they basically bet the entire company on each new drug that goes into human trials. [end quote]

          The Babe Ruth rule? Is giving up helpful to anyone? Anyone who reads a lot of history knows Edison was a complete failure, blew up a train, kicked out of school by a teacher who thought he was stupid. Alexander G. Bell…again a failure….Freud did not speak until age four….the Wright Brothers…..read about these men with your kids…throw in Mother Teresa…Florence Nightengale…all faced failure and terrible adversity….yet their perseverance changed history and mankind.

          • http://Www.twitter.com/alicearobertson Alice

            Correction….Einstein…..a Freudian slip!:)

  • jsmith

    My view is somewhat different from yours, Kevin. I think that we’re on course for ruinous costs with or without the ACA and that something big will have to happen in the next decade pretty much regardless of what the politicians of Supreme Court does. This could take the form of Medicare for all, with or without an option for the well-off to pay for extra care. We could see much worsened rationing by cost. I think worsened rationing by queue is also likely , with or without MC for all, given severe and worsening supply constraints in medicine. This seems to be the course were dead set for, while naturally the politicians maneuver for the 2012 election.
    Be prepared for more heartbreaking stories about people dying from lack of care.

  • http://wellescent.com/health_blog/5_ways_to_limit_rheumatoid_arthritis_pain_without_pain_medication Wellescent Wellness Blog

    I also find it hard to believe that a single payer system will be the result of successful repeal efforts. While the Republicans do have support in senior citizens and would hate to anger this constituency, raising taxes to cover Medicare increases is going to anger both those against “big government” and those specific fiscal conservatives who don’t see past spreadsheets. If the Republicans have power, my view is that they will move in the direction of pushing the costs onto individuals. Since they are funded by corporate interests for the most part, they will attempt to appeal to the majority of the public who aren’t suffering from health issues at any given time and want tax relief.

    • gzuckier

      the gist of the republican argument, however, is that the government does not have the right to mandate your purchase of a PRIVATE service; the right of the government to tax the citizenry to provide a service itself is not in question. thus, defeating the mandate to buy insurance from a health insurer on the grounds of being nonconstitutional may well end up with Medicare for all.

      • http://Www.twitter.com/alicearobertson Alice

        It is not just a Republican argument. I am reading Seeds of Disintegration by both a Democrat and Republican who are award winning economists. They show how Obamacare will make the nation sicker. I can share more later…..traveling and do not have the book handy.

  • Anonymous

    Giving more power back to the doctors and patients IS the answer.

    Patients largely don’t want that power, since that would come with having to pay medical costs out of their own money, rather than having them paid for by third parties. Of course, the third parties’ costs are indirectly paid by the patients (or others, in the case of Medicare), but that is more hidden from the patients.

    • http://fertilityfile.com IVF-MD

      Ahhh, but if/when we have a free market, patients who DO want that power can have it and those who want free or third-party paid health care can have that. Over time, the system that serves patients better will win over more converts. So that way, we don’t waste time theoretically debating the merits of each system. We just let people free to choose and over time, the good doctors, good companies, good systems will rise to the top and the bad doctors, bad companies, bad systems will be diminished.

  • soloFP

    Currently Medicare is my second best payer. It is the plan that does not require prior auths for CTs/MRS/stress echos etc. Medicare, despite being subsidized by the gov’t, does not deny patients with prexisting conditions or raise premiums on patients who have multiple medical conditions. Medicare currently is the most fair plan in the US.

  • RR

    Blatantly violating the Commerce Clause of the Constitution is a good idea?

    • Brian

      RR, it’s not a “blatant” violation of the Commerce Clause until SCOTUS says it is. Ever since Marbury v Madison, SCOTUS is charged with the interpretation of the Constitution. They may not even take up the issue if there is agreement in the Appeals circuit.

      Until such time as they issue a ruling, however, it’s a bit presumptuous to argue that it “blatantly violat[es] the Commerce Clause of the Constitution.” Maybe if you said what you actually mean, it might be better. Here, I’ll help:

      I think this blatantly violates the Commerce Clause of the Constitution. Do you think that’s a good idea?

  • Donna Carrillo Lopez

    The past decades of the business model of managed care failed miserably. Then insurance companies sought to lower their costs by denying coverage to individuals with preexisting conditions. In Texas, the insurers were denying coverage to young men and women with eating disorders as well as denying coverage for other maladies and threatening lives and fragile livelihoods, a national epidemic and tragedy. Having worked in California with an insurance company during the Clinton years, I was disgusted with their modus operandi – that of serving their own monetary self-interests (paying some of the highschool educated insurance reps $400-600,000 a year, including bonuses).

    The worrisome present model now being considered by the GOP is a corporate model (one which did not function in these last 30 years and will not function in the next 30 years). Obama’s health care plan was a collaboration by stakeholders but it was an aperture (not the ideal), an incipient effort for propitious change, much needed for the welfare of a recession challenged society.

    • http://Www.twitter.com/alicearobertson Alice

      an incipient effort for propitious change, much needed for the welfare of a recession challenged society.[end quote]

      And to help create a bigger welfare state. Sigh!

  • http://fertilityfile.com IVF-MD

    Brian, I realize the limitations of having a discussion via the pseudo-interactive manner of leaving each other comments on a website. It results in misunderstanding and misquoting what the other person says.

    We appear in disagreement about who should make healthcare decisions. I can say for certainty, and I’m guessing you’ll agree that people tend to know what they want. You probably know what you want in a doctor or healthcare experience much better than a third-party bureaucrat does. Maybe you value just getting your problem solved, maybe good attentive customer service is more important to you, maybe for yourself, PRICE is more important etc etc). It’s very possible that what you want might not be what your neighbor wants. Do the third-party authorities really care if your wants are different from your neighbors’ wants. Or would they like to force you and your neighbor to uncomplainingly conform to what THEY think is best for you? In other words, does your denigration of the “mathematical competence” of Americans give the third party the right to patronize them and tell them what to do? By the way, by third party, I’m referring to insurance companies and government committees.

    So either I overestimate Americans or you underestimate them, because as you claim, your “Evil Cabal of Government Bureaucrats(TM) ” magically has the knowledge AND more importantly, the sincere motivation to do what’s best for the common man and not necessarily what’s best for the lobbyists who support their campaign, which we all agree is an important determinant of who is put in power. Right? OK, so if we agree with your argument that people are imperfect and fallible, is it really a smart idea to let some OTHER imperfect and fallible person (ie third party participant) in charge of your healthcare decisions? Mull that over.

    I’ll also agree wholeheartedly with you that “evaluating a “good” versus “bad” provider is a bit trickier than evaluating a car.” Yes, that is true. But who do you think is more motivated to do an accurate evaluation – the patient who is about to undergo the surgery or a third party? Both are imperfect, but nobody is forcing a person to decide on their own. The key is choice. Therefore, a patient may say “I want to CHOOSE ON MY OWN to go to a chiropractor, midwife or Chinese herbalist or I might want to board-certified surgeon and take these products made by this pharma company. It’s my money, and the fruits of my own labor, so I will very cautious and choose in my own self-interest. Yes, that’s an imperfect model, but it’s no less imperfect than a model that says the fruits of your labor are to be taken by force by a third party. Then that third party will (after keeping a large chunk for administrative purposes) tell YOU what’s best for you. You MUST go see this board-certified doctor or you MUST NOT go see this board-certified doctor. However, if as you fear, some people can’t make that decision, I’m very happy with giving you the choice to say “Hey, I don’t trust myself to find a good doctor so I want to just put my trust in the hands of the insurance company or the medical board or somebody else and trust THEM to send me to a good doctor whom they regulate”. Either way, by giving people a choice, they win. The savvy ones will do their diligent research and find a doctor they want. The ones reliant on authoritarian guidance can let the “experts” decide.

    As for your comment on new tech such as DaVinci, I’m more on your side than not. In my practice, I am always on the lookout for new technology, but after evaluating it through a multitude of means (the official literature, surveying my colleagues, critical thinking) I reject many of them until more evidence is out. You can probably imagine how many times, the hot new fad panacea of 2002 has been proven worthless (or even harmful) by 2011.

    And when you parrot me and say “Lastly, do you not realize that our current system rewards insurance company monopolies? ” I can only say WAKE UP. That’s what I have been trying to say to you. Yes we actually agree on this! Of course patients put weight on price in their healthcare decisions, but that is by no means the only thing they weigh. In a free market, a company has to provide a balanced product in terms of both price and quality. When you say “the biggest insurance company has the biggest patient population”, ask yourself how it got that way. In a free market, the only way a big company can get the biggest chunk of the pie, is if satisfied patients CHOOSE to spend their healthcare dollars there in that particular company. So how would a company be able to accomplish that? Compare that to the current model where there is a huge barrier to entry for honest competitors to try and steal away that business by producing a better product, thereby allowing the big companies to thrive even though people AREN’T satisfied.

    In summary, I wish simply to discuss one common idea here. I truly believe that better solutions can be achieved by peaceful, voluntary consensual means than by coercive authoritarian means. Let’s hope to break away from pitting one group vs another group. Almost all of us have a common goal – more access to better healthcare for the people. When I say ALMOST all of us have this common goal, it’s a fact that there will be some small minority of people who stand to profit from a less than perfect system, so they might predictably NOT want people to choose their own healthcare.

    If you care and can think of a place where we can have a more direct back and forth discussion, I’ll be glad to accept your invitation, but I am already grateful to Kevin for allowing me to air on his site this lengthy comment on such an important issue.

  • ninguem

    Given the fact that Obama has said on the the record, many times, that he wants a single-payer system, this monstrosity he created is not surprising at all.

    Of course it will lead to single-payer.

    That’s what he wanted all along.

  • Matt

    Ninguem…what would be so bad about single payor? It seems to me that much of the administrivia ‘red tape’ in HC today would be eliminated (along with the costs) virtually overnight. All the rules and restrictions as well as the related actions of various payors have virtually no impact on care delivery or quality. In other words, nobody benefits – outside the insurance companies and their shareholders – from all the different rules and requirements of the various plans. In fact, I cannot think of a better, faster way to reduce the cost and inefficiency of HC than the creation of a single payor approach.

    • http://Www.twitter.com/alicearobertson Alice

      Ninguem…what would be so bad about single payor? It seems to me that much of the administrivia ‘red tape’ in HC today would be eliminated (along with the costs) virtually overnight. [end quote]

      Matt….this is obviously tongue in cheek? The answer of quality care is so obvious I feel certain you are being facetious.

  • Molly Ciliberti, RN

    The real waste of money in healthcare today is the money wasted on healthcare insurance and the vultures who own and run them, as well as the legal profession who make anywhere from 1/4 to 1/3 of whatever they make for their clients who sue, sue, sue. Single payor system like Medicare (with a real effective watchdog for waste, fraud and abuse) and flat fees for lawyers could provide real healthcare for less money.
    We need to get rid of the leeches in the system: health insurance companies and malpractice attorneys.

    • Matt

      Molly, it’s that kind of thinking that got us here. If you added up every dollar taken out of the system by attorneys (and remember, much of a malpractice award goes BACK into the system to pay for past and future care), you’re talking about less than 3% of costs. (Yes, I know, I know, defensive medicine blah blah blah – but when we’ve instituted physician backed reforms, there is no reduction in it, so let’s quit counting on it to save anything).

      The health insurers don’t have any control if they don’t have physicians who sign up to take their money. If you don’t want them to have control – stop taking their money. That simple.

      • http://Www.twitter.com/alicearobertson Alice

        . Single payor system like Medicare (with a real effective watchdog for waste, fraud and abuse) and flat fees for lawyers could provide real healthcare for less money.
        We need to get rid of the leeches in the system: health insurance companies and malpractice attorneys.[end quote]

        Molly….you just described the UK……it is not the dream care people believe. In their legal system the loser pays the legal fees. Their medical system does not provide the quality care we are used to…and if it wasn’t for the private insurance that picks up the expensive drugs and helps with wait times their stats would be worse (most doctors there have private insurance).

        I really like PM Cameron and think his cuts were necessary. I applaud his changes….but not the cuts in medical that will prevent treatment and updating equipment (that is already aged in most hospitals……I am surprised some patients haven’t been microwaved…….sigh).

        We just have to choose if we want good care for mostly treatable illnesses, or good catastrophic care. We can deny that…but studying other countries shows us that cost is the major issue and budgets are necessary…but they hurt.

    • http://Www.twitter.com/alicearobertson Alice

      Molly…this is part of the problem, but there is progress. There is a new MLR which says at minimum the insurers have to spend 80% on patient care. Lawyers and doctors both charge by the hour…so they rack up hours….it is not outcome based…it is how they thrive or survive irregardless of whether the patient survives (although, sick patients can often be profitable if they remain sick…innovative ideas can mean less income). The difference is lawyers cannot bill insurers and we cannot buy legal plans with pre tax dollars. Lawyers use the courts…and in many ways it has helped patients. It may be saving untold lives? The law can be a cruel taskmaster, but without it…..for another day.

      I believe malpractice is down…settlements are down…I do not solely blame insurers, doctors or lawyers for this “crisis”, but indeed there is plenty of blame. We pay for service, not results and this method has it’s risks and rewards. We pay whether the service is astounding or miserable.

      I like incentives for patients and doctors (struggling a bit with this one though…because some doctors will only care for people with expected good outcomes for a type of bonus which already happens with the grading system).

      I asked what the crisis is and no one responded. I knew the answer, but wondered where others thought it was. If what I am reading is correct the crisis is on multiple levels. A wrap up is….as you stated partially malpractice, partially doctors (costs and treatments vary a lot…so compensation is a problem of geography and rank), insurers are part of the problem, the insured and uninsured receiving quality care, pharmaceuticals, Medicare and Medicaid’s low access and compensation, etc.

      A monstrous task, but for most Americans we seem satisfied with our care. Room for improvement…yet, I still feel like we are kneecapping the majority to help a minority that had/has resources available.

    • gzuckier

      tort reform in its most extreme forms are estimated to drop costs no more than 5%; insurance adds about 25% overhead (total, including profits and administration) to costs, but in return drops medical costs by nearly 50%, through the power of group purchasing.

      i don’t think you’re going to cure the healthcare cost crisis by eliminating these.

  • Matt

    Nothing changes, and the march toward single payer continues, as long as physicians accept the third party payment system. Until they are willing to step back into the free market they left 40 years ago, the market nearly every other professional service provider is in, we will keep heading to more government/insurer (really, is there a difference?) control over healthcare delivery and value.

    It’s in the hands of physicians, and really no one else.

    • http://Www.twitter.com/alicearobertson Alice

      we will keep heading to more government/insurer (really, is there a difference?) control over healthcare delivery and value. [end quote]

      A bit….the insurance companies are some of the most highly regulated businesses. If we switch to government only…care is of a lesser level…appeals….rejections…the government in control of itself? Complete power…..public servants running the system? I’ll take the insurance company.

  • lenben

    The dissatisfaction of the public with their current health care has been taken advantage of by the new wave of politicians elected in November, by baldly stating that the problem is the “Obamacare”. The fact is that most provisions of the health act do not start until 2014. The current strategy is to move forward on the elimination of the health care act, as if this will solve the current crisis. The impetus for the act was to improve upon problems that are inevitable and repeal will only advance that timeline. I daresay most of the new Congressional crop has never read the provisions of the act and have no idea what they will be voting for or against. They will, however, do what their significant money sources tell them to do.

    • http://Www.twitter.com/alicearobertson Alice

      Let’s dissect what the true current crisis is….personally, the 33 million or 46 million number of uninsured has been broke down by the Census…..it is not what it appears to be. The insurance companies? What is the answer there? The government….forget it…they already run half the payment system…and not well…and cuts are coming.

      What is the public dissatisfied with?

      And why is Obamacare taking in money before action? Sounds like casino style healthcare that duplicates the supposedly horrid insurance companies people want the government to duplicate….God forbid!

  • http://Www.twitter.com/alicearobertson Alice

    Kevin writes:
    So, what next? I don’t pretend to have a crystal ball, but all analyses point to a showdown in the Supreme Court, with Justice Anthony Kennedy being the ultimate decider.[end quote]

    That was the widespread opinion, but today The Huffington Post wrote that Scalia is the major player (on the defensive side): snippet

    But legal scholars and defenders of the bill are increasingly convinced that another court member, not Kennedy, will play the critical role. And the name tantalizingly floated, often in private conversation with health care advocates, is Antonin Scalia.

    An unapologetic constructionist, Justice Scalia doesn’t strike the pose of philosophical champion for Obama’s signature legislation. But his opinion in the 2005 case of Gonzales v. Raich has led to speculation that he could begrudgingly okay the underlying principles of the individual mandate — the legally-contested provision at the heart of the bill.

  • http://www.davisliumd.blogspot.com Davis Liu, MD

    Kevin, you nailed it right on. We should be concerned that this “supposed” victory in fact would the the path to a single payer system.

  • Smart Doc

    “Health reform repeal will lead to single payer, Medicare for all”

    Maybe yes. Maybe no. I profoundly doubt it, but it is possible. Single payer for all is, however, far more likely with ObamaCare, which is carefully designed as a bridge to total government control.

    Repeal and Replace. Do it openly, with debate, in the light of day.

    • gzuckier

      yes, nothing spells “total government control” than imposing a penalty of $95 per year for anyone who can afford to purchase one of a number of products from a number of various publicly traded corporations but does not, preferring instead to get their healthcare paid for by transferring the costs to those who do make such a purchase.

      it’s much more intrusive than our current system of having your employer choose a couple of products from one or two corporations for you to choose from (or, of course, transferring the costs etc. etc. etc.)

      this is how Canada started on the road to Gulags.

      • http://fertilityfile.com IVF-MD

        Isn’t there a little more to the Obamacare bill than just that? What about the stipulations that forbid new competing insurance companies from offering different packages? There could be a lot of low costs alternatives available to the consumer if only the government regulations permitted companies and their insured to mutually agree to the specific terms of their contracts.

  • Donna Carrillo Lopez

    To be able to critique the present health care bill, it would be wise to look at the recent history (40 years) of health care in the US in terms of economics, politics, equity and quality, as well as the most common causes for seeking and need to provide primary care (like URIs and back pain), the costs of early care vs. late care to hospitals, clinics, health insurance companies, Medicare, costs of care, med/mal issues, uninsured (which is climbing well over 40 million Americans), realizing that health care spending has increased to the 2004 estimates of over 16% of GDP, critical need for research funds for stem cell research, pharmacogenomics/genetics (to relieve the issue of epidemic pharmacologic iatrogenesis). We currently have a panoply of avoidably expensive medical errors, a woeful lack of clinical expertise for caring for patients in chronic pain, duplication of expensive technology in urban and suburban areas, insurance company denials of life-preserving care for fellow Americans, expensive and often out of reach COBRA costs creating vast increases in the uninsured population, huge bureaucratic expenses with insurance companies that will always dwarf that of a one payer system, rationing of health care is already being actualized since many unemployed/underemployed families find health care (both preventive and therapeutic care) out of reach of shrinking family budgets.

    I would prefer that the current health care legislation replace sanctions with incentives in purchasing health care coverage (increased tax credits for individuals and families for both state and federal income taxes) and that there would be prescription drug reform that would effectively create a fair market for health care consumers.

    Now does anyone really think that the private sector has the motivation, the skill/initiative or ability to handle the ponderable complexity of where health care is and needs to go?

    Like the five blind men and the elephant, it will take many to skillfully navigate this tenuous and difficult social and political journey to a future that envisions solvency.

  • Donna Carrillo Lopez

    Scalia actually denies he is a strict constructionist and his statements are often intentionally reductio ad absurdum in regard to taking the Constitution inside an anachronistic context.

    “Although Justice Scalia believes that one must be an “idiot” to
    believe in a living Constitution,34 distinguished jurists from other
    countries are more sympathetic to the contextualist approach. Justice
    Aharon Barak, President of the Supreme Court of Israel, has written
    an eloquent defense of the contextualist approach to Constitutional
    interpretation:
    The intent of the constitutional authors, however, exists alongside the
    fundamental views and values of modern society at the time of interpretation. The
    constitution is intended to solve the problems of the contemporary person, to
    protect his or her freedom. It must contend with his or her needs. Therefore, in
    determining the constitution’s purpose through interpretation, one must also take
    into account the values and principles that prevail at the time of interpretation,
    seeking synthesis and harmony between past intention and present principle” (see website: law.vanderbilt.edu: Conducting the Constitution: Justice
    Scalia, Textualism, and the Eroica
    Symphony
    Ian Gallacher)

    Alice, I am not sure whether Scalia knows where to stand on the health care legislation issue as constructionism or neo-constructionism hardly matters here where the health, if not fiscal existence of a nation is deeply dependent not only on creating a solution to massive unemployment and impoverishment but also on changing a bankrupting trajectory, as is currently the case in health care in the US.

  • http://Www.twitter.com/alicearobertson Alice

    Now does anyone really think that the private sector has the motivation, the skill/initiative or ability to handle the ponderable complexity of where health care is and needs to go? [end quote]

    You mentioned “incentives” which is interesting, but then you asked the above question. I would love to hear more suggestions because I am bit confused. Prescription drug reform that creates a fair market for consumers? Would that include more government involvement? If so, how much more government involvement can the market handle (asking because regulation has cost our friends their jobs…good jobs…but the companies suffocated under regulation and moved overseas)? You seemed to question the free market and their ability? What do you propose? We have few options in that regard, but I love for this to be expounded upon.

    The judges opinion this week was really interesting. It rested on the word, “severability”. Odd this was missing from the bill….but may be the loophole to trash it because it means it cannot be fixed or severed. Of course, like the income tax it could become an amendment…but the repercussions of this would be so far reaching and threatening it is hard to conceive.

    It will be interesting to reread this thread a year from now…..to wait and see if the original Constitutional framer’s intents are kept…or the liberal leanings where personal opinions matter more than constitutional rights.

  • http://Www.twitter.com/alicearobertson Alice

    What about the Ninth Amendment?

  • Donna Carrillo Lopez

    Refreshing argument and I agree with you, Brian. The private pay health care insurance has not been vulnerable to free market conditions and …monopolies (that have compromised the society’s welfare) have predominated. Libertarian views similar to ‘IVF’s’ comments are confused with what free market is in theory and the profound reality deficits of the supposed existence, in this era, of a free market in practice. This knee jerk reflex is a theoretical one that truly is not based on the socio-political-economic realities of the past 30+ years. Sherman anti-trust laws have been retired on the backburner for too many years, whether it is the monopolies created by healthcare insurance companies or broadcast/internet mainstream media (both of which threaten the historical egalitarian values of this nation’s republic … and a free and independent press, the iconic reminder of a democratic society). The indignant claims against the present health care legislation has much to do with a queasy antagonism to the illusion of monopsony by conservatives and others. But really monopoly and monopsony both diminish free choice in what is theoretically free enterprise. The proverbial fly in the ointment of those who wish to overturn the present health care legislation is that this nation’s overall welfare depends on not only decreasing unemployment but insuring that most, if not all, Americans have health care coverage for a lifetime. As the recession begins to fade in our back mirrors, let’s look ahead to tackling the complexities of health care reform with a sense of humaneness and consciousness of what made this heterogeneous nation once so enviable around the world. It begins as a quiet, peaceful concept within each one of us. Many miles to go before we sleep…

    • http://fertilityfile.com IVF-MD

      Donna, if you were in charge, would you be amenable to people having a choice, meaning they could choose to buy into the government system or they could choose to opt out of the system and take their money and find solutions more to their liking? They would acknowledge that the government system has no obligation to nanny them if their system fails. I would be happy letting people choose to participate in the “Obamacare” system if they so desire and happy letting other people opt out if they so desire. That is the most ethical and moral way, leaving the choices to the individual. It just seems that one group of people want to force EVERYBODY to do their will and how can that be right by any standard?

      • Matt

        IVF MD…nothing would make me happier than for that to happen b/c it would demonstrate quite quickly how badly the government needs to be involved at some level. I believe a large majority of folks arguing against ‘Obamacare’ already have Medicare, military HC, or are subsidized by taxpayer $$$ (see Congress) and thus, have zero understanding of how badly broken the ‘free market’ is for small companies and individuals. I would love to give older folks against Obamacare all their Medicare money so they can shop on the open market instead. BTW…that’s pretty much what Rep. Ryan is proposing with the voucher system…let’s implement and see what happens.

        • http://Www.twitter.com/alicearobertson Alice

          believe a large majority of folks arguing against ‘Obamacare’ already have Medicare, military HC, or are subsidized by taxpayer $$$ (see Congress) and thus, have zero understanding of how badly broken the ‘free market’ is for small companies and individuals [end quote]

          There is some truth to this…but it is just too wide sweeping a generalization. The problem is those who gain the most from the government vote in high numbers to make sure the entitlement mindset keeps the money flowing their way. So politicians like to create more needy people…a hungry cat comes home when it gets hungry…and so hungry voters vote for entitlement fulfilling candidates under the guise that they are desperate and want the government (via those who do pay taxes) to keep up the love affair between the candidate and their entitlement. And Obamacare creates more and more entitlement. The beast has become insatiable…but the beast is deceptively disguised.

        • http://fertilityfile.com IVF-MD

          Haha. OK. It’s a deal. If only it were that easy. But the reason this would be good is it would resolve all this theoretical arguing with one side claiming the free market is great and the other side claiming government central planning is great. An open-minded rational individual would acknowledge that either side could be right or wrong to varying degrees, but any thought experiments pale in comparison to an actual trial. Scientists don’t usually sit in a room and argue whether this substance is denser or that substance is denser. Instead, they experiment and study the results (which often go contrary to predicted). Granted this is a much more complex system than a simple lab test, but the same principle applies of evidence being superior to theory. So how can we make this happen?

  • http://Www.twitter.com/alicearobertson Alice

    Donna…I completely disagree. Sherman anti trust? Really…and the libertarians are considered radical? Hmmm….okay…moving on….Obamacare and the new Medical ratios is going to cause the vast majority of small insurers to go under or be bought out by the big guys. Monopoly creating?

    I have libertarian leanings……but I am hard to peg. I admit I volunteer at a Judeo Christian think tank that spans across three states. I do not agree with them either….I am a skeptic.

  • Dr George

    This post assumes that when this is thrown out hopefully by the court that nothing will follow. I think starting over will make a lot of sense now with Republican control of the house in big numbers. They should be able to get things that they agree on with both parties into seperate bills and get them enacted to fix some of the things that are wrong with healthcare. You do not need a 2000 plus page bill, but several mini bills targeted at problems. Then you can sit back and see impact with each over time and continue to make corrections. There is nothing wrong with this approach and it can have very profound impact on both quality and costs.

    Also the stimulus act move to get everyone on EMR in a few years makes no sense either with billions going to waste. Right now there is little communication possible between various systems and we will end up moving from where we are to a tower of babel. The money being thrown at this should stop and the funds utilized for other areas of need in healthcare such as getting payments up for primary care in medicare and medicaid. In fact, you could use the funds to root out fraud and abuse and it would have more impact. The existing EMR systems are designed for the borken system that needs to be fixed. If we fix things, I think you will soon see that what is now being pushed on doctors and hospitals will be obsolete. Change first and then figure out how to move to an effective software communication system.

  • Molly Ciliberti, RN

    Truth be told there is no free market period. It is manipulated or subsidized or favored so please give up already on the free market. It is so clear that those who fear the new healthcare plan see socialism under every bed. Maybe it is time for you to travel to Europe and find out how the other half lives. Or maybe better yet, have your job gone and healthcare gone and get a diagnosis or cancer. I bet that might change your mind on universal health.

  • http://advocateyourself.blogspot.com Cheryl Handy

    US can’t afford another entitlement system. Medicare, Social Security, Managed Care & now ObamaCare? OCare is a disaster waiting to happen. OCare marginalizes the medical profession & treats docs as interchangeable commodity. Docs aren’t. But, med care is already rationed and docs & pts have an ever widening “gap of trust” that jeopardizes care.

  • Molly Ciliberti, RN

    Cheryl, I have paid into social security since I was 14 with my first job and I continue to pay for medicare, so entitlement is an odd phrase for something we have paid into (it isn’t a freebie.) Also the health reform law doesn’t marginalize physicians or anyone in the medical profession. You don’t know what you are talking about. Medical care is rationed between those who can pay for the outrageous private insurance companies policies or are fortunate enough to have health insurance via their job and those who don’t have any healthcare insurance including those who are now out of work. Single payer health care for all would end that rationing. I wonder what tune you would sing if you lost your job and had your home foreclosed and had neither health insurance nor a home? There is no such thing as Obama care; that is something stupid the repurblicans and their minions like to say to show how ignorant they are.

  • Cheryl Handy

    Molly -
    I stand by my post. Medicare is a disaster. You make many assumptions about me and whether I have a job, health insurance, financial or health issues and a home.

    I hope you are less judgmental with patients bc you could be wrong.

    • http://Www.twitter.com/alicearobertson Alice

      My friend called last night and said her husband will lose his foot because of a Medicare rejection. A panel of three doctors at Case Western would not agree with the top specialist whose every prediction about the process and consequences of inaction have come true. He suffered a heart attack because sepsis traveled from his foot. He is caught in the system.

  • http://Www.twitter.com/alicearobertson Alice

    Molly…this pure fallacy about single payer. Just come sit with me at the new wing on Cleveland Clinic and while you wait chat with Canadians who pay out of pocket because waiting may kill them. Even Premiers from Italy, Canada, etc. Come to the states for care they pay for themselves.

    Why force the vast majority of Americans to succumb to something they do not want? There is a way to help others without forcing a type of VA/Medicaid system on us…that will eventually lead to cuts and budgetary problems.

    Altruism is a great virtue…but reality is what it is….healthcare is about money and money is a defined amount….which makes it rationable…then trickle down. What we really need is more credentialed people like you to volunteer their professional skills as a charitable act to help those without insurance.

  • Molly Ciliberti, RN

    Well Cheryl, I am on Medicare (which I have paid into and still do as an employed person) and it works better than high paid insurance from a company that is only motivated by how much they can skim off the top and which contributes not one iota to improving my health or anyone else’s. I have been to Canada, Germany, Denmark, France and Sweden to name a few and they by and large are astonished that we do not provide healthcare as a right of citizenship. When I asked if they would be willing to give up their universal healthcare for lower taxes they always said no. I actually think that most Americans would love universal healthcare if they didn’t have the conservative Republicans trying to scare them to death that it is the dreaded socialism and the first step towards communism. That of course is the old lie that keeps coming up over and over. Ironically I have worked as a volunteer for migrant workers and Native Americans helping to provide healthcare to those much in need of our compassion.

    • http://fertilityfile.com IVF-MD

      Nurse Ciliberti, I’m curious if you would respect people having free choice on this matter, meaning every individual would have a choice whether or not to pay into and benefit from government-run healthcare. Those who don’t want to participate would be responsible for taking care of their own family and are not entitled to any government healthcare whatsoever. They would have to rely on themselves or on voluntary charities. On the other hand, those who don’t like private options nor charity options would have the choice of going with the government-run option. Of course, they would have to pay into it to the best of their ability, under whatever rules the government sets up.

      It’s fine if YOU love the way something like MediCare works, but would you respect that other people, who might not have the same beliefs as you, deserve the freedom to practice their healthcare the way THEY believe?

      What are your thoughts on that?

    • http://patientsafety-advocateyourself.blogspot.com/ Cheryl Handy

      US doesn’t need ObamaCare (aka Affordable Care Act). In fact, it would destroy the medical care system in this country. I am glad it works in other countries but I will fight to my dying breath to protect the patient-physician relationship and the integrity of the medical profession.

      Our medical care, medical schools, research leave other countries’ in the dust. And that superiority is a function of our physicians and researchers having the freedom to be the best they can be. Govt interference is as horrible as insurance interference. (That’s why Medicare hurt medical system/care, managed care worsened it & ObamaCare would destroy it.)

      We are US & not Canada, Germany, Denmark, France, or Sweden. US didn’t become the world’s best country (with finest medical care) by emulating other country’s programs in a piece-meal fashion. (Esp when countries like UK, Germany are scaling back universal hc because they can no longer afford the programs).

  • Molly Ciliberti, RN

    No system is perfect, but to claim that our current system doesn’t limit coverage or cause people to die because of bean counters or other droids is just not accurate.

    • http://patientsafety-advocateyourself.blogspot.com/ Cheryl Handy

      Nurse Molly: You are correct. Our current single payer system (Medicare) does limit coverage & causes ppl to die because of bean counters. We can’t trust Fed Govt to be honest stewards of $ set aside for healthcare-failed at Medicare & SS. Don’t trust them as the single payer.

      Patients I assist are injured and die bc of Medicare rules. The families receive EOBs from CMS delineating expensive DME that were never ordered or delivered. I report fraud. Medicare doesn’t care (“oversight on part of DME supplier”) but if pt needs the DME later, Medicare says no.

      The only variable cost in the single payer system (Medicare) is pt care. Pt care must be rationed in order to save money. Frightening, scary, marginalizes the medical profession (making docs an interchangeable commodity).

      • http://www.twitter.com/alicearobertson Alice

        No system is perfect, but to claim that our current system doesn’t limit coverage or cause people to die because of bean counters or other droids is just not accurate. [end quote]

        Even if rationing is a moot point (it’s not….but we know the government rejects more claims than the private insurers they regulate] let’s look at quality. You are willing to sacrifice quality for quantity? And that quantity will be with small stuff….catastrophic care will be less quality. America does have the best cancer survival rates in the world because of the free market and research. That means a lot to me.

  • Molly Ciliberti, RN

    What happens when your person who opted out is in a serious auto accident and is taken to the ED and has no insurance. The law currently requires the hospital and the ED physician to care for the patient irregardless of their ability to pay. And we all pay for that with our higher medical care. Are you willing to give up that law? Will you allow dumping like the bad old days or patient’s to die because they are not insured and are unconscious and unable to say they will pay? What about a child? You see it isn’t that easy. Sometimes we have to band together for the common good. as a physician, I would guess you support vaccination for the good of all and the herd effect which protects those either too young or too ill to get a vaccination. We are in this together whether we like it or not. I would gladly pay my share into a common healthcare system so that no one would die or suffer from not having the ability to pay or be insured. My compassion is part of my becoming a nurse; it sure wasn’t to become rich. Those are my thoughts.

    • http://fertilityfile.com IVF-MD

      Hmmm? My understanding is that EMTALA does not provide for any funding for the care. It just mandates it.

      In any case, I’d be in favor of private charity to fund the care of children or other needy. In fact, I donate my time already to indigent care at a teaching clinic for which I get paid $0 (but it’s my free choice and I’m not mandated to do so), and I might donate more money too from my earnings that are currently wasted to support middle-income bureaucracy.

      Honestly, is it really proper to brag about charity that is taken from you involuntarily? If somebody brags, “I’m proud that my tax money goes towards welfare and indigent healthcare because I care about the poor”, I’d tell them two things. 1. A welfare system does not help the poor, not in the grand scheme of things (but that’s a whole other debate) 2. Why be so high and mighty about your contribution when it’s not even your choice?

      Am I not correct here? :)

    • http://Www.twitter.com/alicearobertson Alice

      Molly writes: What happens when your person who opted out is in a serious auto accident and is taken to the ED and has no insurance. [end quote]

      We are going to pay big time with Obamacare via higher premiums that all already crippling. This same scenario means these who opt out, or just can’t be bothered can wait until they are sick then an insurer can’t deny them….but the insurer will have to pay for the negligence of the new policy holder. It is like waiting until you wreck your car then buying insurance.

      It is, also, curious when seniors who pay little to no tax get all cozily, compassionate and want single payer under the guise of altruism. Another rant……AARP’s involvement here has been disingenuous.

  • Matt

    Sure IVF-MD…folks can keep their money and shop on the open market for their own HC coverage. I think it’s a brilliant idea that should be tried ASAP. I’m sure the private payors will be anxious to access your funds and offer much less care for your $$$ (assuming you don’t have any pre-existing conditions). Just one other hitch in your great idea…you have to find doctors who were trained without the benefit of Medicare GME support since those are doctors who got where they are due to significant taxpayer support.

    • http://fertilityfile.com IVF-MD

      Sure, Matt. Does it make logical sense to you that if the private option were, as you describe, really that much worse than the government option (and it might turn out to be that way), that people wouldn’t then turn towards the government option instead? That’s what’s so great about flexibility and freedom of choice. It’s good to make insurance companies and the government both compete for your support, bringing out the best effort in everyone. It sure beats just saying “You must pay us even if you don’t like our service. Take it or leave it. Tough luck to you”. Coercion is a terrible model compared to free choice. To make it even better, you have to allow insurance companies the freedom to make voluntary agreements with patients. One company might offer “we are very strict about not covering pre-existing conditions at the time of initial enrollment. However, in return, we offer really really low rates”. Another company might offer “our rates might be a bit higher, but we’ll take all comers regardless of your pre-existing health status”. People can then choose which one to contract with.

      • Jeff Taylor

        ‘Another company might offer “our rates might be a bit higher, but we’ll take all comers regardless of your pre-existing health status”’

        No insurance company will take people with any major preexisting conditions. Or if they did, the rates would not be a ‘bit higher’. The point I’ve always failed to understand is why people like you prefer to drive people who can’t obtain insurance into taxpayer-funded high risk pools rather than open up the private market with reform, as Obamacare is doing. Surely you prefer a regulated private market to expanding public Medicaid and high risk pools and diminishing private provision.

        • http://fertilityfile.com IVF-MD

          I really don’t get what you are saying. Who’s driving whom? Don’t you think that people have the right to engage in mutually-voluntary win-win transactions. Nobody has the moral right to force any innocent person or company to do things against their will. A customer should be able to choose which companies to work with. A company should be able to choose which customers to work with. Of course they are free walk away to take their transaction elsewhere if there is a better deal. Reason it out logically. It should make sense and make for a friendlier world. We need that.

          • Jeff Taylor

            Your response makes no sense. If you have a major preexisting condition you cannot obtain any affordable private insurance until 2014 when the reform kicks in for adults. (It’s why we have Medicare for seniors.) So you have no ability to take your transaction anywhere, and so we have public pools such as they are, to try and cover people who cannot engage in your free market.

        • http://Www.twitter.com/alicearobertson Alice

          Jeff…that is not true. My son had an astrocytoma brain tumor as a child, that has left him with deafness in one ear, and partial deafness in the other. His tumor was malignant, and inoperable. He has had a few jobs and not once has he been denied in many years. My daughter has cancer (just had her second operation from spreading to her lymphs a few months ago) and works in dietary at a small nursing home. She was offered insurance on her 18th birthday last fall.

    • http://fertilityfile.com IVF-MD

      I’m not sure what GME is but I assume it has to do with government funding of medical schools? Well, I’d be in favor of lifting the monopoly on medical education and opening it up for people to start a school that does not rely on other people to subsidize it. You can’t ethically seize a monopoly on something, not allow other people any alternative and then claim credit for providing it. It would be like forcing every man and woman in the US to give you $10000, using a portion of that money to give them Microsoft Office (and forbidding them from using any other software) and then claiming credit for every letter, book, document or spreadsheet they composed because you gave them the software.

  • Matt

    IVF-MD…I think that would be perfect. When the HC debate raged, I so desperately wanted Obama to announce that Medicare was ending, folks would get their money back who paid into it, now the budget would be balanced and folks could no longer argue ‘government takeover’ was the evil outcome. While absurd and irresponsible, it would at least point out how naive many folks are about Medicare.

    As Cheryl indicated “Medicare is a disaster”. To which I respond…would HC be better or worse without it? One major reason that Medicare is facing a funding shortfall is that it funds so many costs of HC that private payors never support. Physician training is a perfect example. Medicare (& Medicaid) provide the only major subsidy for physician training. What does the ‘free market’ model look like? Med students find private investors to fund their residency training? How many fewer doctors would we have in a field already facing huge shortages in many areas? Moreover, for the small % of hospitals who provide a large majority of care to uninsured…where do they make up those costs? Do you think private payors kick in a little extra to help? Hardly…they have profit goals. These hospitals receive DSH funding from Medicare/Medicaid equal to tens of billions annually. The requirement that folks carry insurance is partially meant to push those costs onto those patients and their insurers and away from the taxpayers. Is it perfect? Of course not but it’s a start and a better alternative than doing nothing.

  • http://patientsafety-advocateyourself.blogspot.com/ Cheryl Handy

    Medicare is unsustainable & a disaster. Fed Govt admits it pays claims on front end w/o oversight. That creates Medicare/DME fraud & the elderly suffer. Fed Govt used Medicare/SS $ on items not related to those programs. As usual, Fed Govt just needed $ (to pay other debts) & Medicare/SS were never really designed to help people.

    Sure our country would’ve been better off w/o Medicare. People could have invested themselves throughout working life. States would be in charge of the safety net. But Medicare is here for now. Let’s learn our lesson/stop another single payer system (where $ is misused again by Fed Govt to pay another government debt!)

    Moreover, the closer we get to a solid patient-doc relationship, the better. Get rid of govt intervention, insurance intervention, employer intervention, hospital administrator/risk management intervention. Exam room door shuts-I want the room to be me, doc, doc’s staff.

    • Matt

      We would be better off without Medicare or government involvement in HC? Where do you think 99% of the subsidies come to support physician training? Medicare/Medicaid. Where do you think money comes to support those unable to pay for care yet still receive it? Medicare/Medicaid (PPACA is aimed at helping mitigate this). Where does a majority of support come for high end clinical research? NIH. You may choose to ingore those inconvenient facts but the reality is that without government involvement in HC, our system would be far worse off.

      • http://www.twitter.com/alicearobertson Alice

        You may choose to ingore those inconvenient facts but the reality is that without government involvement in HC, our system would be far worse off.[end quote]

        You are right, the government pays for about half of all the healthcare now and they do it poorly. Anyone who studies the way the government runs healthcare would know it shouldn’t be duplicated. Who wants the VA or Medicare duplicated? Anyone who studies other countries healthcare would want the freemarket to stay involved, because as it stands those on the government programs gain from the freemarket innovations.

  • alice

    Of course you can obtain insurance. There are companies who will take the risk without the government bully pit. Right now companies do it willingly….soon it will be compulsory…but everything is not peaches and cream….never will be.

  • Molly Ciliberti, RN

    Not so fast Alice, you may be able to get insurance but if you are an adult with a pre-existing condition you will not be covered for this condition no matter how much money you throw at them. They will not cover it period. So heaven help you if your pre-existing diabetes kicks up because you are on your own. The private health insurance companies have one goal to make money. That is the only thing corporations are required to do as described by the guru of the Republicans, Milton Freeman. So they get you to pay them money and skim off at least 20-30% for themselves and then try to move heaven and hell to not pay out a single penny for you to receive healthcare. They all give huge bonuses to their senior management and reward the bean counters for denying payments (this is well documented) while people die because the treatment that their physician wants for them is denied. My husband is a physician and his hands were tied more by bean counters working for private insurance companies all of the time. They only care about their profits.

    • http://Www.twitter.com/alicearobertson Alice

      Molly…I am scratching my head. My daughter is 18 and my son is 33 years old….not minors. They both have pre existing conditions and get insurance through their employers without any problems (daughter refused it….we were surprised they insured her. The whole nursing home had five tests per individual…if you failed two you pay an extra $100 per month on your policy. When the paperwork arrived we were surprised they insured her).

      It is not a subject covered in concrete terms like this. Yes, pre existing conditions are *sometimes* a problem…..not always.

      They think my daughter’s cancer may have spread…so I was getting more tests today Just had the weirdest doctor experience. More later….need to shake this one off….and look up info. Right now I am speaking from personal experience from two grown, adult kids.

  • http://patientsafety-advocateyourself.blogspot.com/ Cheryl Handy

    Nurse Molly: I do not take cheap shots at ppl on blogs & I respectfully ask that you not take cheap shots at me. I also try to stay on point/not share my medical history for emotionally impact. I do avoid “beating my chest” bc it is quite painful. I’m a breast cancer patient, recently had partial mast., chemo, RT & not cleared from oncologist.

    I quit my job in Chicago to return to my home state (NC) & care 24/7 for my elderly dad w/ colon cancer. I made the move when I had cancer. I arrived in NC w/ a pre-existing condition (cancer) & no job. NC has a high risk pool for ppl like me. I could have received Medicaid but I chose to be thrifty, save, make tough choices & get my own insurance instead of having the govt pay for my health insurance or health care.

    Now I have health insurance, my dad is dead bc his care was rationed, I still have cancer & now severe osteomyelitis. My tibia bone is dead. I could die at any time if the infection reaches my blood stream. Despite the fact I have health insurance, I can’t get health care for the osteomyelitis (bone infection). My cancer complicates the disease, prior doc messed up & I can’t find a doc to help me. Whether govt or private, insurance doesn’t equal healthcare.

    Life isn’t fair. People die. In America, we take care of ourselves & each other. We don’t have a right to anything – not even healthcare. I don’t have a right to healthcare even though I have insurance. I can’t make a doc save my life. I can only take care of myself as best I can.

    America isn’t a democracy. It’s a representative republic & thrives on self reliance, not dependence. US govt isn’t going to make healthcare better or “available to all.” That is naive & just plain silly.