Obamacare

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Nobody asked (well, actually a couple HAVE asked, come to think of it), but I'm going to set down my thoughts on the whole "health care thing".

I am a business owner (25 employees), and a physician. I have dealt for over a decade with government and private health insurance, and it's my livelihood to understand the issues and costs surrounding health care delivery in America. So, I actually have a pretty good grasp of all the various sides of this issue. At this point, I'm still a little ambivalent about the whole health care reform attempt, but I'll let the points below speak to the specifics.

So, in no specific order, my thoughts:

ALL HEALTH CARE IS RATIONED. Let me repeat that: all health care is rationed. The complaint that "the government will ration health care" is idiotic. Of course they will. So will every private insurance, every time. At some point, the costs associated with your health care are too high for any insurer to afford. I work with some insurances that will not pay for allergy medicines, and others that will cover Wii Fitness. There will always be a balance. Rationing doesn't just happen at a cost level - it happens at an intellectual level. If your belly hurts and you want an MRI "just to be sure", that doesn't mean you're necessarily going to get it. If you watch a commercial for a drug and think that it's exactly what you need, but I as your doctor do not, you're not going to get it. And of course, for the 40+ million citizens who are uninsured, their health care is absolutely rationed.

ALL HEALTH CARE IS EVENTUALLY PAID FOR: Just because we aren't paying more taxes to take care of more people, doesn't mean we won't be paying to take care of them. It just means the costs will be shifted to other forms. At some point, if someone is sick enough, they will seek health care, or wind up in an ER, and be treated. The hospitals, doctors, nurses, and everyone else involved in that care will be paid for it. Maybe not directly, but they will recoup the costs of the patient who doesn't have insurance by charging the one who does much more, to make up the difference. That charge then is recouped by the insurance companies in the form of higher premiums, which are in turn absorbed by businesses who pass the costs along again (by charging more for their product or service, or reducing employee benefits, or passing it back to the taxpayer by dropping insurance). This type of system actually costs us all MORE, because when people wait to receive care till they have no choice, the problems are more severe and the care more costly. If more people had insurance, and preventative care, there would be less catastrophic care and less health care spending.

SINGLE-PAYER IS THE MOST EFFICIENT DELIVERY DEVICE: I don't really expect the US to ever adopt single-payer, I think it would take an utter catastrophic breakdown of the health care industry before this happened. However, with multiple payers you have the significant problems of inefficient duplication of services, and smaller risk pools. The amount of money spent on insurance duplication of services is criminal. Our business office bills over 20 different insurance plans, all with their own particular rules, contracts, payment and payee specifics and a thousand other processes, all with their team of middle managers in some insurance office building, all taking their piece out of the health care dollar. It is a HUGE waste. Additionally, as long as an insurance company can be selective about who it does and doesn't cover, insured lives (that's me and you) will be subject to the whims of pre-existing conditions, and other restrictions. And the smaller pool you're in (self-insurance vs. Wal-Mart employee plan) the harder time you're going to have getting coverage.

THE GOVERNMENT DOES NOT HAVE A GOOD TRACK RECORD IN HEALTH CARE DELIVERY: Despite all the people who tout it, Medicare, Medicaid, TriCare (military) plans are lousy. At least from my perspective as a doc and business owner who earns part of my living from them. (For the patients on the programs, the care and covered services are adequate, roughly on par with the lower-tier private insurers). While private insurances have to at least compete a little bit for our business, the government plans in most instances could care less about anything but the bottom line. Over the past decade, the amount I as a doctor receive from government insurance has consistently fallen in terms of real dollars. It was only when doctors finally made a public stink that got enough attention to worry lawmakers that the recent planned 10% cut in Medicare funding that was scheduled was halted. The government's take on paying docs is to basically keep tightening the screws till enough people complain to lawmakers that they can't see doctors. Add to that the ridiculous rules that say since health care has "traditionally cost less" in certain areas (like Oregon), the government will only pay me about half of what it will pay a doctor in Florida or Texas for the exact same service, and you can maybe understand why I am wary of the government having too big of a hand in health care payment. There are basically no primary care physicians in my city (McMinnville) who will take new Medicare patients. This is because above a certain percentage of Medicare or Medicaid patients, it is simply impossible to even meet costs, let alone make a living. For a routine 15 minute visit, for the exact same care, Blue Cross pays me $120, and Medicare pays me $35. To put it another way, every time I see a government insurance patient vs. a private insurance patient, I make 40-60% less money. And to put it yet another way: if I saw only private insurance patients, and dropped all my government insurance patients, I could work half as much as I work now and see no loss in my income.

THE FREE MARKET DOES NOT WORK FOR HEALTH CARE: Whether or not you feel health care is a "right", you cannot apply or advocate for the "free market" to only be utilized in health care for one simple reason: we don't turn ambulances away at the emergency room door. If you want to apply the same capitalistic rules to the health care delivery business as you do other businesses, then you have to allow for only caring for people who can pay you. Medicine is the only private business I can think of where a business is required to provide someone a service, often a very expensive service, even if the customer has no intention or ability to pay. And since I can't imagine anyone wanting to live in a country where an injured child is not treated because the parents can't afford it (as DOES happen in other countries, by the way), to try to argue that we should let the private sector control health care is ridiculous.

WE'RE SPOILED, AND IT'S EXPENSIVE: Most Americans have access to MRI machines, complex lab tests, surgeries and specialists of every persuasion, medical devices and gear - all of which are cutting edge and very expensive. It is not that these things do not have or add value, but in many many cases, the costs far exceed the value. In many ways we expect care-on-demand, even for chronic issues. We expect the best tests, the top-of-the line medical devices, the costliest drugs and the most advanced therapies, and we expect them now. This is not necessarily a "bad" thing, but it is certainly a costly thing. People lived healthy and contented lives long before open MRIs and titanium hip replacements and laparoscopic gastric banding, but because these things are available now, we expect that they be an option for us no matter what the cost.

YOU WILL GET SICK AND DIE: This involves two issues: end-of-life care and personal responsibility. The medically costliest time by far in someone's life is their last 3 months. We have costly and invasive ways to extend life beyond limits we were previously able to. Without the acknowledgment that death is where we're all headed, we pay a high price to extend out as far as possible whatever life we have left, no matter how poor the quality. The end-of-life counseling that has been met with such mocking derision and fear by "conservatives" is not only a valuable personal aspect of health care, but a cost-saving one as well. We're not talking assisted suicide here, we're talking not instituting extraordinary interventional measures that do little besides extending the natural processes we all face. And on the personal responsibility part: stop expecting medicine to compensate for your bad habits. Most of the costs of health care (by far) in this country could be eliminated or vastly reduced by actions taken on an individual level: eating right, exercising, not smoking, getting preventative care. If we worked health insurance like we worked car or life insurance, the cost savings would be astronomical. Imagine if smokers paid more for health insurance, or those who never exercise had additional charges factored in. It's probably a slippery slope, and I doubt it'll ever happen, but know that we ALL pay the costs for those who simply choose to not make their personal health a priority.

SMALL BUSINESS PAYS A BIG PRICE: It is interesting to be on both sides of the private (and public) insurance dollar. We have routinely seen the cost of the private insurance we buy for our employees rise from 8-14% each year. We also negotiate with them for payments to us each year, usually to the tune of an increase of 3-5%. So clearly the additional costs are not being passed along equally. People are screaming about the tax costs to business of health care reform, and it's good to be concerned about that. But for our company of 25 employees to be paying in excess of $150,000 / year for health insurance (and this is only the 75% we pay), it seems like if there were a public option for our employees, even with a tax hike, we would be saving a lot of money.

OTHER COST SAVING POINTS:
- Tort reform. Despite what the lawyers tell you, the defensive and protective medical costs due to our lawsuit-happy society are huge. Any health care reform that does not also include significant tort reform is pointless.
- Drug Collective Bargaining. Medicare part D, in which Bush provided drug coverage with government dollars and DIDN'T do any type of competitive bargaining or formularies with the drug manufactures was a huge financial gift to the drug companies; one we all pay. Obama also has caved and not made this a part of the plan. Until the drug companies have to bargain for their use, they will continue to rip us all off with their vastly overpriced products.
- Preventative Care. I counsel someone for 30 minutes on healthy living, managing their diabetes (or avoiding it), reducing heart disease risk, and I get paid $90. I spend 45 seconds burning off a wart, and I get paid more. The medical payment system is slanted to throw money at "procedures" and pay lip service at best to preventative medicine. Until there is more of a financial emphasis on prevention, we're throwing money away.

POLITICAL POINTS: I don't want to get too political outside of the direct discussion about the plan. But, for all the people that bemoan "the loss of our America" or are afraid that this is some sort of master plan for Obama to usher in socialism: shut the hell up! If you get all your news from FOX News, or parrot back anything that Glenn Beck or Rush spew, you have no place in open and honest debate. I say the same thing to the "Obama can do no wrong" crowd, but they're not nearly as vocal these days.

There's probably more I could say, but even I'm bored at this point.

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