Audacity of Dichotomy: My Answers for Fixing Healthcare

President Obama continues to speak with a forked-tongue regarding healthcare policy in an attempt to sway his audience – whichever leaning they may have and wherever they happen to be sitting.

Now I am certainly not the first to point out Obama’s political two-views rhetoric. This is politics after all! But a recent Wall Street Journal editorial illustrating these bipolar views on healthcare really drove it home for me (“ObamaCare's Contradictions”, August 20, 2009). This is the synopsis of the article:

He stated in Portsmouth, NH: "What is truly scary - what is truly risky - is if we do nothing." We can't "keep the system the way it is right now," he continued, while his critics are "people who want to keep things the way they are."

But in Grand Junction, CO he proclaimed: "I keep on saying this but somehow folks aren't listening...If you like your health-care plan, you keep your health-care plan. Nobody is going to force you to leave your health-care plan. If you like your doctor, you keep seeing your doctor. I don't want government bureaucrats meddling in your health care."

Which is it Mr. President? We can’t keep things the way they are, or if you like what you’ve got, it turns out you can keep things the way they are?

There’s more.

In New Hampshire, he added that people were wrong to worry "that somehow some government bureaucrat out there will be saying, well, you can't have this test or you can't have this procedure because some bean-counter decides that this is not a good way to use our health-care dollars."

But while still in New Hampshire, Mr. Obama explained he wants to create "a panel of experts, health experts, doctors, who can provide guidelines to doctors and patients about what procedures work best in what situations, and find ways to reduce, for example, the number of tests that people take.”

So there will be no government wonk saying you can’t have a test, but a panel will provide guidelines for which tests doctors should order.

Still more.

While speaking in Colorado: "The only thing I would point is, is that Medicare is a government program that works really well for our seniors," and then back to New Hampshire, "If we're able to get something right like Medicare, then there should be a little more confidence that maybe the government can have a role - not the dominant role, but a role - in making sure the people are treated fairly when it comes to insurance."

But while still in Colorado he noted that Medicare is "going broke" while back in New Hampshire Medicare is "unsustainable" and "running out of money". In Montana, he quipped that Medicare is "in deep trouble if we don't do something, because as you said, money doesn't grow on trees."

I’m so confused. Medicare works really well or it’s in deep trouble. Aren’t those mutually exclusive events in the real world? Words have meaning, Mr. President.

OK, so I’m a doctor and by definition partisan, biased, and not capable of honest thought, right? For those who would like to listen to an informed opinion, keep reading. If you think I’m a racist just because I disagree with the President, then stop now on go back to the Daily Kos.

Let me be unequivocal. Healthcare needs reform. Now that the foundation is laid, here are some observations of healthcare policy from the inside.

Government run healthcare does not function well. Medicare already rations care and pays at such a low level that many doctors no longer accept Medicare patients. The VA system? Fuggedabout it. Talk about rationing and subpar care! I know - I’ve worked in two VA centers, both affiliated with academic medical centers, both supplying tertiary and quaternary care. In other words, my experiences were at the VA’s “best”. Yet they didn’t even rise to the level of “OK”. According to the GAO, in 2002, only 25% of VA patients have private health insurance. Think about that. If federally run VA care is so great, then this percentage should be higher, but I can tell you that the VA is not the first choice health provider for privately funded veterans. They go elsewhere. I myself have a relative who is a veteran with Medicare who chose a private hospital and not the local VA. I don’t have an answer for these two issues, but merely use them to point out that the feds have a poor record of running healthcare enterprises.

Uninsured folks need coverage. Obtaining care through the ER is bad medicine. But let’s be careful how we define uninsured.

Illegal immigrants should not be counted, as they are not entitled to government subsidized healthcare – unless it is their host country paying. (There’s an idea, bill foreign countries for the healthcare we provide their citizens.) And any talk that they do indeed deserve care because they are paying taxes is bogus. Statistics show that illegals fall within the tax bracket of “no taxes”. Philanthropy has a role here, but not my tax dollars. If coverage for illegal immigrants is tolerated, then I want a “get out of jail card” for a broken American law of my choosing (capital offenses excepted). They got one, so should I.

The uninsured but working healthy and young should not be counted as uninsured. They made a conscious decision to roll the proverbial dice with their health by not “wasting” money on health insurance. This is why I believe that every US adult must pay into a health insurance program of some kind.

So who’s left? People who work for employers who do not provide health insurance and have an income that is too high to qualify for Medicaid. These folks are defined as the “working poor” and they really do deserve assistance. In 2005, the Working Poor Families Project used U.S. Census American Community Survey data to estimate that there are approximately 5 million families (22 million people) who fall into this category. Since the National Coalition on Healthcare reports that the annual health insurance cost per family is right at $13,000, this puts the annual total to help these folks at $65 billion. But this is to fund these folks with private insurance polices – not a federally run system. This funds the real deal and with doctors of their choosing. Seems like equal access to me.

Now I think that $65 billion is still too high, so that means we need to “bend the cost curve” for healthcare. How do we do it? Here are some simple ideas.

The aforementioned mandate that youth and the financially capable begin paying into the system will significantly broaden the risk and revenue pools thus decreasing the costs for everyone. This population may not like it now, but they’ll sure appreciate their lower premiums as they “age” a bit.

There should be no such thing as a “for profit” healthcare entity. Private, independent, or even corporate; yes. For profit; no.

State boundaries which artificially dictate insurance coverage are unwise. These need to be eliminated. I have no problem with a federal insurance oversight entity replacing these piecemeal toxins. I know, I know, “state rights” and the 10th amendment. Get over it people. Not only would this lower costs, it would also allow portability.

The “in-office” exception of Stark Law must be revoked (sorry for the “wonk talk”). In summary, Stark Laws provide for some of the rules which doctors (and healthcare entities) must follow if they are to be reimbursed by any federal healthcare program (i.e. Medicare & Medicaid). These Stark Laws forbid referral by a doctor to an enterprise in which they have a financial interest. The rational is that some greedy folks would over-utilize such a facility if they were guaranteed a personal monetary windfall. Makes sense, right? Well, there is an “exception” which states that this situation is A-OK if said enterprise is defined as being “in-office”. The rational here was legitimate at the time of bill pasage – namely promoting patient convenience. But it hasn’t worked out that way. Doctors left and right across the nation have installed labs and imaging equipment in their offices, and studies have shown without doubt that referral patterns to such facilities are far over-utilized compared to practices without in-office facilities. To make things worse, a study of Medicare patients showed that only about 3% of Medicare patients had in-office imaging performed the same day as their clinic appointment. So much for patient convenience! This loophole must be closed. Billions in unnecessary tests would be saved. Am I saying some doctors are unscrupulous? You betcha.

Tort reform must be a part of any healthcare reform. It is very difficult to quantify C.Y.A. medicine, but from firsthand experience I can assure you it is a colossal problem and likely occurs with nearly every physician-patient interaction. I have provided medical-legal expert testimony in the past, and let me tell you some of the claims and suits are absurd. If we can get a handle on this, malpractice rates will decrease, and less cost will be passed on to the patient. A side benefit would be that some communities which can no longer retain OB’s and neurosurgeons may be able to do so. Injured patients need appropriate recourse, but it must also be fair recourse. The current healthcare tort apparatus is not a fair one.

In summary, I ask folks to consider individual solutions that address specific problems while reforming our broken national healthcare policy. Sometimes you do have to trade in your old car for a new one, but more frequently it just needs a trustworthy repairman and a few new parts. I’m looking for Mr. Goodwrench.

More To Come

Do not despair - I will return. Since may last post in 2006, things have been pretty tough. No need for details, but suffice it to say I've been quite distracted. But the allure of the political climate is pulling me strongly back into the personal-post'in-biz. I will soon have more time for this and hope to whip Greg's iPinions into shape.

Tchau for now!

Rudity: The New Great American Way

I’m back; newly anonymized and with many things remaining stuck in my craw. One of these is the rudity now experienced everyday across America. Long gone are the days of Miss Manners or even anyone giving an iota about etiquette or respect.

Listen: there is nothing wrong or shameful in respecting others with which one disagrees. Also, please realize that having a difference of opinion does not furnish carte blanche for letting the poo fly.

In January of this year, I received this comment to my Cindy Sheehan post:

“I wish I could say I was sorry to see you have no stamina. I'm not. You are more of the same drivel coming through the AM airwaves. And I thought people who lived in Park City were cool. You are probably lying about that.”

Of course, with impressive bravado, this was posted as a message from “ANONYMOUS”. Wow, now there’s evidence of a strong belief in one’s opinions, eh?

So, I have no stamina. Gee whiz. And I thought a series of life events which I have experienced over the past year had diverted my attention out of personal necessity. Forgive me Father for I have sinned against the church of anonymous followers.

I’m also apparently full of drivel. Gosh, thank you for the constructive dialogue which will most certainly allow for an open exchange of information and astute opinions which may sway readers to an alternative viewpoint. Way to make your case! Quite impressive!

Lastly, I’m a liar. OK, let me frame this. I have uploaded just two posts. I call my blog “Greg’s iPinions”. I have clearly stated that I am giving an OPINION and am not surveying the factual landscape of all politic. Yet ANONYMOUS has drawn a decision that I’m a liar. Quite the conclusion.

Perhaps ANONYMOUS is capable of learning something. If so, ANONYMOUS, pay attention and get help reading the big words if you must:

Paraphrasing Margaret Mead; “Respect for manners is a way of dealing with people you don't agree with or like.”

Just Another Duped Ideologue: Cindy Blogs Again

Drudge Report 9/12/05: “Cindy Sheehan calls for U.S to ‘Pull our troops out of occupied New Orleans’”.

Good Lord. How pathetic. Let’s talk about ideologues generally and then specifically. First a definition from Merriam-Webster:

Ideologue (variant idealogue): (1) An impractical idealist, theorist; (2) An often blindly partisan advocate or adherent of a particular ideology.

Please note the words “impractical” and “blindly partisan”.

Ideologues are often folks who are nothing but mindless sheep being herded; going, doing, and saying what they are told from ideologues higher up the food chain. And they are often too stupid to even realize it. Impractical means it ain’t practical, got it? Blindly partisan means to follow someone else’s lead without thought or self-awareness, which is the bedrock from which zealots like Nazis arise. To top it off, ideologue agendas are purely for the advancement of the self with no regard or concern as to the needs of society.

To understand the fallacy of ideologue logic, consider that hypothetically as long as one ideologue is followed 100%, there’s no problem within the scope of their limited worldview. But what if, like the real world, more than one exists? Only one can be followed and all others will judge society amiss and erroneous. See the conundrum? Each adds nothing and merely establishes negative and unachievable courses of action. In short, ideologues are nothing but loud-mouthed divisive farces (please note the satiric pun on “forces”) that should be ignored.

And I am very tired of them. Worse, I’m tired of the press covering them! The worst scum are ideologues with loads of money, whom people follow simply because of the wealth they can spread. George Soros is the best example of this, but both ends of the spectrum, liberal and conservative, have their fair share of reprobates.

Back to Cindy Sheehan; an ideologue manipulated by an ideologue (Michael Moore). Let’s see what her qualifications are for having the international political voice which the American press has given her. She is a mother and she can camp. Wow, I guess that makes her a political mastermind.

Now let’s dissect Cindy’s blog (http://www.huffingtonpost.com/cindy-sheehan/a-bright-spot-in-bush-wor_b_7433.html):

“George Bush needs to stop talking, admit the mistakes of his all around failed administration, pull our troops out of occupied New Orleans and Iraq, and excuse his self from power.” Cindy, your ignorance of law betrays your extensive background for political analysis I just mentioned. Federal law prohibits the federal government from sending troops into a state; the troops in Louisiana and Mississippi were invited, in writing, by the Governors of those states. Hey, who needs facts anyway? Besides, can we really “occupy” our own country? Back to Cindy’s blog.

“The only way America will become more secure is if we have a new administration that cares about Americans even if they don't fall into the top two percent of the wealthiest.” Gee, those pesky facts keep getting in the way. Bush's 2004 budget added 2% more for entitlement programs than Clinton’s last budget. In fact, Bush is spending more on poverty entitlement programs and education than any President in history.

Unfortunately, Cindy is not unique. All ideologues preach ideologies of division and worse, of hate; she just makes for a perfect example. All ideologues, left and right, should just shut the hell up and let the rest of us pound out the daily “hard work” of establishing strategies and programs that advance American society as a whole, within a camaraderie of partnership and unity.

“Like an unchecked cancer, hate corrodes the personality and eats away its vital unity. Hate destroys a man's sense of values and his objectivity. It causes him to describe the beautiful as ugly and the ugly as beautiful, and to confuse the true with the false and the false with the true.” -Martin Luther King Jr.

Go With Grace?

AP Wire, July 14, 2005, 9:00 PM: "I am not about to announce my retirement. I will continue to perform my duties as Chief Justice as long as my health permits."

And so ends all media speculation as to the retirement plans of Chief Justice William Rehnquist. I guess the press can now take down their emblazoned tents, pack up their kit bag, and prepare for immediate departure to the doorstep of D.C. United States Court of Appeals Judge John Roberts, whom President Bush just announced to replace retiring Justice Sandra Day O'Connor.

It is worth noting that the L.A. Times reports that Supreme Court colleagues state that Justice Rehnquist’s illness has not affected his abilities; “…he was fully prepared to discuss and debate the cases that were voted on in the court's private conference each week. Rehnquist led off the discussions, and he was known for running the meetings efficiently. His written opinions were clear and concise.”

That’s nice.

We’ve all heard of the infamous blue shield. Is this a facsimile “marble shield” simply serving to “protect thy own”?

As a physician, I have seen the denial and disbelief many times. Fact: Justice Rehnquist’s health problems have forced absences from the bench and emergent hospitalizations. Fact: He has cancer, and at 80 years of age faces a difficult life challenge regardless of the specific cancerous species. Fact: He is the Chief Justice. Remember, this position carries with it the awesome power and responsibility of leading the judicial branch; one of the three balance powers of our uniquely American government. This ain’t just a sack-boy job down at the local grocery.

Political analyst Dick Morris has stated, "If he has any sense of responsibility to the Republican Party, he has to give George Bush some wiggle room.” Keep in mind, even if Judge Rehnquist considers himself fully capable, we must all wonder how long it will be so. As a confirmed conservative, he needs to consider the timing of his departure and of the nomination process that will eventually replace him. “Who” and “when” this replacement process occurs become very big issues in the Supreme Court Justice game.

Let me be clear, I am not calling for his imminent resignation. To do so would be unfair; I do not know the man personally, I am unaware of his health details, I cannot see into the man’s cognitive processes.

I just hope that Justice Rehnquist does not allow a personal hubris of perceived importance, uniqueness, and immortality to affect his decision to retire, as the ramifications can truly become “larger than life”. I only request that he consider the responsibility of his position to the American people and to our future generations, as his actions in this role can affect our way of life for decades, and likely much longer.

Judge Rehnquist, please choose wisely and with clarity of purpose.