What you can do for your country

Perpetual Majority Hidden as Health Care

By the time I was 30, I started to realize that when someone articulates an opposing view its best to assume they are right and I am wrong.  Introspection informs one argument.  So, I have been carefully listening to the Health care debate trying to understand how to cover more people, deal with pre-existing conditions, address rising costs, and assure medicare does not go bankrupt.  I listened with the hope of addressing these issues while expanding innovation.

Despite the various erroneous statistics claiming deficiency in quality of care in our current system, the United States is the center of world wide health innovation.  Our market has created the new technologies that socialized program around the world use to deliver high quality care.  Our innovation  gives other nations a free ride. 

I hoped in the present debate over health care that we could fashion improvements in our system while protecting the innovation that has made it great.  I hoped that we could preserve our rights of choice, while expanding coverage.  I hoped that we could go beyond any other countries' success with a model that expands rather than constrains.  I listened between the noise of Right and Left to find real answers that could achieve wholehearted support across all demographics and political persuasions.

But alas, my deductive reasoning is taking over.  Having read many insightful articles on how to fix the health care problem and having read the bills before congress, I see no correlation.  For example:

• Health savings accounts have reduced health care cost by 5%-15%, but they are essentially banned by the bill
• The core source of health care issues in the United States is poor preventive care, but there are few motivating provision for preventive care in the bill
• Innovation is a significant component of care to date but the bill increases taxes on companies that develop new technologies thus discouraging innovation
• Different people need different care but the bill implements new authorities that will regulate the scope of health care to limit variations
• The free market has rapidly reduced cost of elective procedures like lasix, but the bill attempts to reduce cost through unproven means like cost controls
• The bill says it will reduce costs but can only be afforded by increasing taxes on the rich by 5.4%

So, I am wondering how experts in the field of health care have views that differ so significantly from the bill in congress.  My conclusion is this is not a bill about health care. This is a bill about controlling 16% of the economy. 

It is interesting to note that the legislative branch was Republican dominated from 1861-1933.  Under the new Deal, and passage of Social Security (amongst other programs), Democrats laid ground work that gave them legislative power, reinforced with medicare and welfare under LBJ, through 1981.  Through a strong believe in the free market and freedom, Reagan laid the foundation to open markets and empower innovation.  Since then we have seen Republican legislative leadership for the almost the last 30 years, reformation of welfare and a range of other empowering steps that accelerated economic growth.

It appears that social programs help Democrats keep legislative control.  Overtime, as people get tired of government, eliminating social programs helps Republicans take legislative control.  So, if Pelosi is writing a health care bill that  does not fix health care, could She really be writing a bill to perpetuate a Democrat legislative majority?  What are the signs? 

• Increasing taxes on the rich who rarely vote democrat anyway
• Let young people remain covered under their parents
• Don't tax high value union health insurance programs
• Accept a narrow vote on a monumental piece of legislation

To add to my cynical view, add the notion of offering citizenship to illegal aliens.  If the Democrats can successfully pass the health care bill and then allow a large fraction of illegal aliens to become citizens, they lay the foundation for a democrat majority for the next 50-60 years.

I am reminded of some key passages of the Gettysburg address:

...our fathers brought forth on this continent a new nation, conceived in Liberty, and dedicated to the proposition that all men are created equal.....The brave men, living and dead, who struggled here, have consecrated it, far above our poor power to add or detract. The world will little note, nor long remember what we say here, but it can never forget what they did here. It is for us the living, rather, to be dedicated here to the unfinished work which they who fought here have thus far so nobly advanced. It is rather for us to be here dedicated to the great task remaining before us—that from these honored dead we take increased devotion to that cause for which they gave the last full measure of devotion—that we here highly resolve that these dead shall not have died in vain—that this nation, under God, shall have a new birth of freedom—and that government: of the people, by the people, for the people, shall not perish from the earth.

Gettysburg reminds me that the United States has achieved greatness through freedom and individual exceptionalism.  As Andrew Jackson said, "One man with courage makes a majority".  I interpret Lincoln to say that we need to respect the mission of individual excellence and to be "...dedicated here to the unfinished work..." of others, dedicating ourselves to "The great tasks remaining before us".

Lincoln professed that freedom and equality are a function of the individual's ability to rise above all else and contribute in exceptional ways.  Lincoln did not mean "All men are created equal" so take from the rich and give to the poor, or have government displace personal freedom.  Freedom is equally challenged by wiretaps as by government driven social programs.

The fundamental reality is there are more than enough ways to streamline health care without a giant government program (See "Layman's guide to Health Care").  The more important message is that Pelosi and gang are attacking the notion of our democracy by driving the health care bill.  They say they are well meaning, but their failure to incorporate market proven solutions like Health Savings Accounts tell otherwise.

If its the case that the underlying purpose of the bill is to perfect the Democratic majority,  it is beyond disgraceful.  Government intervention to save money does not work.  Government intervention to protect a majority does work.  As citizens we need to dig in deeper to understand what is really going on with this bill, demanding real reform that reduces cost and expands care using the free market.  If the bill just protects the majority, it is immoral and cynical.

FACT CHECK: Health insurers' profits 35th of 53

The Chicago rules say to pick on folks to win your points; (Alansky's Rules for Radicals)

RULE 12: Pick the target, freeze it, personalize it, and polarize it." Cut off the support network and isolate the target from sympathy. Go after people and not institutions; people hurt faster than institutions. (This is cruel, but very effective. Direct, personalized criticism and ridicule works.)

It seems, as highlighted by a recent article in AP, that the administration should have followed the "...not institutions..." part of the Alansky rule set.  Institutions have fact's that in the end come out.  Institutions at some point fight back.  The AP article goes on.....

In the health care debate, Democrats and their allies have gone after insurance companies as rapacious profiteers making "immoral" and "obscene" returns while "the bodies pile up."  But in pillorying insurers over profits, the critics are on shaky ground. Ledgers tell a different reality.  More.....

2.2B on vaccine that will arrive too late, an imperfect plan? Smart power?

We have known about the H1N1 (Swine Flu), risk for many months now.  We knew that last spring's outbreak would turn into a more virulent strain by this fall.  That is all basic science.  Concerned for our citizens, the government recognized the need to produce substantial volumes of vaccine.  We have spent more than $2.2B for H1N1 Swine flu.  To date, only a minor amount of this vaccine has been delivered, but concern seems muted.  Despite new vaccine manufacturing technologies, we persist in using outdated methods and to spend huge sums of money in a wasteful manner.  Why? 

Here is a bit of background....

• Clinton (HRC) pushed the Vaccines for Children policy in 1993, which caused most manufactures to exit the industry
• In early part of Bush administration R&D in vaccine research was dramatically increased
• 2004 season: a combination of fewer manufactures and accusations of Bush incompetence resulted in ~40M dose short fall vs. plan of 100M doses for season flu
• Fear of Bird flu and other emerging pandemics led Democrats to accuse Bush administration of multiple failings.  Budgets for pandemic research and preparedness were increased substantially (more than $4B over 2005-2007 time frame) 
• Additional $1.5B was authorized in Spring of 2009 to produce H1N1 vaccine.  Total spend for H1N1 Vaccine of approximately $2.2B 
• By Fall of 2009, only 11.3M doses of a planned 250M doses have been delivered.  HHS claims there have been minor "glitches", DHS claims all is per plan
• Critical study shows vaccine will arrive too late for impact on H1N1
• 1,000  3,900 people have died so far in US (if you recall 1,494 died in Katrina apparently because of Bush's failing and global warming, which is also Bush's fault)
• Main Stream Media is mum on whole issue, Fox (non) News is not

My frustration comes from a few issues.  The historic process of making vaccines in egg shells is arcane and subject to numerous production risks that can result in last minute issues like contamination (cause of 40M dose shortage in 2004).  Liability clauses discourage drug manufactures from manufacturing vaccine, and Government is unwilling to wave terms.  Companies like Novavax (www.novavax.com) have had a novel technique, using virus like particles to make large volumes of vaccine, for many years, but government continues to buy from companies using old egg technique.  Per the time line below, Democrats have put huge amount of effort and money into realigning national efforts for pandemic response (and ridicule of the past administration for its failures) but seem to deliver worse results.

So, we are spending dramatically more money.  We have all the best minds focused on the subject.  Every resources of government is focused on success.  Obama has every resource he has requested.  We have been spending the last 4 years realigning efforts for pandemic. And, we are 210M doses short of plan for H1N1.  When the vaccine does become available, the pandemic will likely have run its course killing more people than died in the (supposed) last government lead disaster (Katrina).  Is this smart government?

Frankly, had government instead focused less than a $1 billion on new production techniques like those of innovative companies (Novavax, etc), we would have all the vaccine we would ever need.  Where are the hearings?  Where is the outrage?  Where is our money?  Is this how stimulus is being spent?  Does anyone in Congress actually think about a problem, look at the fundamentals, and perhaps question why we are still building vaccine the way we did in 1940?  Great innovation guys, where are our coffins?  

Timeline

1993

HRC (Clinton) implements Vaccines for Children program gutting profitability in the vaccine industry and imposing government control over a large share of revenue.  Major players exit industry in response.

2001-2004

Bush administration raises vaccine funding from $39 million in 2001 to a proposed budget of $283 million in fiscal year 2005. The National Institutes of Health has increased its spending on new ways to make vaccines to $60 million from $20 million. (NY Times) 

2004

January:Senators Bayh, Landrieu and Durbin introduced the Flu Protection Act (S. 2038) to strengthen the nation’s vaccine supply and establish a plan to prevent, prepare for, and respond to an influenza pandemic.

October:Vaccine production for 2004 season falls short ~40M of a planned 100M doses.  Bush was accused of incompetence and insensitivity.  The 40M  dose shortage was associated with a contaminant found late in the manufacturing process.  Senator Kennedy requested from Acting Commissioner of Food and Drugs Lester Crawford a complete record of all contact between FDA and Chiron Corporation, a major supplier of influenza vaccine to the United States.  While Chiron had announced problems with vaccine production back in August 2004, FDA claimed to be surprised by the early October announcement that Chiron’s Liverpool facility had lost its license to produce vaccine.  Kennedy expressed the great importance of a stable, effective vaccine supply to protect Americans from seasonal flu, which is also necessary to respond to a pandemic influenza outbreak.

2005

March 2005: Senator Obama successfully amended the Foreign Relations Committee Authorization Act to authorize $25 million for international efforts to combat avian influenza and called on then-President Bush to create an inter-agency task force composed of representatives of the Department of State, Department of Health and Human Services, Department of Agriculture, and other appropriate agencies.   

April: then-Senator Obama introduced the AVIAN Act (S. 969), the first comprehensive bill addressing the threat of pandemic influenza.

May: Senate Democrats secured $58 million in the Supplemental Appropriations bill (P.L. 109-13)to purchase more antiviral medication for the Strategic National Stockpile to better prepare for pandemic influenza.  This law also directed $25 million to USAID for programs to control the global spread of the avian flu. 

August:1,464 people die in Hurricane Katrina

September:Senator Reid took to the Senate floor urging immediate action to prepare for the threat of pandemic influenza and expressing the importance of immediately committing the resources necessary to protect Americans.  Senator Reid stated that the nation could not wait any longer for the Bush Administration to finalize its pandemic influenza preparedness plan and announced that Democrats would offer a pandemic preparedness amendment to the Department of Defense Appropriations bill.  Senate Democrats, led by Senators Harkin, Obama, Reid, Durbin, Bayh, and Dodd, successfully amended the Fiscal Year (FY) 2006 defense and emergency supplemental appropriations bill (P.L. 109-141) $3.9 billion to the Centers for Disease Control and Prevention to fund pandemic flu preparedness.

October:the Senate approved an amendment by Senator Harkin to the Labor-HHS-Education appropriations bill adding $8 billion to prepare for and protect against the threat of an avian flu pandemic. 

November: President Bush released a final pandemic influenza preparedness plan and requested $7.1 billion in emergency supplemental funding for pandemic flu preparedness, almost a billion dollars less than what Senate Democrats had successfully included in the Labor-HHS-Education appropriations bill.

December: the Republican-controlled Congress approved only $3.8 billion to prepare for a flu pandemic in the emergency supplemental appropriations bill (P.L. 109-148) – less than half of the $8 billion the Senate had passed through the Harkin amendment.

2006

February:Democrats fought to include $2.3 billion in additional funding for HHS in a second emergency supplemental appropriations bill passed during FY2006 (P.L. 109-234).  32 Senate Democrats sent a letter to President Bush, calling on him to make pandemic flu preparedness a priority in his Fiscal Year 2007 budget.  President Bush released his budget proposal for Fiscal Year 2007, including a $2.3 billion allowance for pandemic influenza activities.  The President did not include the $2.3 billion in pandemic flu funding in his emergency supplemental budget request to Congress.  Fortunately, during the Appropriations Committee markup of the supplemental in early April, an amendment offered by Senator Harkin to add $2.3 billion in pandemic flu funding was approved by voice vote, and the funding was included in the version of the supplemental signed into law on June 15, 2006 (P.L. 109-234).

May: Senator Kennedy released a report entitled, “Too Little Too Late: The Bush Administration’s Record of Failure in Preparing for Pandemic Flu.”  The report detailed failures of the Bush Administration and Republican-led Congress to adequately prepare the United States for pandemic influenza, due to limited appropriations, lack of coordination among government entities, and an overly narrow focus on only a few of the actions necessary to prepare the nation for pandemic influenza.

2007

May: President Bush vetoed legislation passed by the Democratic-led Congress which would have provided $625 million for pandemic flu preparedness at HHS (H.R. 1591). 

November: President Bush vetoed the FY2008 Labor, Health and Human Services, and Education Appropriations bill (H.R. 3043).  This legislation would have provided $870 million to prepare for and respond to an influenza pandemic, including funds for vaccines, antiviral medications, medical supplies, diagnostics and surveillance tools.  In order to pass a bill the President would sign, pandemic flu funding was reduced to $302 million in P.L. 110-161.

December: Senator Clinton introduced the Influenza Vaccine Security Act (S. 2456) to improve and secure our nation’s supply of influenza vaccine, improve vaccine distribution, and improve stockpiling of supplies to prevent and treat pandemic influenza.

2009

January: the Senate Appropriations Committee approved the American Recovery and Reinvestment Act, which included $870 million for pandemic flu preparedness activities.  Unfortunately, this funding was removed as a condition for final passage and, therefore, was not included in the final version of the legislation signed into law by President Obama (P.L. 111-5).

Spring:Major outbreak of H1N1 Swine flu suggests pandemic will emerge, stronger in Fall 2009

March: the Senate approved the Fiscal Year 2009 Omnibus Appropriations bill.  Led by Democrats, this legislation (P.L. 111-8) included $818 million for pandemic flu preparedness.

April:President Obama requested $1.5 billion in emergency appropriations to respond to the H1N1 influenza virus, and Senate Democrats, including Majority Leader Reid and Labor-HHS-Education Appropriations Subcommittee Chairman Harkin, indicated the Senate was poised to comply with the President’s request.

May: President Obama’s Fiscal Year 2010 Budget Request included $584 million for pandemic flu preparedness.  This funding is in addition to the $1.5 billion requested in April as part of the emergency supplemental appropriations. The Senate Appropriations Committee approved the Fiscal Year 2009 Supplemental Appropriationsbill, including $1.5 billion to prepare for and respond to a global disease pandemic, including the H1N1 influenza virus.

Orders for Bulk Supply of H1N1 Influenza Vaccine Antigen and Adjuvant: May 22, 2009

Manufacturer	Bulk Vaccine Antigen	Oil-In-Water Bulk Adjuvant
Novartis	$150 million	$139 million
GlaxoSmithKline	$ 38 million	$144 million
Sanofi Pasteur	$191 million
CSL Biotherapies	$180 million
MedImmune	$ 90 million
Total	$649 million	$283 million

Orders for Bulk Supply of H1N1 Influenza Vaccine Antigen and Adjuvant: July 9, 2009

Manufacturer	Bulk Vaccine Antigen	Bulk Virus Concentrate/FFF	Oil-In-Water Bulk Adjuvant
Sanofi Pasteur	$61,425,000	0	0
GSK	$0	0	$71,400,000
Novartis	$346,334,450	0	$343,810,470
CSL	$0	0	0
MedImmune	$0	$61,008,000	0
Total	$407,759,450	$61,008,000	$415,210,470

September: With vaccine shortage becoming apparent, Government releases study showing less vaccine is required than orginally expected.  This changes dosing requirment from 2 shots to 1 shot.  Essentially doubling the expected capacity and eliminating major forecasted shortfall.

HHS orders an additional 56 million doses of vaccine: September 21, 2009

Manufacturer	Total Cost
MedImmune	$295,660,000
Sanofi Pasteur	$143,483,025
Total	$438,143,025

October: CDC Defends Reliance on "Antiquated" H1N1 Vaccine Production Despite Shortage.  Government's original modified order of 251M doses, expected to receive 40M by this point actually has yield only 11.3 M doses.  1000 have died and 20K hospitalized so far due to H1N1 (and presumably lack of vaccine).

Siebeus "Blamed the vaccine shortage on lower than predicted yields from vaccine manufacturers and on some manufacturing 'glitches' that have occurred since May. ....the yields are now more in line with original predictions and that any glitches have been corrected." 

Napolitano said "federal officials had assumed there would be a lag in vaccine availability and a spike in the flu, so officials are not surprised that H1N1 has spiked at a time when there is not enough vaccine available."

Study shows vaccine will be too late to have impact on H1N1

Lieberman holds hearing on Vaccine shortage, but only Fox News reports  MSM ignores (WH Embargo?)

> 1000 people in US have died due to H1N1

A Layman's plan for Health Care

I am not a health care expert, congressman or a brilliant inspirational president.  I really have no credentials on politics.  Practically, my skills as a graduate of a tier 1 business school with a concentration on innovation, years of technology investment, years of operating new successful innovative businesses and other business success probably has no applicability to markets, innovation and health care.  Really, what could I understand if I have not been on the cover of Time or Newsweek?  Given my ignorance, I do have some thoughts....

That given, perhaps we should concentrate on some fundamental principles:

• Tax bad behavior (pre-existing, tort, free rider, fat, receivables)
• Encourage good behavior (wellness, cost innovation, direct pay, savings)
• With respect to national policy, only implement successful strategies
• If a third party is paying, doctors won't innovate to meet needs of the patient
• Innovation is the only way to truly reduce cost of an item of care
• If people don't take care of themselves, the cumulative cost of health care will be high

There are many ideas and issues within the overall health care discussion, many misdirected:

Universal coverage: I am not a lawyer, but it seems that if Federal Law mandates universal coverage, that constitution then requires universal application/availability to all persons (not just citizens).  That is a back door path for any plan that is heterogeneous or does not cover illegals/non citizens (I think SCOTUS is Obama’s back door for illegals, which he has to get in so he can maintain perpetual democrat majority).  So, it would be best if any federal plan was constrained in its offering to avoid opening Pandora’s box.

DNR: Just like someone can sign a Do Not Resuscitate order, so should they also be allowed to sign an opt out order (Do Not Save – DNS).  The opt out would basically say, “I understand I will not get care unless I can prove I have means to pay”.  People could self insure and certify ahead of time, perhaps validated through some credit worthiness service.  If you no longer are credit worthy then perhaps you fall under a mandate penalty provision given your imposed burden on society.

Tort: I don’t love the lawsuits, but seems freedom of speech trumps tort reform.  However, in an effort to reduce the cost of one's policy, a patient should be allowed to opt out of tort, or allow form of arbitration.  Sort of like how workman’s comp limit claims.  As you get a discount on homeowners insurance if you have a burglar alarm, you will get a premium discount if you sign a tort limitation clause.

Catastrophic: A underlying issue in insurance is that your costs go up as you get older, because your likely care costs go up.  Everyone, except those that die suddenly like my father, impose some level of big cost towards the end.  But no one who is young fears this cost.  Thus, the right instrument is an annuity, in which you are compelled to pay in to a catastrophic pool which would not pay in until you reach a very high level of burden, like $100K.  This could perhaps be an extension of Medicare of social security, preferably a 401K/IRA/HSA.

Low Cost Transactions (HSA): All low cost high volume transactions (wellness visit) should be direct pay.   Most doctors offices operate with 180-240 days of aging for receivables.  That means there is a bunch of profit wasted in the payables process (i.e. interest on 500K of average receivables).  Though direct pay seems like a burden (out of pocket), it would eliminate the cost of a lot of oversight and receivables management.  A transparent process at the front end (i.e. I know what my doctor visit costs) would impose proper price dynamic currently missing because of third party pay.  So, everyone should be motivated to buy a high deductible plan, like an HSA.

Taxes: Do not introduce new special taxes on those that innovate (Drug companies, device manufactures, etc).  We need the innovation to improve quality/cost of care.  Either Eliminate deductibility of corporate plans, or permit deductibility of all health care plans (i.e. self employed).  Maybe only allow tax deductibility for elements of a basic plan for plan costs associated with wellness, insurance for first 100K, retroactively pays back portion of premium for reducing weight, or motivates direct pay (i.e. the portion of an insurance plan that allows third party pay for initial costs below $5000 would be taxable).

High Cost of Healthcare: That we pay more for healthcare is irrelevant.  We pay more for media content should we regulate revenue in that market?  U.S. market prefers to pay more than other countries for care because we like to be fat and eat at McDonalds.  Promote tax deductions for those practicing wellness (actually don’t, I am a libertarian).  Remove any restrictions on insurance plan penalties for obesity, weight, high blood pressure, etc.

Pre Existing Condition: If someone goes off insurance or never has it, they should take responsibility for their pre-existing condition.  The catastrophic insurance (govt plan) should impose no limitation on pre-existing condition, but it will only cover costs above 100K.  Practically I think the market will overtime accept pre-existing conditions, it already has on some policies – basic concept is a business will offer a service (insurance) until marginal revenue = marginal cost.  Alternately there could again be a form of government re-insurance in which a portion of Medicare fee is put into a pre-existing condition re-insurance pool.  Any insurance plan that eliminates a pre-existing condition test would have access to that pool.  Fundamentally though, we need to use the market to motivate free riders to join a plan.  Some plans offer retroactive discounts for wellness behavior – so if you have high blood pressure  and reduce it, you get paid back the premium delta for the last couple of years from a normal vs. high risk plan.

Health Savings Accounts: There should be a tax code preference offered to forms of HSA, in which consumers pay in pre tax to a savings account (IRA like) to help eliminate front end costs.  Savings account can be used for wellness efforts and all healthcare co-pays bellow deductable cap.

Poor: For people that cannot afford healthcare, they should be put on a HSA.  The deductable portion should be paid in via welfare with some form of lifetime cap on govt. funded portion of savings account (i.e. 50K).  Participants should be means tested, and their portion of payment should be in relation to their salary.  Perhaps work this a bit like the micro loans in India/Africa in which a portion of the money paid into the savings account can be used to pay premiums.

Innovation: Innovation occurs when there is a market for early adopters.  The best innovations (balance of technology and price) are always best incubated through market pressures.  Public has been served well by Judge Green (Telco rulling in 1980).  Universal coverage would force universal solutions (equal to all).  The federal proposals would substantially constrain the right of end-users to buy what they want.  Seems like an antitrust situation.  If Government wants to apply the commerce clause, it would seem government would need to stay in the regulate role rather than “I am also in the services” role.  It would also seem that government should not be allowed to take action that inhibits federalism (in as much as federalism is a principle of differential approaches to governance).

So the summary of the plan would be

• Everything above $100K will be covered by a universal plan administered or authorized by government. Private plans could be made compliant under the government plan, to act as agent on governments behalf.
• Private insurance plans for everything below $100K
• Government pays for premium (COOP, Private or Govt) if person is on Public assistance
• Do Not Save – DNS: anyone who opts out of private must sign a DNS order or pay a penalty (as a libertarian I would actually prefer that hospitals just did not care for those who have not bought insurance or committed to a financial obligation.

I need to think more about this approach.  I am trying to avoid government having to serve a direct regulatory role for service level.  I don’t think I mind them in the guarantor or re-insurance role.  For innovation to thrive, government needs to be on the sideline.  We cant have innovation if changes to care require congressional approval.  Waxman and others are into the minutia which will halt innovation.

A Doctors View: Government healthcare already rations

From an E-Mail I received....

This letter is from Dr. Zane Pollard. He is operates at Children's Health Care of Atlanta. Google him, he has a very impressive CV.

http://www.eyeconsultants.net/pollard.html

http://www.healthgrades.com/directory_search/physician/profiles/dr-md-reports/Dr-Zane-Pollard-MD-36307DFF.cfm
 
Friends:
 
I have been sitting quietly on the sidelines watching all of this national debate on healthcare. It is time for me to bring some clarity to the table and as your friend by explaining many of the problems from the aspect of a doctor.
 
First off the government has involved very few of us physicians in the healthcare debate.While the American Medical Association has come out in favor of the plan, it is vital to remember that the AMA only represents 17% of the American physician workforce.
 
I have taken care of Medicaid patients for 35 years while representing the only pediatric ophthalmology group left in Atlanta, Georgia that accepts Medicaid.Why is this. For example, in the past 6 months I have cared for three young children on Medicaid who had corneal ulcers. This is a potentially blinding situation because if the cornea perforates from the infection, almost surely blindness will occur. In all three cases the antibiotic needed for the eradication of the infection was not on the approved Medicaid list. Each time I was told to fax Medicaid for the approval forms which I did. Within 48 hours the form came back to me which, was mailed in immediately via fax and I was told that I would have my answer in 10 days. Of course by then each child would have been blind in the eye. Each time the request came back denied. All three times I personally provided the antibiotic for each patient which was not on the Medicaid approved list. Get the point--rationing of care.
 
Over the past 35 years I have cared for over 1000 children born with congenital cataracts. In older children and in adults, the vision is rehabilitated with an intraocular lens. In newborns we use contact lenses which are very expensive. It takes Medicaid over one year to approve a contact lens post cataract surgery. By that time a successful anatomical operation is wasted as the child will be close to blind from a lack of focusing for so long a period of time. Again extreme rationing.  

 

Solution- I have a foundation here in Atlanta supported 100% by private funds which supplies all of these contact lenses for my Medicaid and illegal immigrants children for free. Again waiting for the government would be disastrous.
 
Last week I had a lady bring her child to me.They are Americans but live in Sweden, as the father has a job with a big corporation. The child had the onset of double vision 3 months ago and has been unable to function normally because of this. They are people of means but are waiting 8 months to see the ophthalmologist in Sweden. Then if the child needed surgery they would be put on a 6 month waiting list. She called me and I saw her that day. It turned out that the child had accommodative esotropia (crossing of the eyes treated with glasses that correct for farsightedness) and responded to glasses within 4 days, no surgery was needed. Again, rationing of care.
 
Last month I operated on a 70-year old lady with double vision present for 3 years. She responded quite nicely to her surgery and now is symptom free. I also operated on a 69-year old judge with vertical double vision. His surgery went very well and now he is happy as a lark. I have been told--but of course there is no healthcare bill that has been passed yet--that these 2 people because of their age would have been denied surgery and just told to wear a patch over one eye to alleviate the symptoms of double vision. Obviously cheaper than surgery.
 
I spent two years in the US Navy during the Viet Nam war and was well treated by the military. There was tremendous rationing of care and we were told specifically what things the military personnel and their dependents could have and which things they could not have. While in Viet Nam, my wife Nancy got sick and got essentially no care at the Naval Hospital in Oakland, California. She went home and went to her family's private internist in Beverly Hills. While it was expensive, she received an immediate work up. Again rationing of care.
 
For those of you who are over 65, this bill in its present form might be lethal for you. People in England over 59 cannot receive stents for their coronary arteries. The government wants to mimic the British plan. For those of you younger, it will still mean restriction of the care that you and your children receive.
 
While 99% of physicians went into medicine because of the love of medicine and the challenge of helping our fellow man, economics are still important. My rent goes up 2% each year and the salaries of my employees goes up 2% each year. Twenty years ago ophthalmologists were paid $1800 for a cataract surgery, and today $500. This is a 73% decrease in our fees. I do not know of many jobs in America that have seen this lowering of fees.
 
But there is more to the story than just the lower fees. When I came to Atlanta there was a well known ophthalmologist that charged $2500 for a cataract surgery as he felt the was the best. He had a terrific reputation and in fact I had my mother's bilateral cataracts operated on by him with a wonderful result. She is now 94 and has 20/20 vision in both eyes. People would pay his $2500 fee. However, then the government came in and said that any doctor that does medicare work can not accept more than the going rate (now $500) or he or she would be severely fined. This put an end to his charging $2500. The government said it was illegal to accept more than the government allowed rate. What I am driving at is that those of you well off will not be able to go to the head of the line under this new healthcare plan just because you have money as no physician will be willing to go against the law to treat you.
 
I am a pediatric ophthalmologist and trained for 10 years post college to become a pediatric ophthalmologist (add two years of my service in the Navy and that comes to 12 years). A neurosurgeon spends 14 years post college, and if he or she has to do the military that would be 16 years. I am not entitled to make what a neurosurgeon makes, but the new plan calls for all
physicians to make the same amount of payment. I assure you that medical students will not go into neurosurgery and we will have a tremendous shortage of neurosurgeons. Already the top neurosurgeon at my hospital who is in good health and only 52 years old has just quit because he can't stand working with the government anymore. Forty-nine percent of children under the age of 16 in the state of Georgia are on Medicaid, so he felt he just could not stand working with the bureaucracy anymore.
 
We are being lied to about the uninsured. They are getting care. I operate at least 2 illegal immigrants each month who pay me nothing and the children's hospital at which I operate charges them nothing also. This is true not only on Atlanta, but of every community in America.
 
The bottom line is that I urge all of you to contact your congresswomen and congressmen and senators to defeat this bill. I promise you that you will not like rationing of your own health.
 
Furthermore, how can you trust a physician that works under these conditions knowing that he is controlled by the state? I certainly could not trust any doctor that would work under these draconian conditions.
 
One last thing, with this new healthcare plan there will be a tremendous shortage of physicians. It has been estimated that approximately 5% of the current physician work force will quit under this new system. Also it is estimated that another 5% shortage will occur because of decreased men and women wanting to go into medicine. At the present time, the US government has mandated gender equity in admissions to medical schools. That means that for the past 15 years that somewhere between 49 and 51% of each entering class are females. This is true of private schools also because all private schools receive federal fundings.
 
The average career of a woman in medicine now is only 8-10 years, and the average work week for a female in medicine is only 3-4 days. I have now trained 35 fellows in pediatric ophthalmology. Hands down, the best was a female that I trained 4 years ago--she was head and heels above all others I have trained. She now practices only 3 days a week.
 
Zane Pollard, MD 

http://www.eyeconsultants.net/pollard.html 

 http://www.healthgrades.com/directory_search/physician/profiles/dr-md-reports/Dr-Zane-Pollard-MD-36307DFF.cfm

Democratic investigators target health insurers to access proprietary corporate data and advantage government program: Antitrust?

Democratic investigators are targeting health insurers, asking for a range of information on critical operational data including:

• Executive Compensation
  • Salary
  • Bonus
  • Stock Grants
  • Realized value of options
  • non-equity compensation
  • Pension value/Deferred compensation
  • All other compensation
• A list of all board members and their compensation
• List of all conferences, retreats, events, etc that were paid for by the company.  Include purpose, participants, expenses, transportation, etc
• For 2003-2008 list
  • Total revenues
  • Net Income
  • Total Dividends
• Documents provided for the board, compensation committee, models, projections, performance criteria, etc.
• For 2005 - 2008, a table listing premium revenues, claims, payments, sales expense, other G&A and profit for all the companies health insurance products.  Aggregate by
  •  Self insured employer market
  • Insured employer market
  • Individual market
  • Government market (Medicare etc)

Now some of this is public data and readily available, so Congress could have found it the same way the rest of us get it, via a 10k.  But a bigger issue is Congress wants to go into the health care business, with the public option.  Can you imaging IBM sending Apple a request to provide all their private competitive data so that IBM can build a competing product to the Iphone?  No.

If government wants to offer health care, they need to get out of the regulatory business.  Or be a regulator, not a health care provider.  Most people would call this request a mater of anti trust.  Waxman thinks its OK to get this data because, hmmmmm......   well I don't know why. 

If this is the way congress acts before health care reform, just think what will happen after once there is no going back. 

The public option is supposed to stand on its own.  That should mean, it competes in the marketplace based on paid insurance plans, without impinging on the rest of the insurance market.  So, hospitals should not be able to cost shift government underpayment of claims by increasing fees on private insurance patients.  Similarly, congress can't use private corporate data to structure a program that will directly compete with private insurers.  Its not fair.  It is theft of valuable data.  

If I were an executive I would tell them to go look at my company 10K, and pound sand.

How Health Care is Killing Us (Government Advocates Mediocrity in Land of Innovation)

I have been working on crystallizing my thoughts on how to fix health care.  I am frustrated that the proposals in Government all seem incremental, taking the solutions we have but locking them in under yet more centralized government control.  We are the most innovative and productive nation on earth, but we seem ready to fix health care by expanding the status quo and replicating the plans of other lesser countries (Europe, Canada, Etc).

I received my issue of the Atlantic last night on my Kindle DX and found a the article I wish I had written:  How American Health Care Killed My Father - The Atlantic (September 2009).  The author very thoughtful integrates his business experience, loss of his father, and political thinking into a very complete approach for health care that drives consumer choice, reduces cost and motivates innovation.

  Key highlights of his article include:

• Why do MRI prices (Covered expense) remain high years after introduction while Lasik surgery (non Covered Expense) has dropped from $2000 to $400?
• Why vilify the profits of health insurance companies when they would pay 4 days of our nation's annual health care costs?
• We don't use auto insurance to pay our gasoline costs, why do we use health insurance for paying routine health costs like checkups?
• Do government regulations limit innovation?
• Why can't a consumer ever find out the cost of a procedure upfront?  How can cost be managed if the customer of the care can't even see the cost?
• Over the life of a typical employee, $1.77M is paid into health insurance (employee and company payment together).  If we gave everyone $1.77M, could they do a better job managing it?

In health care, the notion of a free market seems foreign to some.  Won't those companies cheat individuals?  Insurance companies and doctors can't possibly do what is right for the patient in a free market because they will just be focused on making a $.  The reality is the market is already being perverted in various ways depending on the direction of various regulations about what can or can't be funded.  Hospitals do everything they can to squash new innovative surgery centers that are set up to take advantage of Medicare's unwittingly payment of higher margins on lower end surgical procedures.  Loopholes will all ways be found in every system.  But can they be corrected quickly?  Only in a market based system.

Government has a key role in assuring integrity and standards in the system, but price really should be a function of consumers engagement with doctors to determine the best price, innovation and quality.  Because of constraints driven by medicare and insurance companies, the most costly health care is typically someone who pays out of their own pocket, but those same people are probably the cheapest people to treat because the doctor does not need to file claims etc.   This is a market perversion driven by a top down driven regulatory environment.

The author goes on to suggest the broader implementation of Health Savings accounts, a form of major medical insurance that kicks in for the absolute worst case tragedy that costs more than 50K (with no cap), and various other thoughtful modifications.

Between the Atlantic Article, the WSJ oped article from Whole Foods CEO, and the plan at Safeway, exists an answer to health care I can live with that will drive innovation, reduce cost, and expand coverage.

What is more important personal freedom or universal care? A test for Obama

I think we can all agree that we want people who are sick to get better, to have access to good health care and to not suffer due to health ailments.  But can we also agree that we believe in personal freedom, the right to make decisions for ourselves? 

Yes, Canada, England, Europe, China etc all have some form of universal health care.  That is great.  They also have limitations to a free press, less innovation, bad economies and less freedoms.  The United States represents 26% of world GDP.  The next largest economy is 1/3 the size of the United States.  The United States went from a start up 230 years ago to the most powerful country in the world.  Did that happen because of the greatness of our government actions or the greatness of our people?  Should the United States follow the path of others, or set the course for others as we have since our inception.  Our personal freedoms and rights to see opportunity, gather and engage each other, partner and invest, and think and dream are just an element of what makes the United States truly unique.

The health care debate is a foil to help us reflect on our rights and personal freedoms.  The President tells us, (Paraphrase) "...Health care is a mess and we need to take immediate action or it will collapse...".  If true, that is bad.  Though it is unlikely true.  I am not sure I know of any period in our country's history where our ability to address a challenge lead to total failure.  We were close in the depression and the cival war, but only close. 

I would argue, innovation and personal freedom have always been a correcting force for government failure.  Isn't that what democracy is about?  We the people have assigned some of our rights to the government because it is easier to manage.  We get to pick the managers.  And if they don't do a good job, we will fire them.  We only gave them some rights, not all.  We reserved all other rights to ourselves, and we are not going to give them up without consensus (i.e. constitutional convention).  Ronald Regan reminded us in 1961 about how subtle encroachment of the state can weaken our rights over time:

"One of the traditional methods of imposing statism or socialism on a people has been by way of medicine. It’s very easy to disguise a medical program as a humanitarian project. Most people are a little reluctant to oppose anything that suggests medical care for people who possibly can’t afford it." Ronald Reagan - 1961

With all the noise on health care and distraction of Nazis, socialism, the bill is not decided, republicans are racist, etc, part of my discomfort with the debate has crystallized around a WSJ article about the President regarding end of life care.  The President starts of the interview....

The President: "Now, I actually think that the tougher issue around medical care—it's a related one—is what you do around things like end-of-life care."

Yes end of life care is tough, each of has had to deal with it in some manner (Wife, Child, Mother, Grand Parent)

The President: "...I just recently went through this. ....when my grandmother got very ill during the campaign, she got cancer; it was determined to be terminal. And about two or three weeks after her diagnosis she fell, broke her hip.....

So now she's in the hospital, and the doctor says, Look, you've got about—maybe you have three months, maybe you have six months, maybe you have nine months to live. Because of the weakness of your heart, if you have an operation on your hip there are certain risks that—you know, your heart can't take it. On the other hand, if you just sit there with your hip like this, you're just going to waste away and your quality of life will be terrible. And she elected to get the hip replacement and was fine for about two weeks after the hip replacement, and then suddenly just—you know, things fell apart.

I don't know how much that hip replacement cost. I would have paid out of pocket for that hip replacement just because she's my grandmother. Whether, sort of in the aggregate, society making those decisions to give my grandmother, or everybody else's aging grandparents or parents, a hip replacement when they're terminally ill is a sustainable model, is a very difficult question. If somebody told me that my grandmother couldn't have a hip replacement and she had to lie there in misery in the waning days of her life—that would be pretty upsetting.

So the President seems to get that end of life care is tough.  He would have personally paid.  But then he goes to statism, questioning if "...a hip replacement when they're terminally is a sustainable model, is a very difficult question..."  Difficult question for who?  The government?  Society?  Its not their question.  Government, Society, everyone (except for the patient and maybe their family) has no right whatsoever to any part of the discussion.  None!  Nothing!  Nil!.  The constitution has provided no power to anyone to infringe on ones personal rights for what to do next with their life.

Recognizing the impact on cost of care, the President goes on:

The President: "Well, I think that there is going to have to be a conversation that is guided by doctors, scientists, ethicist. And then there is going to have to be a very difficult democratic conversation that takes place. It is very difficult to imagine the country making those decisions just through the normal political channels. And that's part of why you have to have some independent group that can give you guidance. It's not determinative, but I think has to be able to give you some guidance. And that's part of what I suspect you'll see emerging out of the various health care conversations that are taking place on the Hill right now."

Guided by doctors, scientists and ethicist?  They will guide the decision about how we mange end of life decision on the economics of care?  Really?  What about the patient and their family?  The President says he would have "paid out of pocket for his grandmother", but wants doctors, scientists and ethicist to guide for the rest of us under the health care bill.  Did we ask for this help?  If we did not ask for it, why do we need it?  Probably because, the only way to run a government program is to cut cost, and the only way to really cut cost with out innovation is to pull the plug on Grandma.  (But he didn't say that right?)

What the health care bill contains and the degree to which the public option restricts funding certain treatments does not really matter if other options exist (secondary insurance and paying cash).  Practically it is hard to believe that the government will close down the right to supplement ones health care.  In a market economy though excessive government restrictions may very well shut down private options.  But what is outrageous is that the government thinks it even has the right to implement a health care program, using public resources, that restricts personal choice.  (all must opt in and follow the "Plan").  Furthermore, it is outrageous for the government to do anything that impinges on our rights to buy insurance (opt out) from other health care innovators.  Impinges includes restricting how other insurance plans can operate, who they enroll, what preconditions they accept, etc. 

The great thing about the "Market" is that people have the right to choose.  People do not have a constitutional right to government funded end of life care.  People have the right to choose if they want to use their resources to buy insurance and/or pay extra out of pocket for grandma's care.  They have the right to choose that independent of the government, doctors, ethicists, and scientists. 

In sales mode, the President keeps saying the choice for end of life care is between the doctor and the patient, not government or private insurance (making some veiled comment that somehow insurance companies already restrict rights).  Private insurance is really not currently involved in the decision.  They contribute, via a contractual relationship, to the decision in their willingness to fund a portion of end of life care, but they don't have ethicist making the decision for patients or ethicist deciding on a formulation for what can/can not be funded.  The calculus of what is paid for at end of life is a result of an economic decision between the insurance company and the patient.  And, really end of life care decisions are not the doctors prerogative.  I have had these conversations with regarding my mother with docotrs (sample size 1) and never found them steering me in any direction.  The Doctors left the decision to the patient and family.

I am pretty sure the President Obama is president of the United States, not the CEO of a new health care company.  I don't think he is a doctor, though he seems to think he knows how doctors should practice medicine.  Since he is president, he should focus on first preserving our rights to personal freedom i.e. "First do no harm".  In the context of Health care, he should preserve our rights to have a competitive health care market that maximizes the ability for patients to choose.  Health care should not be about society choosing/limiting our options through government regulations.  That might work for Europe, Canada or China, but the United States is made of different stuff. 

Through personal choice we have created the most prosperous country in the world, driving unbelievable levels of innovation and opportunity.  The WSJ interview with the President signals that he is a man that believes Doctors, Scientists, and Ethicists can shape the best decisions on our behalf forgetting that its individual freedom that made us great.  He needs to choose between Statism and personal freedom.  I have.  We can innovate our way through this problem if he gets out of the way.  That would be the honorable path to universal health care.

Obama's healthcare horror (Heads should roll -- beginning with Nancy Pelosi's)

Camille Paglia wrote a great article in Salon, critical of the health care plan.  Critical from the sense of, Health Care is an import issue to address so don't waste the opportunity to do it right.  She goes on to outline how the President is being poorly served by his staff and congress.

As an Obama supporter, she describes her frustration with the hard push to agree on a health care plan despite limited debate.  She contrasts the "Its in there don't worry" repose of government despite the fact that there are 5 competing health care bills, no one of which is near settled.

I believe the anger we are seeing in town halls is pent up frustration, from the Stimulus bill on.  Statements like "The economy is getting better because of Stimulus", when less than 10% of stimulus has been deployed, makes you wonder if the rest of stimulus is needed.

I am frustrated that the president says "If you like the health care you have now, you can keep it", when HR3200 outlaws Health Savings Accounts, which is my current health care plan.  I am not sure who to believe or trust when there are so many blatant contravening facts and assertions.

Ms. Paglia does a good job capturing the frustrations of many.

Obama Says "CBO not Telling the Truth on HealthCare" - Elliot Richardson where are you

Well, in an effort to push health care, it seems the only Truth is what comes out of the mouth of Senator Reid or the President, everyone else is not telling the truth or is a partisan.  Reported in todays Washington Post, President Obama "Urged Congress to push past growing doubts......"

As you likely know, the Congressional Budget office, an organization intended to review and assess the impact of legislation, stated something to the effect that the current health care bill moving though congress would likely increase the cost of health care and increase the deficit.  The CBO issued a 17 page report making several important observations:

.....Among other things, the legislation would establish a mandate for legal residents to obtain health insurance; set up insurance “exchanges” through which some individuals and families could receive subsidies to substantially reduce the cost of purchasing insurance; significantly expand eligibility for Medicaid; make modifications to the Medicare and Medicaid programs; and impose an income-tax surcharge on high-income individuals....

....CBO’s and JCT’s preliminary assessment of the impact on the federal deficit for the bill as introduced is summarized in the following table. The enclosures with this letter provide estimates of the changes in the nonelderly U.S. population with health insurance coverage, the primary budgetary components of the bill’s major provisions related to insurance coverage, and a detailed table of the other provisions’ impact on federal direct spending. The estimated impact of the provisions related to health insurance coverage is based on specifications provided by the committee staff, rather than on a detailed analysis of the legislative language....

Even with a bunch of other revenue increases and savings from other government programs CBO concluded...

...According to CBO’s and JCT’s assessment, enacting H.R. 3200 would result in a net increase in the federal budget deficit of $239 billion over the 2010-2019 period. That estimate reflects a projected 10-year cost of the bill’s insurance coverage provisions of $1,042 billion, partly offset by net spending changes that CBO estimates would save $219 billion over the same period, and by revenue provisions that JCT estimates would increase federal revenues by about $583 billion over those 10 years.....

This report from the CBO was signed by Douglas Elmendorf, a former Clinton administration economist who was appointed to lead the CBO by the current Democrats in Congress.  So, the democrats appointed the guy bearing bad news.

As written on the CBO website....

CBO's mandate is to provide the Congress with:

Objective, nonpartisan, and timely analyses to aid in economic and budgetary decisions on the wide array of programs covered by the federal budget and

The information and estimates required for the Congressional budget process. So, what

As Reported by MSNBC....

"The New York Times writes that the Congressional Budget Office’s Douglas Elmendorf “told Congress that the health legislation proposed so far would not curb the federal government’s runaway spending on medical care and that lawmakers would need to take more forceful action to meet Mr. Obama’s goal of controlling costs. The testimony by Mr. Elmendorf before the Senate Budget Committee drew criticism from Democratic leaders, highlighting their rising frustration over the difficulty of paying for an overhaul. Asked about the testimony by Mr. Elmendorf, a highly regarded economist, the Senate majority leader, Harry Reid of Nevada, snapped derisively, ‘Maybe what he (Elmendorf) should do is run for Congress.’”

And as reported in the Washington Post and other outlets President Obama said "That's Simply Not true" in regard to the CBO's assessment and its forecast of deficits.

So apparently the President and Senate Majority leader, believe the Democrat's appointed head of the CBO should either run for congress or stop lying.  I know its not the CIA lying to congress but can we stop attacking the messenger.  Apparently the President and Reid, both partisans, know more about economics than an Economist (Elmendorf).

One would have hoped that maybe Reid and the President could have said "The conclusions by the independent assessment arm of the Congress, the CBO, has raised some concerns about the affordability of health care.  The Bill is still evolving.  We look forward to their future assessments and will work hard to successfully address the CBO's concerns".  I mean, isn't that a bit nicer way to say you disagree with someone. 

This is not Pelosi saying the CIA lied, but at some point we need an Elliot Richardson moment where someone stands up and calls out congress and the president on the sham they are shoving down our throat, called healthcare reform. 

Do you know your cost of Health Care? A reality test for congress

I have often thought that a basic problem with health care is insurance.  That insurance, promising full coverage for those with the right employer, motivates bad behavior from customers and doctors.  Why be a savvy shopper when all health care is free?  This is often referred to as moral hazard, one abuses a resource if there are no repercussions.  Conversely, the need to mitigate health care cost (counter moral hazard) has been regulating price, not paying more than $X for a given procedure.

Now in most other markets this combination of moral hazard and cost constraint, constrains innovation.  Why innovate if I can't sell more product and make more money?  If the customer can't decided on procedure, why offer any options?  If there are no options, there is not concept of early adopters willing to pay a bit more for a more innovative product, that might not be perfect but none the less appealing to savvy shoppers (like the folks that bought an iPhone before it was a cool idea, in my case it was testing for CRP before it became a routine blood test).

I am a student of innovation.   A true believer in the concepts of Creative Destruction (Schumpeter et. al.)  What that all means is that if a buyer and seller can negotiate different options of what might be bought, then over a period of time better products will emerge and people will learn what is the best product, in terms of the needs of the customer (not some actuary in a tower).  And, as early adopters consume products, costs will come down and quality will go up.  For example, a $1,000 Dell computer today can do more than a $1M cray computer could do in 1980.

So, I have been testing the health care industry.  I have my own insurance and use a Health Savings Account.  Essentially this lets me put $2,500 into an account pretax and increases my deductible to $2,500.  My overall insurance cost is much lower, but I am at risk in a sense for the first $2,500.  So, I am now a consumer.  I want to know how much everything costs, what its value will be, and wish to know more about my options. 

So, here is my story.  I go to a specialist today.  He looks at my problem and says "I can do either A or B.  A may work.  B definitely will work.  What do you want to do?"

So, I say "Choice B, but what does it cost?".  The doctor says "What does it cost?  Hmm.... I don't know?  Maybe my Administrator knows". 

I go to the administrator, "What does it cost?".  The administrator says "Well, the doctors cost or the other costs for the procedure?  I am not sure?  You need to call the place the procedure will be done?".  I am thinking, "My cost.  Why do I care what the doctor gets paid.  And why do I need to call the surgery center where the doctor plans to do the procedure."

Would you buy a car without knowing what it costs?  A house?  A cell phone?  When doctors don't even know what the cost is, how can some remote bureaucrat figure it out accurately?   And by cost I mean A vs. B.  I am making the A vs. B decision.  The Insurance company might set a rate for A or B, but they really have a hard time forcing my hand if the difference is marginal.  They are just not that good at understanding my "Reservation Price" and other related costs.

The way you control cost and quality is to establish a relationship between buyer and seller.  Period!  Some will say "But this is not a normal transaction, if you get ripped off its your health and you die".  Well maybe you do, but you also die by having piss poor doctors that are not motivate to make more money, do better for themselves and the patients.  I want people who work for me to make money, because then they work harder for me.  People judge their self worth and learn to do better by the interaction they have with those around them.  If you are a smart person thinking about a great profession, do you want to get a job where your hard work pays off or where you just follow a routine and have a defined revenue stream (Defined by Congress).

I personally think we would all be better with an HSA.  The $2,500 deductible can be managed in almost all cases, low income can have a subsidized spending out and the rich can self fund.  We would become more aggressive about our health care, limit our use to when we really need care, and in so doing become a more active participants in the health process.  The ensuing competition would continue to motivate good people to enter the profession.  And, most importantly of all, through innovation, what amounts to $1M Cray computer in health care (i.e. liver transplant or such) will over time come down in price (quickly with innovation) because smart doctors will figure out better tricks and tools for driving better care, because their patients reward them for it monetarily and through the customer/supplier relationship of commerce.

So, your homework assignment - when ever you go to the doctor (if you are paying or not), ask what it costs.  See what you find out.