Trying Something Different

The more I listen/read what's going on in this country (the US in case you live somewhere less prone to shouting), the more I'm concerned that the focus on what separates us is blinding us to what holds us together. I firmly believe that the people in this country are not as divisive, are not as far apart on many issues as the media, politicians, and those who seek to manipulate us would like us to believe.

I think most of us, in many walks of life, of varying degrees and forms of faith, of different political flavors, of different educational, cultural and geographical backgrounds as well as different social and economical status, still have a great deal in common, other than the fact we are all, more or less, human beings.

I think we generally want others, even strangers to succeed, be happy and prosper. I think most of us don't want others hurt unnecessarily. I think we generally believe we are stronger as a nation than we would be as an anarchy. I suspect we largely (with a few polarizing exceptions) generally want the same thing for this nation, even if we don't all agree on the best way to get there.

I also believe (because, hey, I'm a dreamer) that there isn't just one way to get there. And, in the interest of moving away from divisiveness, I'd like to focus some attention on what we have in common, ways diverse individuals with vastly contrasting viewpoints are moving down the same path, working toward the same goals.

This week, my goal is to showcase an example every day, at least until Saturday. I've already found three.

Today, I'm going to start with my good friend but frequent critic, especially when it comes to politics, Relax Max. Now Max and I have gone round and round on the healthcare debate. There are many points on reform that we just don't agree with each other on. However, it was brought home to me that that's mostly details. The other day, he wrote a post about what we need in healthcare reform. Reading his bulleted list, I realized that, fundamentally, we both wanted exactly the same thing. We just need to figure out a way to get there. And, neither way we envision it is necessarily wrong. In fact, either one is a vast improvement on where we are now.

How do I know this? Because there are dozens of countries with universal healthcare and they run the spectrum from the government owning everything down to the q-tips to having groups of private insurance provide the services that everyone has to have. There's more than one way to get this done. Whether my way is "best" or RM's way is "best," either way (and probably a dozen more) will get us where we need to be. We've just got to get off our butts and do it.

And stop using our differences as an excuse to do nothing when so many of us agree that something needs to be done.

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If I Were Dictator

You know what, I'm glad I'm not Obama. And not just because every citizen in the country (and several others) think they can do the president's job better than he can to nearly the same extent they thing they can all design a better space program.

I appreciate the notion of being in charge and wanting to clean up a big mess just because the mess is overwhelming (which may or may not be how he sees it) and bothering you. I saw a couple of articles today about the challenges Obama faces with healthcare not because he does or doesn't have a good notion about how to go about it, but because he can't just dictate it and make it so. It's more or less a democracy so he needs a consensus a majority of people in Washington to agree with him. The first one I found in (*gasp*) the New York Times. The second one was forwarded to me by the Mother. Oddly, I think I walked away with something entirely different than she did when I read it.

One of the down sides to democracy is you rarely get the the right change the first time - because you have to water it down to get anything past those that want the status quo. You tweak and weaken in order to appease this group or that knowing that, if you weaken it too much, it's worse than nothing. Those who want it to fail will use it's failure as an excuse to put of meaningful change a little longer.

So, what would I do if I were dictator (because, take it from me, I don't have the diplomacy or charisma to get anything past people who don't want it - I either beat them down with data or I fail)?

I'm glad you asked.

(Again, this is from the back and forth between the Mother and myself - give her any credit you care to; I can take the blame. I've embellished a bit since the conversation, too).

Here's what I thought...

We address the health care cost issues I mentioned yesterday: tort reform, subsidizing medical education, support electronic recording keeping, and, since I'm a dictator not a politician, set up a single payer system (in conversations with the Mother, I was talking about a public option, but, hey, I'm in charge now).

One of the things I've seen successful in my 20 years working for the government are something called FFRDC (Federally Funded Research and Development Center) organizations. Funding with usually federal funds:

An FFRDC meets some special long-term research or development need which cannot be met as effectively by existing in-house or contractor resources. FFRDC's enable agencies to use private sector resources to accomplish tasks that are integral to the mission and operation of the sponsoring agency. An FFRDC, in order to discharge its responsibilities to the sponsoring agency, has access, beyond that which is common to the normal contractual relationship, to Government and supplier data, including sensitive and proprietary data, and to employees and facilities. The FFRDC is required to conduct its business in a manner befitting its special relationship with the Government, to operate in the public interest with objectivity and independence, to be free from organizational conflicts of interest, and to have full disclosure of its affairs to the sponsoring agency. It is not the Government's intent that an FFRDC use its privileged information or access to facilities to compete with the private sector. However, an FFRDC may perform work for other than the sponsoring agency under the Economy Act, or other applicable legislation, when the work is not otherwise available from the private sector. [Per Federal Acquisition Regulations System (FAR) 35.017(a)(2)]

The Jet Propulsion Laboratory is effectively one for NASA and DoD has a number and so does the Department of Energy. They are generally conglomerates of highly trained, highly skilled individuals who provide objective evaluation and assessment for contracts, do testing, etc. for different government departments, without the politics, without the profit motive. Because of the nature of their business, we have to have a secret clearances and demonstrate that they have no conflicts of interest - that means no kickbacks from special interests, big pharma, anything. If they get more money from the government than they need, they pay back the extra. They are expensive per hour, but tend to be so efficient (because there's no incentive for waste and they are top notch experts) that it works out to be cost effective.

Now, what if, instead of a government entity, one set up a single payer system as a not-for-profit. You hire doctors and insurance experts built up a current successful FFRDC structure with only a skeleton admin support staff (Some companies have a subject matter expert:admin ratio of ~1:10 - good luck finding that elsewhere) . 100% of "insurance" fees (or healthcare taxes) collected go out to pay for medical care. If they pay out less than they take, fees go down. If they pay out more than they take, fees go up. But this part of it costs the government nothing – care and fees are always the same. The government only pays for the salaries of the employees. Any reimbursement of fees for the poor – that’s done elsewhere by the government. That reimbursement and the salaries are all the government pays for. The doctors/experts on staff are prohibited from any financial ties to institutions or drug companies.

Payment of fees for doctors are agreed between my fictitious not-for-profit and the doctor/hospital (and we have an option for a salary for X number of people or fee for service – I’m not an expert so I don’t know which is better, but, if I was dictator, I'd let them argue it out and decide). The treating doctor enters a diagnosis and a treatment electronically; standard treatments are automatically approved (within seconds). If it's something out of the ordinary, a corresponding doctor expert on call for X doctors must respond within minutes with approval or questions for clarification. If accepted, the treatment is performed and the doctor is paid by close of business that day. No forms, no mess, and the potential doublecheck keeps everyone honest and forces the doctor to think about what he’s doing and admin is minimized.

Ideally, electronic systems would have popups letting you know if you’re prescribing something the patient is allergic to (as has happened to me, even though I answer dutifully each time I go to the office) or other conditions the doctor needs to know about (PREGNANT! As has happened to me, even though I informed everyone, including the doctor, that I was).

Because all of the information is in a large database, trends, secondary infections, botches, relapses, etc can be tracked. Ideally, you'd take a random sampling of patients and quiz them about service and success, but the data should match. Their performance is reviewed if, say, they come in over (or under) averages for the region/specialty. My FFRDC would want to make sure everyone is getting the proper care. Again, not necessarily bad--women, for instance, often limit their practices so they can stay home more hours.

This FFRDC can also serve as part of the tort reform as an objective body to review errors and alleged malpractice.

Experimental care is auto reviewed for efficacy and relevance to research.

I could throw in an ethics board (probably separate but interacting with my FFRDC, probably another one), to evaluate such ideas as euthanasia and assisted suicide. When is enough enough. Those ideas will have to come from the top. They might have to be regulated, because the individual patients don't understand the concept, but medical judgment will allow for individual evaluation.

*Sigh*

I don't think things will be so simple for Obama.

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So Much for Stirring the Pot

The problem, of course, with trying to stir up controversy is that you need mindless gullible folks who think with their emotions, respond from their gut with kneejerk vehemence in order to do it right. To the best of my knowledge, I don't have any readers like that and, if I do, they don't generally show up in my comments.

Since my readers are overwhelmingly intelligent and thoughtful, they gave courteous considered answers that made sense, which, although not adding to the controversy, does make for a much more pleasant conversation.

Now, the Mother and I spoke of many other things regarding healthcare reform. I'm going to include many of them and I won't be making a distinction between ideas she had and ones I had. That's not entirely fair to her, of course, so I encourage you to assume the ideas you like are hers and the ones you don't are mine. That ought to even things out nicely. That and she is encouraged to jump in if I've misrepresented her views in any way.

The Mother and I address this problem from different directions. I don't know that we are looking for different results (though I suspect we have different levels of confidence that anything appreciable will be done to address it any time soon), but we are seeing it from different sides. I am looking as a patient, as a citizen, where prices appear ungodly high and, though I have good insurance that reduces it drastically (a) the costs are still very high for a quite healthy family - aside from the high cost of the insurance itself - and (b) I know personally half a dozen families devastated by the high cost of medical care for a loved one. And that's aside from the millions in this country who have no protection. Not only are they not cared for in a way that could preclude serious maladies, because they have no insurance, medical care when they have serious conditions are much more costly and still fall on us to pay - in medical costs for those costs absorbed by hospitals (and higher insurance premiums and copays as a result) and in higher taxes.

The Mother (paraphrasing from our conversations) doesn't see a way to reduce costs without making some serious changes to how we do things. Cost reduction must include (some of these are mine):

• Reducing outlay for the care of those who have no chance of survival and no quality of life - to what degree, well, there's a debate (as I discussed yesterday). This includes limiting care for those who will not help themselves.
  
• Tort reform to limit malpractice to a reasonable level and assure that cases are not tried that are not based on solid fact. Malpractice insurance, even for successful doctors, is outrageous and, believe me, that increases the cost for all of us. Don't think that the fact that we have the highest healthcare costs is completely unrelated to our rampant litigiousness. Even clearly baseless lawsuits can be expensive because the one suing is not held responsible for the costs (something I'm all behind).
  
• Administrative costs. Most doctor's offices have more staff to deal with (often fight with) insurance companies/medicare/medicaid and submit 18 kagillion different forms in triplicate to get reimbursement often months later. Money spent on administration goes into fees for service and money not spent on nurses or other medical support.
• Doing something about the high cost of medical education. Most doctors don't get to practice until they're practically in their thirties. That's a long time to live without a viable income aside from what can be hundreds of thousands of student loans. Doctors are a huge boon to any society, but the exigencies of becoming a doctor forces a certain level of greed on them just to survive and recover. It makes sense to provide some sort of subsidization, especially to encourage doctors to go into some of the less lucrative but undermanned subprofessions.
  

Now, the Mother is scared to death that a public option will be like Medicare, which, in her (and other doctors she knows' opinion) starves doctors for fees, reduces fees willy nilly whenever funds are cut without rhyme or reason. Clearly, there are other doctors who agree and, at least a handful who do not. I don't know what it's really like, whether it's an inherent problem with the system, whether the recent privatization is a factor, whether this is a side effect of having a vehemently anti-medicare faction in the government (either dominating Congress or the White House or both) since 1980 (with the exception of 2 years). Possibly, it is a factor of all three, but what I can say is that there is a significant potential for a public option to be mismanaged due to the political winds that blow and suck in Washington, because of factions that actively want it to fail will work to ensure it's failure, because a long term program is always struggling in an environment that changes the budgetary rules every year.

But, here's the thing, there are powers that very much want to have a viable healthcare system, one that doesn't leave huge swathes of the populace at a disadvantage, powers that want the right healthcare for everyone. They know very well that an option that doesn't work is more hindrance than a help toward their goal. It is very much in their interest (and surely the rest of our interest) to find an option that works because I believe very much that it's possible. The industrialized world beyond our borders is proof positive in my opinion that it can exist (and I find it every bit as compelling as the evidence of vaccination's great good).

In healthcare reform, in my opinion, involves several medical things and several nonmedical things. It's about reducing cost, preferably by removing as much from the equation as possible that isn't medical (and yes, that can include health insurance, but also administrative costs, protection against unreasonable lawsuits), while (a) improving care by reducing unnecessary errors (I'm of course for electronic records) and penalties for excessive secondary infections or surgical botching, and (b) providing care to everyone in a reasonable way, which, in my opinion, would also reduce costs associated with nonemergency medical care in an emergency setting, and reducing the burden of preventable disease. The cost of a mammogram is far less than the cost of treating stage 4 breast cancer, but people without insurance are going to end up with the latter if they can't afford the former.

It is about reducing the overall cost, but I don't see it, if it can be done intelligently, reducing the burden on the citizens because we're already paying for all those that don't care until its too late, by those who can't afford it, and, of course, for billions of dollars in profit to the health insurance "industry". Big pharma is a whole other topic, of course. I want to see a big change in where the money's going: to doctors and medical practicioners instead of lawyers and insurance companies - if we can do it, doctors won't go broke and we'll pay less than we did before. For better care.

Tomorrow, I'm going to postulate one way I could see doing it. So, if you feel like arguing, get ready. Or practice on this post. :)

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Thieving Thursday: Making the World Better

Joel Klebanoff again has provided me a venue to steal a good comment this week. He wrote a blog this week about how cool (but unlikely) it would be if we could all get along, stop warring and treating people with intolerance, stop killing and raping, stop beating up the old lady and kicking puppies (I'm paraphrasing). Then, he noted the terrible unemployment that would result from all those jobs in the army, in the military contractor venue, in crime fighting, etc that would be lost and horror would lay across the land. He meant it all in fun (and I knew it), but, around here, that kind of thinking is considered just short of gospel.

I don't get it.

Yes, military contractors would have to change focii or go out of business. Horse drawn cart builders did, too. And we survived. So did milkmen and ice deliverers and door-to-door brush salesmen. But they did so because the money still gets spent. People scream at the money the government spends BUT it largely goes back into the economy here. That's working against my argument but bear with me. See, let's say we had a balanced budget and a reasonable deficit (pause for uncontrollable laughter). Chances are, the bulk of the money not spent on ugliness, spent to support police and federal prisons and federal courts and FBI and CIA and the military and all the military contractors would be spent another way. Heck, shutting everything down would probably eat a chunk, at least the first year, and that money would be spent on jobs. But what about next year? Same thing. Or it could be spent to support universal health care that would allow more businesses to do their own hiring and would allow regular people to have more money to spend on other things rather than medical care/coverage. The money still goes out into the economy. Or it could be spent on rebuilding architecture. Or putting those technical minds to NASA or inventions or green energy or ...

Given, of course, that we won't be seeing a balanced budget any time soon or a deficit that isn't frightening, if this happened say, tomorrow, it might just go toward debts we're making or have already made. What about that? Well, everything we pay toward the principal is something we don't have to pay toward the interest, don't have to pay back later. Which means, in the long term it will do the same thing, put that money back into the system, our system, for our benefit.

It's really not complicated.

So, for our economic health, we're supposed to buy that war and violence and intolerance and nastiness in general are a small price to pay? This Rocket Scientist calls BS.

What is unfathomable to me is how the US public is brainwashed into thinking we owe whole industries a living. We're supposed to protect the profits of big oil and the auto industry and the military contractors and the...well, you name it.

Take for instance health insurance. Health insurance is screaming that the government can't be trusted to be a middle man between people and the ones that actually do the healing, that cutting out their incredible profits will somehow do the general populace a disservice and leave them paying more for less. Uh. How? The government doesn't have to make a profit. Hell, breaking even would be great. How could those using it not benefit? And, if there were only a one payer system, every doctor would be on it (thereby providing more assurance of choice, not less), but he wouldn't have to pay half his staff to do only filing for insurance because there'd be only one organization to deal with instead of eleventy dozen - so he could instead hire staff that would, I don't know, help people get well instead of shuffle forms.

And health insurance knows this which is why they're busting a gut trying to convince us we don't need a public option along with all of their private options. If government were really going to do such a crappy job, they'd be pushing for it. But, since they live and die by profit, they will lose in a head to head every time. Good riddance as far as I'm concerned. I have no sympathy for any company that profits on the pain and suffering of others. Maybe they can do something useful now. Or work for the government.

Of course, no one does this like big oil. "You need to keep buying oil and forgo those useless green technologies because they're too expensive." Oil is indeed cheaper. Today. Investing and more research can change that, though not necessarily overnight. However, conservation today saves the consumer money, no matter what oil costs (or green energy sources too, for that matter). And having solar or wind power available does the consumer only good. Every drop of oil they don't spend not only makes the world a better place, but also keeps further off the day when unavoidable skyrocketing oil prices sky high. It also limits our need to poke our noses where it doesn't belong militarily to protect our oil interests.

That, of course, brings us back to war. Shouldn't we be smart enough to know better by now? I've used this quote before but I think it fits perfectly.

Every gun that is made, every warship launched, every rocket fired, signifies, in the final sense, a theft from those who hunger and are not fed, those who are cold and are not clothed. The world in arms is not spending money alone. It is spending the sweat of its laborers, the genius of its scientists, the hopes of its children.
-Dwight David Eisenhower, 1953, a speech to the American Society of Newspaper Editors

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Can You Afford to Live?

In the US, one can't really talk about health care without talking about the cost of health care. You may be gasping. Politics! Say it isn't so, Stephanie!

Well, that's my point. Why exactly is health care a political issue? When did we say to ourselves, people are only entitled the amount of health care they can afford and even contemplating otherwise is a political hot-button topic? I'm completely floored, actually, with the notion that someone thinks that's anyone should go without health care if they can't afford it.

Who really thinks one's health is a matter of merit? That only those that deserve it become ill or injured? And why--why?--do we feel the need to protect the profits of insurance companies? If the government stepped in with their own program, it would provide an unfair competition with the insurance companies because the government doesn't have to make a profit. Um, so what? Much better that US industry is at a disadvantage because we're the only first world nation that still eschews universal health care? Much better to have families decimated and destitute because someone in the family develops cancer? Why do we think it better to protect the profits of those who make those profits on the suffering of others?

I wonder if anyone has done that math. Insurance companies make money two ways: first, failing to cover anyone they expect to pay out for and, secondly, charging the customers more than they pay out. So, replacing health insurance with a government single payer system doesn't have to be expensive - in fact, well designed, covering those who were already covered means it shouldn't cost the "taxpayers" a dime and those covered still pay less. Why? No profit; just break even.

It's covering those that aren't covered that brings up the cost. To an extent. Many of those not covered today are healthy. That's why they haven't bought insurance. Many of those not covered are not healthy; that's why they can't get coverage. So, does that mean, if you're sick and can't get coverage, that you deserve to die? That you aren't entitled to be cared for? What does it say about our society that this is even a question?

I suppose, for the sanctimonious, there's a belief that people get what they deserve. I am not one of them. I've seen children who died of a brain tumor and families who, more than dealing with the devastation of the loss of their child, had to also deal with a mountain of debt that can keep their other children from college, limit their options, ruin their lives. That's not justice. That's a tragedy, an insult added to unimaginable injury.

It doesn't have to be this way. In 2007, the U.S. spent $2.26 trillion on health care, or $7,439 per person. The US government spent $2724 per capita in 2004 (>$600/capita than the Canadian government, which has Universal healthcare). In France (ranked #1 by WHO in 2000 for heathcare), the government pays $3926/capita. The US, in that same ranking, ranked #37 in overall health care.

What are we paying for? Well, we're paying for tests that provide profit for doctors and clinics since visits are now paid so little by insurance companies that a doctor loses money to see you. We're paying for extra help in the doctor's office to deal with eleven billion different forms of insurance so he has four admin staff to handle the insurance hassles instead of, say, another nurse and a physician's assistant. I've read estimates where ~50% of our health care costs were related to insurance dealing admin activities. So, we double our bills to have all this private insurance and then pay the middle man for the privilege. Nice job. We're paying, through the nose, for new drugs that may or may not be better for us than the drugs we already had, depending (in some cases) on whether or not one is making a profit from them.

And, in this country, more than 47 million people don't have health insurance or any health care coverage. 47 million put off taking their kids to the doctors or live in fear of what they'll do if one of their kids falls and breaks an arm. Many have jobs that make ends meet, but little more and health and the steps to ensure health are often what falls behind. One serious infection, on bout of meningitis, and families lose their homes, their futures. And they might not get the care they need until too late.

I don't know about you, but that's not acceptable to me. Can health care be better? Yeah. Can it cost less than we're paying? You bet. People all over the world are doing it. For what we pay per capita, no one in this country should be deciding between taking their kid to the doctor and rent.

That's the kind of choice no one should have to make in a civilized society.

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