Fixing Obamacare is not good enough

medicare for all

National health insurance has become a defining issue in the contest for the Democratic nomination. Bernie has put “Medicare for all” squarely back on the table. Hillary calls that pie-in-the-sky: instead, she would build on the Affordable Care Act…As she says, market-based private insurance was originally her idea.

We can all agree that the ACA has benefited many, particularly the poor and the sick.

But Medicare for all has picked up some interesting supporters: for example, Fareed Zakaria, a high-profile TV commentator whose beat is foreign affairs, and Donald Berwick, MD, who, as administrator of the Centers for Medicare and Medicaid Services, supervised the roll-out of the ACA.

Moreover, the Kaiser Family Foundation December 2015 Tracking Poll demonstrates majority support among ordinary Americans – 58%; a 2014 survey of physicians and medical students in Maine showed that many doctors also (in Maine at least) would prefer single-payer, especially those practicing primary care.

So it is disappointing that liberal economists whom I respect, such as New York Times columnist and Nobel laureate Paul Krugman, conclude that single-payer would be too expensive and too disruptive — that we should improve the ACA instead.

Krugman, of course, is trained to crunch numbers — I can’t. But from the exam room where I sit, his conclusion doesn’t make sense. The principal advantage of single-payer, after all, is that it is less expensive than our market-based system.

That is not just idle speculation: every other developed nation has either some form of single-payer or highly regulated private insurance with price controls — and they all achieve better health outcomes, with genuinely universal coverage, for at least 30% less (as a fraction of the Gross Domestic Product) than we do, even though we still cover something less than the entire population.

Perhaps the economists simply substituted Treasury payments for employers’ contributions to their employees’ health insurance (something the ACA was specifically designed to preserve), and left everything else in place: that would indeed be a huge hit to the federal budget, particularly since employers, representing a large group of mostly healthy employee families, can negotiate better deals with insurers than individuals can.

But that is not how Medicare for all would work. Instead, it would be like Medicare today, improved to make it even less expensive for the Treasury and individual beneficiaries. Since everyone would receive the same, comprehensive benefits, administrative costs would be much lower. The huge transaction costs engendered by the ACA — hundreds of thousands of annual negotiations between insurers, doctors, hospitals, pharmaceutical benefit managers, and manufacturers — would decline significantly…

Finally — and most controversially — Medicare, which currently sets prices for doctors and hospitals, would extend price controls to other health services, such as prescription drugs and devices, through open procedures with due process and opportunity for comment as mandated by the Constitution. Or Medicare could negotiate prices, as the Department of Veterans Affairs currently does.

I didn’t include the whole article. The core is here. RTFA for details – which further illustrate the benefits of Dr. Poplin’s proposal. I’m pleased she included mention of the negotiations already standard procedure for the Department of Veterans Affairs. Nothing new. Part of normal operations for years resulting in significant cost savings.

Speaking of costs, you should take notice of the history of what’s accepted as standard in the medical-industrial complex vs federal government management of Medicare or, say, Social Security. Administrative costs to civil service managers run in general less than 3% to run those programs. Insurers bag taxpayers 15-25% for the same kind of work.

A cost I look forward to seeing brought down to the level of existing entitlements.

Woman texting while driving – lands her car in lake


Hyundais apparently don’t float

Charles County, MD, police are reporting that a car and the driver ended up submerged in Wakefield Lake in Waldorf…The woman reportedly told officers she had been texting and driving when she lost control of her vehicle. Texting while driving is illegal in Maryland.

…The 25-year-old Temple Hills woman was driving her Hyundai north on St. Charles Parkway near St. Thomas Drive in Waldorf when her vehicle went off the roadway and struck a tree. The crash propelled her car about 60 feet into Wakefield Lake where the vehicle quickly submerged in about 5 feet of water. The woman was able to get out of her car through the driver’s side window.

She had no visible signs of injury, but was transported to Charles Regional Medical Center for treatment.

Cpl. J. Hopkins of the Charles County Sheriff’s Office Traffic Operations Unit is continuing the investigation and charges are pending.

There’s stupid and then there’s oops – and then you’re back to stupid.

I wonder what she’ll tell her insurance company.

As nurses achieve doctorates, medical doctors start to whine


Doctor Patti McCarver meeting with a patient

With pain in her right ear, Sue Cassidy went to a clinic. The doctor, wearing a white lab coat with a stethoscope in one pocket, introduced herself.

“Hi. I’m Dr. Patti McCarver, and I’m your nurse,” she said. And with that, Dr. McCarver stuck a scope in Ms. Cassidy’s ear, noticed a buildup of fluid and prescribed an allergy medicine. It was something that will become increasingly routine for patients: a someone who is not a physician using the title of doctor.

Dr. McCarver calls herself a doctor because she returned to school to earn a doctorate last year, one of thousands of nurses doing the same recently. Doctorates are popping up all over the health professions, and the result is a quiet battle over not only the title “doctor,” but also the money, power and prestige that often comes with it.

As more nurses, pharmacists and physical therapists claim this honorific, physicians are fighting back.

An illegitimate characterization. “Fighting back” implies medical doctors are losing something. The quandary is over their ego-smitten self-worth. Standards for doctorates in most fields, medical or otherwise, allow the term “doctor” for anyone who reaches or surpasses those standards.

For nurses, getting doctorates can help them land a top administrative job at a hospital, improve their standing at a university and win them more respect from colleagues and patients. But so far, the new degrees have not brought higher fees from insurers for seeing patients or greater authority from states to prescribe medicines.

Nursing leaders say that their push to have more nurses earn doctorates has nothing to do with their fight of several decades in state legislatures to give nurses more autonomy, money and prescriptive power.

But many physicians are suspicious and say that once tens of thousands of nurses have doctorates, they will invariably seek more prescribing authority and more money. Otherwise, they ask, what is the point..?

The point is knowledge, skill and understanding. For the nurses. Obviously the point for the doctors is money and status. And money.

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