The view from the other side re health care

I had a fascinating conversation yesterday with a physician who fervently supports the proposed health care plan — at least in theory, as he admitted he didn’t know what was actually in the 1000+ page bill that seems to be the House front-runner.

He and I began with a few points of agreement.  He and I both agree that medical costs are out of control, and that this lack of control reflects a perversion of the market.  As matters now stand, the current system does (as Obama so inarticulately said) give an incentive for unnecessary treatment.  I’ve always seen that in the way in which elderly relatives of mine get their health care.  Because their doctors are compensated by office visits, the doctors refuse to relay information over the phone.  Every test requires a follow-up office visit to be told the test’s results.  The doctors are also hugely in favor of giving tests.  When my mother had ulcer symptoms, rather than trying a two week round of Prilosec (which, if it controlled the symptoms, would have been pretty good evidence that there was an ulcer), the doctor insisted on an expensive and invasive scoping — which showed an ulcer.  I suspect this excessive testing is also a reflection of malpractice concerns, but there’s no doubt that profit figures in there too.

This doctor and I were also very supportive of the Kaiser model.  I happen to be a Kaiser patient and am extremely pleased with the care I receive.  Because the doctors are salaried (and salaried well), their only goal is to give appropriate care.  Giving unnecessary tests doesn’t provide any benefit to them.  Nor does withholding tests save them money.  Because Kaiser is so large, it owns all the necessary labs and equipment, so tests are pretty much a fixed cost.  Also, because it’s so big, it can negotiate cheaper pharmacy costs.  I’m sure people have had bad experiences with Kaiser — it is, after all, run and staffed by humans who are fallible — but overall it is an incredibly highly ranked medical care provider.

Aside from those agreements, though, my doctor friend and I strongly parted ways at a philosophical level.  I believe that legislation can be created to change the incentives in the marketplace — or that, at the very least, we should start with that experiment, before diving into a wholehearted destruction of the current system.  My friend, however, believes that our current system creates “social injustice” and that the only way to remedy it is through government intervention.  To the extent doctors and companies profit from the current system, he believes these profits are immoral.  When I mentioned the marketplace determining what is just and what works, he said that’s just wrong.  The government, he said, is singularly well-suited to deciding which treatments (and, by extension, which profits) are just and which are not.

Incidentally, as part of the social injustice issue, this doctor believes that it is appropriate to extend the plan to cover illegal aliens.  He likens the Mexicans who come here and send money back home to Jews trying to escape the Nazis by immigrating illegally to Palestine in the 30s and 40s.  That is, he thinks the Mexicans are in precisely the same situation as death camp refugees and that we are morally wrong to deny them free ingress.

The doctor had a very interesting take on the current uninsured.  I said that a lot of people are opposed to the proposed plan because they recognize that those numbers being bandied about regarding uninsured are false.  That is, the 45 million (or whatever) uninsured aren’t uninsured simply because of poverty.  The vast majority are either illegal aliens (and you can see his views about those above) or voluntary uninsured.  As to the latter, my friend thinks they’re the real problem.  He understands that these people are voluntary uninsured because they are young and healthy.  They’re gambling that they won’t need insurance.  Or they might be marginally insured, in that they buy a $10 policy with a $10,000 deductible, just in case something really bad happens.  They are not putting money into the system.

What this doctor likes about mandatory universal health care is that it forces the voluntary uninsured into the system.  He thinks it grossly unfair that they are not paying into the system, while people who need insurance are paying.  If there were more money in the system, the person with a preexisting condition would not be required to pay as much for his insurance.  In other words, he thinks that the insurance system should be a cross between an uninsured motorist requirement and social security.  He freely admits that this is a government mandated spread the wealth approach, and one of which he approves.

Because he has a philosophical approach that requires everyone to be in the health care market, whether they want to be or not, he is unperturbed by CBO numbers projecting vast increases in the cost of health care under the new plan.  He thinks the CBO people, being accountants and not doctors, have no idea what they’re talking about.  What he envisions is a brave new world in which the government simply provides more insured people who will use medical services.  He finds it inconceivable that universal health care (which is a system by which all people are insured, but medical care providers continue to be privately owned) can shade into a single payer, government-owned system.

He does not believe that having the government as an insurance provider will change the system and drive out private insurance.  Nor does he believe that, even if all private insurance is gone, with the government being the only bill-payer, that this will do anything other than purify the private medical system of the current social injustices that plague it.  He also refused to believe that, in other countries that have socialized medicine, there are treatments that are denied to people, not because the treatments don’t work, but because the people are deemed (by government mandate) to be too old or too ill to be worthy of treatment.  As for government lists of treatment, he says we have them already, because every care provider is in thrall to Medicare and related government programs.  He did not see a difference between the fact that Medicare sets prices, but does not yet set age or health boundaries for providing treatments.

He is very disturbed by the opposition to the health care plan, which he sees as the product of Republican cabals who are shipping agitators into local town hall meetings.  The absence of any concrete evidence of such busing (such as buses) does not change his mind.

I explained that people are also concerned that they’re being sold a bill of goods that is not as promised.  The rush to pass a bill (three weeks “deliberation” to change a sixth of the economy) didn’t bother him at all.  “That’s how things go.”  When I raised specific concerns about the existing bill (the inability to stick with your insurance if you change jobs, the incentive for employers to dump insurance and drive people into the government system, the government decision boards re treatments, the enhanced access the government will have to our finances) he just didn’t care.  He thought those were petty concerns and was sure I was wrong.  He also discounted the hidden taxes in the bill.  “Obama promised that he’d veto any taxes.”

The doctor also dismissed the fact that many of the bill’s proponents — including the president himself — are on record as supporting single-payer care (which is different from the universal care this doctor supports).  He denies that Obama lied at the New Hampshire townhall when he when he said ““I have not said that I am a supporter of a single-payer system,” despite several past instances of his having said precisely that.  “There’s no lie there,” said my doctor friend.  “Obama did not say that he ‘never’ supported single payer care.  He’s talking in the present tense.  He doesn’t support it now.”  I said that, if that’s what the great communicator meant, that’s what he should have said, including explaining why he’s changed his mind.  “Nah,” said the doctor.  It was clear.

The conversation ended there.

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Comments

  1. says

    Bookworm,
    Although I don’t think ObamaCare is a good idea, I actually agree with mandating some basic coverage for everybody, not unlike the car insurance. Why? Because people choosing not to buy the health insurance make this choice without any real consequences. Nobody is denied health care. Thus, if those people get into a car accident, for example, they still get treated. And, if later they can’t pay the bill, the cost is passed to those who buy insurance. You could argue that they are free to choose not to have insurance if they were left on the side of the road. Because then they would have taken their chances and lost their gamble. But you can’t really do this in a civilized society. Thus, those young healthy people choosing not to buy health insurance are actually gaming the system.
    By the way, you don’t really have to buy car insurance. Instead, you can deposit a rather large amount with DMV. I would not have a problem with the same requirement for health insurance. You are young and healthy? Deposit 100K with the hospital near you, and you don’t have to buy health insurance. Or a tax should levied against those people in order to pay for their care, should something happen to them.
    Eric.

  2. Mike Devx says

    eric #52:
    > Nobody is denied health care. Thus, if those people get into a car accident, for example, they still get treated. And, if later they can’t pay the bill, the cost is passed to those who buy insurance.

    Well, there’s a genuine health reform right there. The cost should not
    be passed on to those who buy insurance. What could be simpler? Send the collection agencies after the deadbeat. Garnish the wages. Etc, etc. Avoiding all that in case of a catastrophically expensive problem is a good reason to buy insurance.

    But then I am a heartless, near-evil reprobate. I believe in a very limited safety net to catch people lost in a free-fall slide to the bottom. I’ll go that far – but only so long as there is government revenue to pay for it. If the government cannot pay for it, even that should become unavailable until we right our economic ship. (And, ahem, that approach would ensure that everyone is rooting for our entire nation’s self-interest, rather than believing that they can simply loot the more fortunate, and loot them even worse during bad economic times.)

  3. says

    BrianE #42: I’ve known people who had that procedure and, sadly, those I knew suffered greatly and then died. That’s an “N”of only two, but I know that the risks were enormous when they had the procedure.

  4. suek says

    >>I actually agree with mandating some basic coverage for everybody, not unlike the car insurance.>>

    Intriguing idea. How are you going to go about that?

    I mean – with car insurance, you can’t get your car re-registered if you don’t have proof of insurance. Or if you’re pulled over, you suffer various penalties depending on the state if you don’t have proof of insurance. Nevertheless, you can take your chances with an unregistered car, you can cancel your insurance as soon as you have your registration renewed, and you can – with luck – avoid being stopped by the police and having to prove your insurance (even then, you might have a card of proof in your car). So what are you going to do about people? require each person to carry a health insurance card on their person, and permit the police to do sweeps to ensure that everybody has one? National health ID card? what do you do about illegals? homeless people? people in jails? Do people in jails get a pass because they’re covered by the prison system?
    Just walk into any doctor or emergency room for health care and the government gets the bill? That might save the hospitals that are going under due to non-payment…

    How?

  5. says

    Suek,
    I would require a copy of the health insurance attached to the tax return, along with the W2. If there is no insurance, extra tax would be charged to cover the hospital bill, should something happen. Of course, just like with the car insurance, there will be some people who manage to cheat the system. But there won’t be very many of them. I bet majority of those who choose not to buy health insurance still buy car insurance. They are basically law-abiding people who simply see nothing wrong with passing their hospital bills to the rest of us. Or, they simply hope to be able to pay. If the law requires, they will buy health insurance.
    Eric.

  6. says

    You do not need an “attempt to defraud” in order to have a contract breached — just a failure to perform, regardless of the intent behind it.

    So it doesn’t matter what contract law stipulates to you nor does it matter what’s actually in the contract. Once you have interpreted that there is a breach, no matter what’s actually in the contract, you believe it is a breach of contract.

    It’s not a breach of contract. It’s a breach of your own personal wishes.

  7. Mike Devx says

    Eric #58:
    > I would require a copy of the health insurance attached to the tax return, along with the W2.

    Eric,
    I think you would solve this particular problem by doing that. But I’d like you to consider a principle here: If you pass a law that requires this kind of a solution, what other potential laws have you just said to be worthy as well?

    To be effective, you’d have to attach proof of health insurance for the entire year, not just currently. Else, you’ll have people buying health insurance for a brief period of time, just to submit their tax return. Can’t have that! This is a very heavy handed solution to the problem, and it must therefore be a strong solution – proof year-round of health insurance.

    Attaching proof of health insurance to your IRS tax return opens the door to a whole host of abusive practices, I think. By saying it is acceptable – and good – to do that for health insurance means you would find it acceptable for any other similar solution to a governing problem.

    Too many uninsured motorists on the road? Well, clearly requiring one yearly check on proof of auto insurance, and having the police check when they pull you over (ick to that – that just makes them an enforcer arm extension of insurance companies, does it not?)… the clear solution will be to require full-year proof of auto insurance to the government when you file your tax return. After all, that’s the goal, isn’t it? Providing year-round PROOF to the government that you’ve been a good little boy or girl?

    The more I think about it and write about, the more I don’t want to be attaching anything to my yearly tax return that proves I’ve been good. The yearly tax return is irritating and maddening enough as it is.

  8. suek says

    >>I would require a copy of the health insurance attached to the tax return, along with the W2.>>

    Many people – maybe even most – people who lack health insurance don’t file tax returns. What about them?

    >> If there is no insurance, extra tax would be charged to cover the hospital bill, should something happen.>>

    That’s already in the bill. If you don’t have “approved” health insurance, you will be charged 2% of your income on your tax bill. It’s also in the bill that the Feds will have direct access to your bank accounts. I assume it’s also in the bill that if you have large medical costs, the Feds will have a first claim on your estate. At least, that’s true at the present with Medicaid.

    How can you charge people who don’t have anything? They used to have debtors jail, but that’s specifically prohibited by the Constitution – not that that means anything to the present administration.

  9. says

    For clarification of meaning, in the ERISA case, there is no attempt to defraud nor is there fraud at work.

    But that example is used as an example of ‘contract breach’ in which the law provides no punishment for. That’s a libel against the law, for which contract law has very specific provisions in this country. In point of fact, this country has one of the strongest contract laws around. Look at Hugo Chavez and the nationalization of White Property in Zimbabwe, formerly Rhodesia, for an example of another system. With its concurrent economic stupidity, of course. People don’t create a vibrant economy without a strong contractual law protection.

  10. says

    But why would a court not just enforce a contract, so if a party fails to perform when it should have, it has to make the other party whole?

    Tort lawyers aren’t part of the rule of law. They are the ones looting the law for personal gain. Providing more power to tort lawyers and lawsuits does not make insurance provide better healthcare, as they are forced to pain Dane Geld every time a John Edwards comes up for air from his mud hole, with the concomitant effect that what the insurance pays out in damages is looted from the contributions of individuals in need of health coverage.

    Insurances aren’t here to make people whole, any more than car insurance is here to guarantee that you get a new car every time you blow up your last one.

  11. says

    BrianE said:

    I would much prefer some sort of arbitration panel to deal with these issues, rather than the courts.
    It would allow these cases to be decided quicker, and at less cost.

    You will be pleased to know that ERISA, as interpreted by the Supremes, does allow states to provide for these types of alternative approaches, with the proviso of course that in no event may a meaningful remedy be available.

    Ymarsakar said:

    So it doesn’t matter what contract law stipulates to you nor does it matter what’s actually in the contract. Once you have interpreted that there is a breach, no matter what’s actually in the contract, you believe it is a breach of contract.
    It’s not a breach of contract. It’s a breach of your own personal wishes.

    I apologize for not making myself clear. Proving a breach of contract means proving a material term of the contract has not been performed. What’s in the contract is critical to this inquiry of course. Nowhere have I meant to suggest otherwise. I do not “interpret that there has been a breach” based on my own personal wishes but by comparing what the terms of the contract requires against what the party did or did not do to perform its obligations according to those terms.

    But that example is used as an example of ‘contract breach’ in which the law provides no punishment for. That’s a libel against the law, for which contract law has very specific provisions in this country. In point of fact, this country has one of the strongest contract laws around.

    You are making my point for me. ERISA eradicates contract law in cases of employment-based insurance coverage. If “one of the strongest contract laws around” applied in that circumstance that would answer every single one of my objections. But they don’t – they are preempted.

    BTW, a conceptual point which may be material to the discussion. Contract law is not intended to “punish” anyone; the law attaches no moral opprobrium to a contract breach. It attempts to achieve not punishment but compensation – to put the aggrieved party in the same position it would be if the contract had been performed according to its terms. If you move beyond simple breach of contract to bad faith or fraud then that changes. My present objection is that ERISA does not allow for even simple breach of contract compensation. We are miles away from even thinking about “punishment.”

    Insurances aren’t here to make people whole, any more than car insurance is here to guarantee that you get a new car every time you blow up your last one.

    Again I apologize for failing to make myself clear. By “made whole” I mean put in the same position, insofar as measures available to the law can do so, as if the insurance contract had been performed according to its terms, and that is all – and my objection is that ERISA forecloses even that level of relief. I do not mean “made whole” in some more cosmic sense.

    I sense we are having trouble understanding each other. Let me ask you this then: what do you believe to be the proper role of the judiciary in the enforcement of private contracts? What recourse does (should) a party have if the other party fails to perform its contractual obligations?

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