HOW DARE THEY - INSURANCE MANDATE

How dare the Government mandate that we must have insurance. And mandate what the minimum coverage must be. And penalize us if we don't buy the insurance from a private company approved to sell that insurance. How dare they!

Of course, I'm not talking about the ACA or as it has come to be called, Obamacare. I'm talking about Auto Insurance. That's right, good old auto insurance. I can't for the life of me understand why the folks on the political right can get blue in the face over the ACA's individual mandate. You know, the government forcing us to buy a product and penalizing us if we don't, since that is exactly what happens with your auto insurance.

Let's compare, shall we. Government sets the minimum coverage required under both. Check. Government must approve which companies can sell both. Check. Government mandates that you buy both types of insurance. Check. Government penalizes those who don't buy both types of insurance in the form of a monetary fine under the ACA and by taking away ones vehicle registration under the auto insurance statutes. Check. The only difference that I can see is that the ACA is federal and auto insurance is regulated by the states. Oh ya, and that the ACA is a program passed by the Democrats under a Democrat President. (Using ideas first proposed by the very conservative Heritage Foundation, by the way.)

They're the SAME, people! No difference at all. The auto insurance mandates were put into place so as to product the public from uninsured, and unable to pay, drivers who cause accidents and damage to those who do take personal responsibility and buy insurance. It's a way to mandate that personal responsibility and the states feel that it's in the best interest of the public that all vehicles are covered by insurance. The ACA is a way to make the uninsured health care consuming public also take the same personal responsibility that those who have purchased health insurance have taken. That way the responsible people don't have to pay to make up for health care services used by the uninsured and then not paid for. Each form of insurance satisfies a compelling public interest. There is no difference.

So, please, someone tell me why one is okay the the other is not? Please. Anyone?

ARE WE REACHING THE TIPPING POINT ON HEALTH CARE COSTS?

I just finished reading a very informative article in last weeks Time magazine about the health care costs that we, insurance companies and the government pay. One can certainly be outraged at being charged $1.50 for a single Tylonal  tablet that cost the hospital 1.5 cents. But maybe this is pointing to an even bigger outrage; that fact that middle class earnings have declined since the 1970s while the price of health care has only increased. At what point do we find that people just can't afford to get sick? And have we already reached that point?

I think that we're there and have been for a while. The single biggest driver of personal bankruptcy are medical bills. pretty much everybody can name a friend or relative (or themselves) who were charged huge sums for simple procedures and short hospital stays. The usual response from the political class is that greater competition and more transparency will make people better consumers of health care and thus drive costs down. It just never seems to happen. People aren't all that excited about asking the price of a needed health procedure. They're either insured in some way, so that they never actually deal with the price, or they are in no condition to haggle. "Gee, I'm going to have to check that other hospitals price to repair my broken leg." "I'll get back to you." We're not buying washing machines here.

That concept, that health care is not like other goods and services, is at the heart of the problem. When you need medical attention, you need it. In many cases, if you don't get that attention, you will die. Or suffer disabling after effects. Or disabling after effects until you die. None of these is a good outcome for the consumer. But, as the Time article lays out, this produces some very good outcomes for the medical industry. They make loads and loads of money.

Now, it's pretty clear that suggesting that maybe doctors and hospitals and drug companies charge less is seen by some to be... un-American. It brings into question the entire capitalist system that we have created and defend. But, I think that if we can look at it from a slightly different angle, or two, we might just see some light at the end of the tunnel that isn't a train.

As I asked at the start, has the health care industry reached the tipping point beyond which people just can't afford to pay any more? If your health insurance goes up 20% and your paycheck hasn't gone up in three or four years, you may have to do without the insurance. The same is true of increasing co-pays and deductibles. And for the uninsured medical bills can be just devastating. If things don't change, each year will see fewer and fewer consumers of health services. From a business standpoint that would be a very bad thing for the health care industry.

But we don't ever seem to get to that point because health care is a necessity of life. So maybe we need one of those different angles to solve this.

As a society we have determined that for certain things necessary for life we don't want to leave outcomes to the free market economy. The water that comes into your home, even if it's from a private, for profit, company, is heavily regulated. Joe's Water Service can't really compete on price or service because Joe has to meet the same quality level as the city water department. The same is true for sewage collection. We assume that these services will be provided by our city or town, or by a public service district. It wasn't always like that.

In the days before the urbanization brought about by the Industrial Revolution fresh, potable water was hard to come by. Rain barrels and hand pumped wells in the towns and, sometimes, water collected from creeks or streams out in the country. If you were lucky, or your ancestors were smart in selecting their homestead, you had a nice fresh spring bubbling out of the hillside behind the house. Whatever the source, your water needs were pretty much your own problem to solve. And, again, the same is true for sewage and other waste. In the country it was dig a hole and put a shed over it and in the cities, well you really don't want to know about the cities. After the age of throwing "slop" out of the window into the street came the age of cess pools in the back yard and a wagon with a tank, and a hand operated pump, used to empty the nasty pit that your grandpa told you to never play near. (Not a problem. The smell took care of protection just fine) These services were provided by private companies which started with two guys and a wagon and grew to rather large firms with dozens of trucks. Notice, though, you were still on your own. You had to contact the company so have them come and pump out the pit.

After the Industrial Revolution caused cities to explode in size and density, and the old model of taking care of your own needs fell under the weight of too many people need too much food and producing way too much waste. In order to protect the public, as a whole, from water borne and waste borne diseases the cities and towns took over these services. They became public utilities.

The same thing happened with natural gas and electricity. Even though we may be supplied by a private, for profit, company, they and their price structure are regulated by public utility commissions. We really don't want price competition on natural gas services. The safety of the population trumps capitalism in these cases. Electricity and natural gas are just too dangerous for price wars and such. Interestingly, heating oil, and propane have not followed this trend. The reason has to do more with infrastructure (pipelines and wire) than with any other economic or public safety issues. You just can't pump heating oil to individual homes by way of a network of pipes. Particularly in the winter. With respect to electricity the problem is economy of scale. It doesn't make economic sense to generate power all over the map when that power is going to be generated with the burning of coal. Or the damming of a river. Or nuclear power. Those are big business and government projects.

So, we see that certain necessities of life are better distributed to citizens by either their government or companies regulated by their government. And then there's health care.

In the case of health care we have turned the whole on its head. We have huge companies, making huge profits, providing the needs of the citizens with lots and lots of outlets for their "products," with some government regulation, but mostly with the attitude that any other system is socialized medicine and a very bad thing. I just don't get it.

We have a necessity of life, health care, that we purposely leave in the hands of private enterprise, and we wonder why the cost keeps going up. Please note that, even though Medicare and Medicaid are government programs, they're designed as a way to pay private health care providers. Not to provide health care. And that is the heart of the matter. We didn't dream up "sewage-aid" or "water-care" to help pay for those necessities of life. No, governments stepped up and took the burden on themselves. Your public utility provides the water or the sewage removal.

I'm afraid that only such a public utility model can cure the health care mess that we find ourselves in. I think we have to look at what the rest of the industrialized world has done and pick out the best practices and adopt Universal Public Health Care for all. Not some patched together Frankenstein monster like we have today, but a real national health care provider. The doctors would work for the government and nonprofit hospitals would actually not make huge profits. The government would fund drug research directly and the consumer would reap the benefit of cancer drugs that don't cost $15,000 a dose. We could, in fact, become civilized. Oh, who am I kidding. Civilized doesn't buy politicians. The health care industry sure does! 

BEWARE THE FUB

Now that the Supreme Court has upheld Obamacare we will again be warned by Republicans about the horror of the FUB; the Faceless Unelected Bureaucrat. These frightening creatures will come between you and your doctor. They will prevent you from getting the care you need. Why, they might even be on the dreaded Death Panels! What utter BS.

First, let's be clear that the GOP is talking about only one species of FUB; the G-FUB or the Government Unelected Bureaucrat. That's the one we have to fear. Nothing is ever said about the P-FUB; the Private Unelected Bureaucrat. That's because, as the Republicans have been telling us, over and over, redundantly, again and again, government is always bad and private industry is always good.

So it came as a bit of a surprise when my lovely bride, the Queen of the Frontier, who has private, employer provided health insurance was informed that, no, she could not have the MRI that her doctor wanted for a back problem. She was informed that the insurance company wanted her to have physical therapy first, and then if (when) that failed to help her the MRI would be paid for.

Imagine, a P-FUB had come between her and what her doctor wanted. Can you believe it?

Of course, that's the real problem with the right wing's view of the American economy. They see harm from government action but ignore harm from the private sector or assume that "The Market" will magically fix any problems. It doesn't matter that the person having the problem won't or can't benefit from the invisible hand of the market as it makes its invisible corrections. Just believe in the free market and all will be well.

But here's the thing that really gets me boiling. The fear of the G-FUB seems to be mainly based on that unelected part. Now, I don't know about you, but I'm pretty sure that the Queen of the Frontier has very little recourse to change what that P-FUB decided. The FUBs that work for private firms have the interests of the company, and keeping their job, foremost in mind. In fact just about the only thing that she could do would be to follow Mitt Romney's advice and "Fire," her insurance company. Opps! Since hers is employer based health insurance she can't just send them packing. She, like millions of other Americans, is just stuck.

But it seems that we do have recourse when a G-FUB makes a decision that we don't like. It's called an election. Perhaps you've heard of that. In fact, it's funny that the folks on the right don't seem to allow for just that kind of corrective action as it relates to health care. They don't have that same problem when the issue is coal.

Those of you that don't live in coal country may be unaware that the Obama administration, by way of the EPA, is waging a "War On Coal." This war is, according to Republicans and their friendly news outlets, Obama's effort to kill the coal industry and raise everyone's electric bill so that wind and solar energy can compete. This would appear to be yet another load of good old bull manure, since, at least in West Virginia, coal production was only down 0.8% in 2010 (with the economy weak), and coal mining employment was at its highest since the '60s! Some war. But here's the thing. The answer to the War On Coal, according to the GOP, is to elect a different President. This, even though the means by which Obama is fighting the war is through, you guessed it, the Faceless Unelected Bureaucrats of the EPA. So, just vote out that guy and vote in their guy and problem solved.

Let's review. Obamacare is bad because Faceless Unelected Bureaucrats will come between you and your doctor, but private health insurance is good, even though we know that Faceless Unelected Bureaucrats already come between you and your doctor. To FUB or not to FUB. What a question.

THERE ARE FOUR HEALTH CARE CHOICES

With all of the heat, and very little light, being produced in the debate over what we as a nation can do about health care for our citizens it would seem that there are dozens, if not hundreds, of different solutions being put forward. the problem is, when you boil it down there seem to be only four.

First, just leave things alone. The problem with this approach is that time is not on our side. If we do nothing about the ever increasing cost of health care itself, and the ever increasing number of people who cannot afford or qualify for health insurance, the whole endeavor is likely to just crash and burn. As noted in the last post, uninsured "Free Riders," put an unsustainable burden on the system. At the same time, drugs, treatments, tests and therapies are all increasing in cost at a rate far in excess of inflation. We will simply not be able to care for sick people if something isn't done. Then, add in the 10,000 Boomers reaching Medicare age each day and the ever increasing number of folks in need who must rely on Medicaid and this house of cards will come tumbling down.

Second, we could mandate that people buy insurance. Thus, the much hated on the right Individual Mandate. This idea, which anyone who has any sense of what's going on in the real world knows, as opposed to pretty much the entire GOP, was a conservative concept that would force individual responsibility (yes, that is an oxymoron) and thus end the era of Free Riders. With everyone in the insurance pool, including the young and healthy, everyone can be covered and the cost of insurance should go down. Of course, this idea by itself does nothing about the cost of care but with everyone insured market forces brought to bear by the insurance companies should hold down the cost of care. Maybe. Sort of. We hope.

Third, we could stop treating the uninsured. This is the "let them die," option. Simply put, if the mandate to care creates the Free Rider problem then doing away with that mandate should solve it. It's not pretty and there isn't an office seeker, except maybe for Ron Paul, who would ever advocate such a change, but it would solve the problem. And as I said in the last post, it sure would get people to buy health insurance.
I don't think that we as a nation want to go that route, but given the political rhetoric out there right now, who knows. I'm thinking that Ted Nugent might like this one.

Forth, we could adopt a "Single Payer," system. You know, the dreaded (by the right) Universal Healthcare model that exists in every other industrialized nation on Earth. Call it Medicare for all or call it socialized medicine, the end result is the same. Everyone has health insurance and can get treatment. Costs are contained in much the same way as under Medicare today or we adopt more of a UK model where the doctors, nurses and technicians work for the government itself. If this were a new idea that had never been tried before I could certainly understand being careful. But this system works and it works all over the world. It really isn't un-American to borrow ideas from abroad.

Finely, I should include a fifth. That would be whatever the hell the Republicans want to replace Obamacare with. We don't know what that is. Maybe there are just four.

THERE HAVE TO BE LOSERS

The Affordable Care Act, or Obamacare, is now before the U.S. Supreme Court and according to some of the cable news talking heads things are not looking good for the Individual Mandate. You know, the part of the law that says that starting in 2014 people have to buy health insurance or pay a fine on their tax return. There is lots of talk of how this or that result will effect the election in November, but really no discussion of the actual alternatives to the Mandate as written.

The reason given by any and all of the defenders of the act, and some non-defenders if you listen to Mitt Romney from 2008, is that without mandatory insurance coverage healthy young people will not get health insurance. Without these healthy people in the insurance pool the companies can't afford to cover people with preexisting conditions. This also causes the uninsured to use emergency rooms and similar services, the cost of which is then passed on to the insured by way of even higher premiums. The idea is to get the so called "free riders," into the insurance system.

No one on the GOP side seems to have any idea of what to do about this problem. They're all very quick to shout "Repeal and replace!" but never offer what the replacement may be. See, the problem they have is, the logical, conservative, Republican response is one that a lot of folks think is a little mean. It was seen at one of the early GOP debates when the crowd cheered for letting an uninsured accident victim die. The only reason that there is a problem is the Federal law that mandates that health care providers help everyone, regardless of their ability to pay. If the GOP is at all true to their conservative colors, they should jump on the repeal of the mandate to treat. Then, our health care system would better fit with the conservative of ideal of self sufficiency and personal responsibility.

I have no idea how many people would die each year from being turned away at the emergency room door, but I'm sure the number would begin to decline after a while as more and more "free riders," realized the error of their way and went ahead and purchased health insurance. The numbers would, of course, also decline as the sickest of the "free riders," died off. This would thus appear to be a win for society and the economy.

Notice, please, that in order to get that win for society someone, in this case those too poor, sick or dumb to get health insurance would, of course, lose. That's the dirty little secret behind any plans for so called free market solutions to complex societal problems. The free market requires that there be losers.

The Liberal and Progressives in American society tend to want to protect the aforesaid too poor, sick or dumb from being losers. They want the government to be a back stop against losing. Conservatives tend to prefer the freedom of the marketplace, without actually telling the too poor, sick or dumb that they will end up as the losers. But be not fooled. That is what will happen because the "markets" demand it.

See, for everyone who buys a share of stock say, at what they think is a good price, someone else sold that share of stock and half the time lost money in the transaction. For every winner in a free market, there's a loser. The real problem for society is as I said; conservatives don't want to mention the losers and liberals want to protect people from losing. Each distorts the markets themselves and both lead to the kind of financial mess that we are slowly working our way out of.

So, keep an eye on how the Obamacare fight comes out and if it gets tossed out, ask your Congressman what he or she wants to replace it with. Good luck!

DOES THE GOP REALLY WANT TO ARGUE RELIGIOUS LIBERTY?

Oh, the fun that comes out of Washington. Now we have one side wanting to make contraception use a statutory right, and the other side screaming that to do so will infringe on their First Amendment religious liberties. It was that claim, "Religious Liberties," that made me sit up and take notice.

Without going into the entire dust up (if you need more information use the damn internet for something other than tweeting) I keep wondering what would happen if the offended religion were one other than Catholic Christianity. You know, like Islam. Would the defenders of faith based scofflawism be just as outraged if the law in question was similar to the French law against wearing a Burka in public? Or what if the defendant in a murder case case claimed that "honor killings" are part of their religious beliefs? Would that be okay? Or even, as I heard from one talking head, that Quakers could object to their taxes being used to fight wars. How far do we what to push this?

As will be no surprise to anyone who has read this blog, I come down on the side of the common good of society being more important than the particular beliefs of any particular religion. That may seem extreme or even anti-religious, but when one considers that their are over 250 different Christian sects in the U.S.A., not to mention the non-Christian religions and of course the non-religious, it seems to me that any other position can only lead to arguments like we are having now.

This puts me in mind of a similar, although not nearly as important as contraception, place where the beliefs of the few are imposed on the many. I'm referring to the good old fashioned "Blue Laws."  You know, the reason that you can't go out to breakfast on a Sunday in, say, North Carolina and order a Bloody Mary before noon. Or run into the grocery store to pick up a six pack Sunday morning in West Virginia. Most of these have been declared unconstitutional or are at least not enforced (much) but the buying booze on Sunday ones seem to have a lot of staying power.

I have been directly impacted by the NC version, and not because I'm a drunk looking to start early on a Sunday. No, The Queen of the Frontier and I owned a restaurant in the beach resort town of Kitty Hawk, NC and we were faced with this every Sunday morning. In comes a car load of happy tourists from some far away land, like New York, looking for a nice beach brunch with a morning cocktail and wham, I have to explain that "I'm sorry but I can't sell you $40 worth of drinks to go with your table full of Eggs Benedict because it's only 11:00 am." Trust me, that does not win friends and repeat customers.

My take on this was always that, if the preachers wanted to make sure that their flock didn't come to church drunk that they, the preachers, should have a chat with their wayward lambs. Why burden me, my staff and most importantly, my customers, with the problem. We don't see Rabbis marching outside of pork BBQ joints claiming that they should close their doors do we? Of course, this was not an argument that was going to go very far in the American south, but it does illuminate the problem.

If you, or your religion, doesn't like the use of birth control fine. Enforce that belief system on your believers. But leave the rest of us alone, please. Because any law that favors one belief system over another, like the blue laws, violates my First Amendment rights. And the great thing about our great country is, my rights are just as important as yours. Let's all defend them equally, shall we. 

MEDICAL MALPRACTICE REFORM IS NOT FUNNY

Well, actually, it sort of is funny. At least the way the GOP uses and abuses the term, that is.

For many years now the primary reaction of the GOP to any Democratic talk of health care reform has been to scream, "We want malpractice reform first," followed by what ever other means of obstruction that they can think up. Conservatives throughout the land would then nod knowingly and the conversation would turn to other, more pressing matters. But then came 2008 and President Obama.

This guy had a pretty fair election mandate, given the vote totals, and both houses of Congress on his team. The Democrats, thus charged up with victory zeal, went ahead and actually passed a health care reform (HCR) law. But, as we now know, said law did not contain the sacred malpractice reform which those on the right have assured us is all that's needed to make health care affordable for all.

Now, the usual reason given by the GOP is that the Dems. are beholden to the trial lawyers for big campaign contributions so they will never, never I say, do anything to stop frivolous law suits. Since the passage of HCR all we've heard from the right is that they will repeal this awful law and replace it with something better that includes malpractice reform. What sends my blood pressure raging is that, in reality, the federal government can't really do much, if anything, about malpractice reform.

Medical malpractice civil actions are a purely state matter, governed and controlled by state law. Now, if you listen to the Republicans and conservative pundits that little fact gets, shall we  say, little notice. In fact, it basically gets ignored. Here's an example from the Wall Street Journal which starts off with the expected position:

Eliminating defensive medicine could save upwards of $200 billion in health-care costs annually, according to estimates by the American Medical Association and others. The cure is a reliable medical malpractice system that patients, doctors and the general public can trust.

But this is the one reform Washington will not seriously consider. That's because the trial lawyers, among the largest contributors to the Democratic Party, thrive on the unreliable justice system we have now.

A careful reading of the whole article does actually, in a sort of back door, off handed way, make mention of the problem:

On July 31, Rep. Bart Gordon (D., Tenn.), a Blue Dog Democrat, introduced an amendment to the House health-care reform bill (H.R. 3200) to fund pilot projects for liability reform, including pilots for "voluntary alternative dispute resolution."

What happened? According to the online newsletter Inside Health Policy, "While Gordon's amendment originally had seven policies that states could implement in order to receive federal funding, the other five suggestions were crossed out . . . due to the agreement with the trial lawyers." (Bold and italics added)

See the catch? The best the federal government and Congress can do is threaten to withhold federal money to states that don't do this or that in order to reform medical malpractice rules. This is that classic form of federal intervention in state law that we enjoyed during the 55 mph years in the 70s and 80s. States had to lower their top speed limit to 55 or they wouldn't get federal highway funds. In the case of medical malpractice I assume that it would be Medicaid funds, or something along those lines, that would be withheld. It is, in point of fact, a method by which Congress could effect the matter at the state level. I just don't think that you can call it malpractice reform.

You see, contrary to what one may think reading this Blog, I'm a firm supporter of State's Rights. But then, so are the Republicans and conservatives who keep pushing for this. My position on this matter is that only the states can, or should, control their own courts and civil practice rules. I can well imagine the conservative outcry if such a federal mandate were added to health care reform. It would be much like the outcry over the insurance mandate that is in the law.

And it's not like the states can't so the job. The WSJ article doesn't  mention the Texas law, or those of other states, that have gone a long way to correct many of the problems of the current way we deal with medical malpractice in our society. Some are better than others, but each at least attempts to find solutions. And please, don't forget that from 2001 through 2006 the GOP controlled both houses of Congress and the White House. Why didn't they do something then?

So here's the best advice that an old, retired lawyer can offer regarding medical malpractice reform. The next time you hear a GOP member of Congress spouting off about malpractice reform and what he or she can do about it, ask yourself why he or she didn't do, or suggest, anything within their own state. My guess is that they think that actually doing something doesn't get them elected nearly as well as just complaining about the other side not doing something.

SOMETIMES YOU JUST HAVE TO RESPOND

Truth be told, on any given Sunday morning I'm a pretty lazy fellow. I read the paper, including the comics mind you, watch some of the talk shows and then a football game or golf, depending upon the season. But sometimes something flips my switch and I just have to respond with more effort than yelling at the TV or throwing down the paper in disgust. This past Sunday was one of those times. Below is a letter which I wrote to the editor of our local paper. The entire letter to the editor to which I'm responding is here. This is slightly edited to eliminate the authors name.

Dear Editor:

This past Sunday's local newspaper contained a letter from a reader who expressed his dissatisfaction with the Obama health care reform legislation and its personal effects on his finances.

 

As a wise man once said, everyone is entitled to their own opinion, just not their own facts. this letter writer says, "(T)his administration ... also has a health plan program that creates a 'donut hole' in the Medicare prescription drug program."

 

Well, not exactly. The so called donut hole in prescription drug coverage was a part of the George W. Bush Medicare Part D prescription drug benefit which was passed by the (then) Republican Congress and signed into law my President Bush. This is the same addition to Medicare which was not funded and which thus added significantly to our national debt. This is the same addition to Medicare which forbade the government from negotiating with drug companies for the best and lowest price for prescription drugs. Let me repeat: the Medicare Part D prescription drug benefit was proposed and passed by the Republican Congress and signed by President Bush.

 

The correspondent goes on to say, "Obama said, 'we know your prescription drug cost will increase, so here is a check for $250 - a one-time payment.'" This letter writer alludes to the idea that since Obama crammed this donut holed health care program, "down our throats," (which he didn't, see above) the one-time payment of $250 was somehow an insult, since his actual donut hole drug coast would range much higher.

 

Sorry, but the $250 was contained in the new health care reform law to lesson the donut hole costs for this year. The new law actually eliminates the donut hole over a few years during which the hole will get smaller and smaller.

 

Finely, the letter writer laments that, "Obama's administration also takes $400 billion from the Medicare plan - thus the 'donut' hole." The $400 billion from Medicare is in the new law, but refers to cost reductions over 10 years or $40 billion a year in savings to the government. And, "thus the 'donut' hole," again makes the incorrect assumption that the said donut hole was somehow created by the current administration. It was not.

 

I would caution this reader and, in fact, all of the voters in our great state, to learn the facts behind the political babble we hear and read daily. Otherwise you'll be voting on November 2 with incomplete, or incorrect, information. I don't think any of us wants to do that.

 

Thank you,

 

I hope that I shed a little light on this issue and that the letter writer, and others with the same mistaken ideas of what's going on in the world, may have learned something. Hey, I'm optimistic.

I WAS WRONG

In my last post I outlined what I thought was a Medicare mess which I had fallen into. It turns out that I jumped a little to quickly to that conclusion.

In fact, it turns out (and yes I knew this, I just forgot it) that Medicare pays a pre-set amount for reimbursement. In my case the reimbursement for the enteral nutrition that I need is $2.57 per can rather than the $11.88 which the supplier would charge me if Medicare didn't pay. Now that, in and of itself, shocks the conscience. It is even more shocking when you realize that Medicare is willing to pay more than a dollar per can over the retail (on-line) price. But it's certainly not as outrageous as I presented it.

Lesson for the blogger; check your facts. Now back to our regularly scheduled ranting.

HEALTH CARE HORROR SHOW

I'd like to share with you a tale of horror concerning our very badly broken health care system. First the facts.

As my friends are aware, I had a little dust-up with throat cancer back in 2006. As I have told many people since, cancer is easy to beat, it's cancer treatment that gets you. The radiation therapy that killed the cancer also did a number on my esophagus. I can no longer swallow and have tube fed for three years. That, in concert with some other permanent side effects means that the Social Security Administration deems me to be disabled. That status also means that I became eligible for Medicare before my 65th birthday. The plot thickens.

In going over the mountain of information and literature available about Medicare that one can find on-line I came across an interesting reference. It seems that Medicare will help pay for what's called Enderal Nutrition. What is enderal nutrition? Why it's the formula which yours truly pours through a tube into his stomach four times a day. And that horrible government run health plan called Medicare will help pay for it. This was starting to get interesting.

Now, anyone who knows me well can tell you that I like to be parsimonious. Waste not want not and all that. Back in the day when I was a roofing contractor I took great pride in never ordering more roofing than was needed and then using up every possible piece and scrap to finish the job. So saving some bucks by letting Medicare pay for what I've been paying for for the last three years was pretty appealing. Not that I was spending all that much. I very kind nurse in the hospital where I received the feeding tube told us that you could order the formula they use in the hospital or just use the WalMart version of a nutritional shake. Well that's all it took. We stopped at Wally World on the way home from the procedure for the first cans and that has been my exclusive source for nutrition since.

Now I'm currently paying $6.87 per 6 pack or $27.48 for a case of 24 cans. Doing all the math means that I need $240 worth of "food" a month. $8.00 a day is not bad, but if Medicare picks up 80% that's even better. So off I went down the rabbit hole.

After some more research I discovered that WalMart is not what Medicare accepts as a provider of enteral nutrition. That would have been far too easy. So back to Google I go until I land on a manufacturer's web site. Not only do they have what I need, but they will deliver right to my door. I call. I wait on hold. I play Solitaire and wait some more. Finely, a very nice young lady explains that the brand name product I need will cost $37 per case. I thought, fine, Medicare's going to pay 80% anyway. "No problem," I said, "So how does this get billed to Medicare?" Oops. Seems that they don't do Medicare sales. I would need to find a provider locally. Just a minor setback. Nothing to worry about.

A quick trip to the yellow pages and I found a local medical products company. The very nice lady there told me that once I get an order from my doctor they can get the product and deliver it to my door. I asked how much my share would be, put she couldn't say until it actually came in. Okay, that sounded good, and since I already had an appointment with my doctor, things were moving right along. The doctor visit and a few phone calls and faxes later and my order for six cases of nutritional shake would be on my front porch.

The six cases came today. In the course of signing nine different documents acknowledging receipt of the cases among other things, I came upon the document that said that if my insurance declined or refused to pay that I would be responsible for payment at the rate of $11.88 per can. 

Let's see now, $11.88 per can equals $285.12 per case or $1,710.72 per month. And how much would my 20% co-payment be? $342.14. So if I order from the approved provider I can pay  $100 more per month for the convenience of having this stuff delivered and Medicare can pay $1,369 for a product that I buy now for $240! This is messed up.

Needless to say, I will not be ordering my nutritional needs from that provider nor will Medicare be helping me pay. My friends on the right (you know who you are) are probably crowing loudly how this proves just how broken the "Government Run Health Care" that we have is and why we should abandon "Obamacare" just as fast as we can. I see a different lesson here.

One of the administration's arguments for the health care plan now before Congress is that it will save $500 billion from Medicare over ten years. The GOP points to this and says, "See, they want to cut Medicare." But clearly, there are huge sums that can be saved if someone just works at it a little. The government will pay over seven times the retail cost of this one product the way the system works now. Is it the GOP's contention then that the greatest nation on the face of the earth, the country that put a man on the Moon, invented the light bulb and the Twinky, can't figure out how to not spend $1,700 for $240 worth of product? I'm just curious.

So that is my tale of horror. Hours of research, hours of phone calls and many games of Solitaire later and I'm right back where I started. Oh well, I got a blog post out of it. Is it time for dinner yet?

THE TORT REFORM MYTH

As the health care reform debate continues we hear again the call for "Tort Reform." Wikipedia defines the term like this:

In the United States tort reform is a contentious political issue. US tort reform advocates propose, among other things, procedural limits on the ability to file claims, and capping the awards of damages.

Of course the sides line up as one would expect. Republicans want to limit jury awards in medical malpractice cases, which would then lower medical malpractice insurance premiums and the health care crisis would be solved. Democrats don't want to limit jury awards in malpractice cases because that would add more harm to the people who are injured by doctors and hospitals and also wouldn't punish those bad actors enough.


OK, that's a little simplified and snarky, but that really is the gist of it. I come down somewhere in the middle. Yes, I think some reform is necessary, particularly as it relates to the election of, and resulting gutlessness, of trial court judges. See my post on that subject here. But I also think that arbitrarily limiting the amount that a jury can award does harm the already harmed. But that's not what I want to address here.


The drumbeat for tort reform in the current debate is a giant straw man built by the Republican right and I wonder why no one ever calls them on it. They would have us believe that if the Democratic controlled Congress and Democratic President didn't owe their positions to the donations of trial lawyers, why we could fix this problem right quick. That position is, shall we say, disingenuous, for two very good reasons.


First, why didn't the Republicans do this when they had all the power? Do we forget that from 2001 to 2007 the GOP held both houses of Congress and the Presidency? Do we forget that the Democrats during that time were gutless wonders who allowed two wars, huge tax cuts for the wealthy and the torture of prisoners held by our forces? Why didn't the GOP just do it? Because:


Second, neither they or the Dems. can reform the tort system at the Federal level. The civil justice system is a state function. Few, if any, medical malpractice cases can be brought in the Federal Court system. It's up to the legislatures of  the various states to make changes. The states have insurance commissions overseeing the insurance industries within their borders. State laws control the rules of civil procedure and I would imagine that it would be the Republicans who would shout "States Rights" the loudest if the federal government tried to push the states around on this issue.


Perhaps disingenuous is too nice a word. I seem to recall that the Republicans actually control the governments of some of the states. So why haven't they instituted tort reform there? How about our good friend greed!


If medical malpractice awards were limited the insurance companies would be forced by market pressure to lower the premiums that doctors and hospitals pay for insurance. They can charge outrages six figure premiums now because of outrages jury awards. Of course, over 95% of malpractice cases never see a jury, but are settled out of court. And, since doctors who are super careful and never have a claim made against them are still charged huge premiums it's not in the insurance companies best interest to have a reason to lower premiums.


Hospitals and physician specialty practices, who might see an insurance premium decrease under tort reform may not actually be in favor of such reform, either. They make an awful lot of money, paid to them by the health insurance side of those same insurance companies, when they perform test after expensive test ordered by doctors who are practicing defensive medicine. Hey, the hospital has to pay for that new CT scanner some way.


What it boils down to is that the "for profit" American medical system maybe can't be reformed. Damn, I think I just made an argument for the so called Public Option insurance plan. Oops.

GREED

Now, this might be what we used to call a BFO, a Blinding Flash of the Obvious, but we are living in a society powered by greed. Not just a little bit of greed. Not just some of society. No, if you stop and think about it, greed permeates every part of American society. And that realization may explain some of the otherwise unexplainable aspects of our lives.

For example, the health care reform debate. People who have health insurance provided to them by an employer seem unwilling to allow the government to help out people without health insurance. They can offer all manner of reasons, but deep down isn't it just that they don't want someone else to get for free (or cheap) what they now have? Greed.

Keeping to health care reform, we also see that the right wing in American politics looks at any government intervention as a failure in advance because "government is the problem." But why is this so? I'll grant that government run programs are, generally, inefficient and wasteful. How does greed enter into the picture? Well, one of the main reasons for inefficiency and waste is that all government programs are designed to try and prevent theft. Whole forests of paperwork are needed to try and make sure that the recipient of a government provided benefit is deserving of the benefit. The assumption is that people will cheat the system. Greed again.

It's everywhere you look. Even the one government program the right seems to always want to increase, the military, is rife with tales of $800 hammers and other procurement messes. Again, paperwork, inspections and reviews written into every procurement contract intended to prevent theft of our tax dollars. Greed.

And it's not just government. Banks that make billions of dollars from overdraft fees. Credit card companies charging 30% or more interest. Airlines charging for checked luggage. Oil companies making record profits from consumers when they had to pay $140 per barrel. It's just about greed.

Please understand, I'm no left wing communist. Having been a business owner for 40 years puts me smack dab in the category of capitalist, but the world we now inhabit seems to me to be awash in greed far in excess of the capitalism of 40 years ago. I've touched on some of this before, here and here. When good old Mom and Pop owned the general store they knew that it was in their self interest to allow the Widow Jones to buy groceries on credit every now and then. Their altruism, based on self interest, could be viewed as greed, but at least it was altruistic toward the Widow Jones. She benefited and that benefit was spread to her children and grandchildren. The benefit out weighed the self interest. Today that general store is owned by General Store Corp., Inc. and the stockholders would not take kindly to letting that old woman get out without paying.

It seems to me that the only real charity in America comes either from the very, very rich (Bill Gates and his wife) or from the poor helping each other in time of need. Every other group and institution in society, when you look under the rocks, is based on greed. 

WHY ALL THE ANGER?

I've been scratching my head over the very vocal anger being expressed by some at town hall meetings, in interviews and in blogs. While it's easy to see that people fed a steady diet of Rush or Glenn Beck distortions and false claims (see my last post), intended to arouse anger, would result in anger, I think that there may be an underlying cause.

Note that most of what is said (shouted) is anger at GOVERNMENT. "I don't want the Government to get between me and my doctor" or "The Government can't run anything right. What makes them think that they can run GM, health care or whatever." While the Obama = Hitler trope is there too, the overall sense is that these folks really hate THE GOVERNMENT. Since Obama has only been in office 7 months this, to me, seems a bit excessive. What is going on here?

Could it be our old friend cognitive dissonance? Our country has been through hell over the past 8 years. A terrible attack on the Homeland. A war to catch the people who planned and ordered the attack and the failure of that war to catch them. Another war started on grounds that proved to be pretty much completely false. A storm ravaged American city and the incompetent Government response. The revelations of mistreatment and torture of prisoners. The past 8 years have shown those average citizens out there in Sarah Palin's "Real America" that, by gosh, the Government IS incompetent and can't seem to do anything right.

But wait. These are the same folks who believed that Saddam had WMD. They believed that if we fight them over there they won't come here. They believed that we don't torture our prisoners. Classic cognitive dissonance. "The uncomfortable feeling caused by holding two contradictory ideas simultaneously" is exactly what we are now seeing. And, since they believe that they should both respect our leaders and their policies and that the Government run by those leaders has resulted in poorly planned and run wars, programs and agencies (can you say FEMA?) their brains are faced with the pain of cognitive dissonance.

What we are seeing now is the expression of that pain against the new guy and his Government. "He's Black you know. Not like us. He has a funny name. I heard he wasn't even born here." They find it much easier to yell about Obamacare now rather than protest the war back then. The anger and frustration has been building for 8 long years (longer still when you consider the 1996 congressional election and the impeachment of Clinton). Their buttons are easy to push, and as we can see, the Rushes and Becks of the world know where those buttons are.

It's going to be a very angry fall and winter.

THE HEALTH CARE REFORM MESS

I've been absent from the blog for awhile due to other projects and needs. I have also purposely NOT been blogging on the health care reform mess, in part because the matter is everywhere right now and because by poor old heart can't take the strain of trying to understand what some of the opponents are even saying. Reading or hearing opinions based upon complete ignorance and misunderstanding tends to put my BS meter into shock. It's not easy to argue with someone who declares, in a loud voice, that the sky is pink when a simple look up reveals pure blue.

In an effort to help clear the air a bit, here is a link to a FactCheck.org post titled: Twenty-Six Lies About HR 3200. It looks at 48 claims made about one of the reform proposals now being debated in the Senate. Enjoy!

IT'S THE JUDGES' FAULT

The continuing debate over Health Care Reform is starting to heat up. I've started to hear that old chestnut about how doctors and hospitals are burdened by the high cost of malpractice insurance, brought about by out of control damage awards, and that we as a nation could lower the high cost of health care if we just enact tort reform.

Some of the arguments for reform include limits on punitive damages, limits on non-economic damages, use of court appointed expert witnesses, the adoption of the English rule that the loser pays and the elimination of elections for judges. The arguments against reform include fairness to persons injured, punishing people or corporations that are negligent and the idea that only by exposing and punishing negligent acts will people and institutions change their behavior. Which political side takes which position is pretty well known, so I'm just going to leave that alone. What I would like to address is the elimination of elections for judges, and how that could have a significant effect on jury awards in general and medical malpractice in particular.

Why should electing judges have any effect on the size or frequency of jury awards? Judges are impartial, right? Well...sort of. We've seen of late that judges can, and do, get their hands caught in the cookie jar when their financial interests and the interests of justice collide. And there's no bigger cookie jar than campaign donations. But, while avoiding even the appearance of a conflict of interest may be a good reason to stop electing judges, I think that there's an even larger conflict that elected judges face. Pleasing voters.

Elected judges like to get reelected. While their appeals to donors can be personal and done in the back room, so to speak, the appeal to voters is public and based on a judges record. And there's the rub. It's far easier to defend your record (to the voting public) as a judge in civil lawsuits if you don't have a long list of the poor injured plaintiffs who you've dismissed out of court before their cases could be decided by a jury. So "bad" cases or cases that could result in huge unjustified jury awards regularly get tried. And juries award huge unjustified sums to injured plaintiffs and we all get to stand back and blame the greedy lawyers. So, as a result, all liability insurance rates go up and more and more cases are settled out of court. More importantly in the medical field, more and more doctors start to practice "defensive medicine," ordering tests and procedures that protect the doctor or hospital from lawsuit, rather than the health and well being of the patient.

As I've said, the public likes to blame the lawyers because they file some really ugly lawsuits. They will include every possible defendant, no matter how remote their connection to the harm. under that tried and true legal theory of "Sue everyone in sight." And our elected judges just roll over and allow such cases to proceed. You see, it's not as if judges don't have any recourse. They do. It's called "The Rules of Civil Procedure." Every state, and the federal judiciary, have them. The rules set out how you start a civil lawsuit, serve notice, make motions, etc. Here's the West Virginia version that I used to practice under.

Now here is the really interesting bit. The rules say that, in order for a party to file a legitimate lawsuit, they have to "state a claim upon which relief can be granted." Say what? In English that means that your lawyer can't just make up a connection between your injury and, say, Dr. Green. There needs to be what's called a causal link. So judges can throw plaintiffs out of court before a case even gets underway. (The particular rule is number 12(b)(6). It also references rule Rule 56, Summary Judgment).

So what's the point? If judges weren't worried about reelection they would have far less inclination to "let a case go to the jury." They might actually throw bad cases out and sanction plaintiffs' lawyers for wasting the court's time in the first place (see Rule 56(g) ). Let a sitting judge charge a few malpractice lawyers with contempt of court and a fine and the number of questionable lawsuits in that jurisdiction will start to go down. Will some good cases get thrown out or not filed? Probably, but that's why we have appeals.

Elected judges are afraid to do this. I know. I've seen it in action. I represented a businessman in a matter involving a contract to buy some real estate. In the course of negotiations the businessman's father hand delivered the contract documents to the seller. When the negotiations went south the seller sued my client and his father! Now, it doesn't take a law degree to see that Dad's connection to this matter was peripheral at best. So, as a favor to my client, I filed a 12(b)(6) motion to have the case against his father dismissed. The judge turned us down saying "I think we should let the jury decide." Result...Dad had to get his own lawyer and proceed with the case. He was ultimately dismissed as a defendant and his son won his case, but at what cost? The father had to pay his lawyer and take time off from work simply because the elected judge was facing opposition and, to a judge, letting the jury decide is always safer than making the decision yourself.

In medical malpractice cases, as we've seen, the results can be much more expensive for the parties and for society as a whole. What should we do then? I think that judges at every level should be appointed for either a limited term (say 12 years for trial judges, 20 for appellate judges) or until they reach a mandatory retirement age. Governors can do the appointing at the state level, just like the President for the Federal Bench, and, if need be to get such an idea passed, confirmation by the state senate. We already know how to do this, it just requires some political courage.

Oh wait. Political courage seems to be in short supply every time this subject comes up. Maybe next year. Ya, sure!

HOW MUCH IS A LIFE WORTH?

That question has been rattling around my brain box for some time now. While it may seem obvious that the answer is "A human life is priceless," a moments thought reveals that "priceless" carries with it a very steep price that we Americans pay in the social policies that we all must live with.

Take medicine. The idea that the adoption of a European type universal health care system will result in rationing (see my post here) only makes sense if you realize that what is meant is rationing of the best care. The government can't be the insurer of last resort because the country would go broke, say the anti universal care types. And since we wouldn't want that, some people (read poor) will be denied care. But the care they are referring to is the best care available. You see, if every human life is priceless, to deny or ration the best care to anyone is to cheapen that human life.

The idea works like this. Comparing treatment "A" with treatment "B" as to their efficiency will lead to the conclusion that, of course, we should use whichever is the most efficient. But what happens when we compare their cost effectiveness? If "B" is 10% more effective but costs 10 times as much as "A" should we still choose "B"? How about if the patient is willing to pay the difference? How about if the taxpayers (you) are picking up the tab? Every life is priceless. With "A" you'll live 30 more days. With "B" you'll live 33. Which makes more sense?

That, in a nutshell, explains one of the many hard questions we will face as we try to solve the health care crisis. Great Britain has dealt with this as it relates to drug costs by setting up a body called the National Institute for Health and Clinical Excellence (NICE). See this Time story for some details. NICE uses a formula to compare "A" and "B" and approves or disapproves any new drug or treatment. That is, whether or not the National Health Service will pay for the drug or treatment. Rationing. Why would we ever want to adopt such a scheme here in America.

Sir Michael Rawlins, chairman of NICE, believes that if the U.S. adopted a similar system, it would revolutionize the culture of major pharmaceutical companies, many of which spend more on marketing than research and development. A 2008 study in the New England Journal of Medicine predicted that incorporating information about cost-effectiveness into the design of U.S. insurance would save $368 billion over 10 years.

Oh ya, that's why. I'm afraid that for this country to be able to afford universal health care we are going to have to come to grips with the idea that "Every life is priceless." We're going to have to make the hard choices about quality of life vs. cost of care. We're going to have to put a price on a human life. Do we have the courage to do that?

HEALTH CARE - ANOTHER VIEW

Here's a very good explanation, from The Anonymous Liberal, of what a universal health insurance plan might resemble.

The Anonymous Liberal: The Need for a Public Option

HEALTH CARE

Today some health care executives announced that they will help out the Obama administration by finding their own ways of cutting health care cost increases by 1.5% per year. At least I think that's what was proposed. I tend to agree with Kevin Drum writing for Mother Jones that this may just be a way for the industry to cut off Obama's plan at the pass. Time will tell.

What I'd like to address is the general position that any government plan for universal coverage will result in RATIONING! They trot out Dr. Whoever from Toronto to tell us how the Canadian model can never work because folks will be denied care, or denied the right to pick their own doctor, or denied some damn right that we as Americans sure don't want to give up. Why, our very lives will be at risk because our health care will be rationed. Just to show I'm not making this stuff up, see this site.

The obvious, and first, question one should ask these guys is, what the hell are you smoking? Out here in the real world people are denied care all the time. If you don't have health insurance (remember that 47+ million number?) health care providers can and do say no. But wait a minute, aren't hospital Emergency Rooms required to see you? Well, yes and no. Yes public ERs can't turn away an emergency patient, but they can decide that you aren't suffering from an emergency. More importantly, the greatest need for most people is continuing rather than emergency care. And Emergency Rooms don't offer patients access to specialists except as part of for an emergency. Try getting cancer treatment at the ER.

The rationing theme is also a fairy tale told to scare the public out of supporting any type of universal health care. This assumes that all of the uninsured, and under-insured, will simply march in to their local ER and we, the taxpayers, will have to pick up the tab. Have I got news for them. When the bills start coming from the ER, the doctors, the lab, the radiologist and whomever else stuck their nose behind the curtain that is trying (and failing) to protect your modesty, you'll see that they all expect YOU to pay for that emergency care. Yes, people do blow off medical bills and the expenses are then spread to those that pay, but less then the anti health care reform crowd may think. And then there's the folks with insurance.

You know, the HMO that tells you which doctors you can see. Or more correctly, which doctors they will pay for you to see. Or the health insurance that tells you well after the fact that they won't cover last month's trip to the ER because you didn't get prior approval...at 3:00 am...on a Sunday. So now all those bills are yours to pay. And don't forget this month's premium payment.

Of course, you don't have to worry about your insurance company paying for a pre-existing condition. It's just not covered. How many uninsured people do you think are delaying even getting looked at because if the doctors finds something it will NEVER be covered in the future? You hope that your next job will offer health benefits so you best not have that lump looked at now. This stuff happens. This is the real world.

So let's review. If our government offers universal health care to the citizens of our great country then some people will be denied care, some will see certain treatments rationed and some will not be able to choose any doctor that they want. I'm sorry, but I just don't see the difference.