Wednesday, August 19, 2009

Facebook Debate

Funny how a brief Facebook status update can spark a debate. It's on a friend's page, so I don't want to publicize his name. But I think the discussion is interesting. It's crazy long--and I actually edited out some of it when I wasn't directly involved--but I still think it's interesting.

My friend: FRIEND

Me: ME

Person 1: not fond of current proposed insurance reform

Person 2: not fond, either.



wants Medicare for all

Person 1: The government can't run cash for clunkers (or social security, or medicare, or medicaid), why would you want them to mess up the health care system?

Friend: It's not working now so why not try something different? Medicare does work and less expensive to run with more choices.

Person 1: Seems to work fine to me. There isn't anyone in this country (including illegals) who can't get medical attention when required. Medicare is going broke, it doesn't work, AARP wants improvements to it. What is needed is a stop to all the lawsuits against doctors and hospitals...that is what is driving up the cost of healthcare in america. Cap the lawyers.

Me: 1/6 of Americans lack health insurance, and many with insurance still face hardships. As a family doc in an underserved community, I can assure you that there are many, many people who lack access to health care. Just because the ER can't turn you away doesn't mean that people can actually get needed health care there. ERs can't handle care for chronic illnesses.

Medicare is going broke b/c it disproportionately insures older patients and many disabled patients--2 groups that are higher users of healthcare services. Medicare is actually 3 or 4 times more efficient than private insurers but is handicapped by its patient profile. Voters who are on Medicare LOVE Medicare.

As a physician, I'd be happy to cap the lawyers. But it won't expand health care to those who don't have it and it won't fix the issues of costs. Medicare for all, or a strong public health insurance plan option, will keep for-profit plans honest, keep prices down, and ensure that anyone can afford care.

Person 1:
I don't agree with your 1/6 number...can you back that up with a reference? Many of the people who do not have healthcare choose to not have it because they would rather spend the money on other things. '1/6' people in america are looking for a free handout as long as they don't have to pay for it, lets get the people who work for a living to pay for it for us.
If the public option cost users $300 a month do you honestly think the '1/6' of people who don't have healthcare would pay? My wife paid for her own plan from Blue Cross for around $300 a month and she had a previous condition, now take your typical 20-year-old and consider what they spend a month on going to the bar and drinking. Lets all sacrifice.
Public healthcare is crap healthcare...I lived in Canada for 30 years so I know. Look at how well the government manages our money. Regardless of which party is in power, they spend our tax money recklessly. Adding 50 million new users with no new docs,nurses,etc does not
expand healthcare. It dilutes it. As for the gov't plan, it will destroy the free market insurance companies, it will not keep prices down (see Canada), and yes 100% of people will have 50% the healthcare that used to exist. Great if you have 0%, but '5/6' who have healthcare get screwed.

Me: I found 2 estimates of uninsured Americans: either 46 million or 54 million. If the US population is 307 million and we average the uninsured # at 50 million: 16% = slightly less than 1/6 of the nation.

# of uninsured references:

1. DeNavas-Walt, C.B. Proctor, and J. Smith. Income, Poverty, and Health Insurance Coverage in the United States: 2007. U.S. Census Bureau., August 2008

2. Chu, M. C. and J. Rhoades, The Uninsured in America, 1996-2007: Estimates for the the U.S. Civilian Noninstitutionalized Population Under Age 65, Medical Expenditure Panel Survey, AHRQ, Statistical Brief #214, July 2008.

Now, if you take out the population over 65 (almost universally covered by Medicaid) then 18% of the country is uninsured.

"Over 8 in 10 uninsured people come from working families"

The Henry J. Kaiser Family Foundation. Employee Health Benefits: 2008 Annual Survey. September 2008.

"Studies estimate that the number of excess deaths among uninsured adults age 25-64 is in the range of 22,000 a year. This mortality figure is more than the number of deaths from diabetes (17,500) within the same age group."

Dorn, S, “Uninsured and Dying Because of It: Updating the Institute of Medicine Analysis on the Impact of Uninsurance on Mortality,” Urban Institute, 2008.

Me: (In my comment above re: # uninsured--I meant to say if you're over 65 you're almost universally covered by Medicare, not Medicaid).

Me: Finally, re: your disparaging comment that people who don't have insurance are simply spending their $ frivolously: The Commonwealth Fund published a study showing that when patients sought to purchase health insurance in the private market, 75% of those families studied ended up not buying a policy either because of cost or because they were denied due to pre-existing conditions.

M. M. Doty, S. R. Collins, J. L. Nicholson, and S. D. Rustgi, Failure to Protect: Why t
he Individual Insurance Market Is Not a Viable Option for Most U.S. Families, The Commonwealth Fund, July 2009.

"Of the 37.8 million people of working age who lacked insurance in 2005, 27.3 million worked at some point that year, according to the Census Bureau figures, which approximate the number of people uninsured at some point in the year. The number of uninsured full-time workers grew from 20.5 million in 2004 to 21.5 million in 2005."

Geri Aston, AMNews Staff. Sept. 18, 2006

Stupid, lazy, good-for-nothing full-time workers!

Mind you, this was 4 years ago. Not getting any better.

Maybe you're worried that a public health plan will put undue burden on small business? A valid concern. However:

"Without health care reform, small businesses will pay nearly $2.4 trillion dollars over the next ten years in health care costs for their workers, 178,000 small business jobs will be lost by 2018 as a result of health care costs, $834 billion in small business wages will be lost due to high health care costs over the next ten years, small businesses will lose $52.1 billion in profits to high health care costs and 1.6 million small business workers will suffer “job lock“— roughly one in 16 people currently insured by their employers."

The Economic Impact of Healthcare Reform on Small Business, Small Business Majority, June 2009

So, comprehensive health insurance reform actually is pro-business.

Person 1:
I will agree with you on one of your points, one area of reform that should occur is in the area of pre-existing conditions.
Your 75% statistic does not differentiate between cost vs. pre-existing conditions. I don't buy the cost arguement, you look at people below the poverty level and the majority of them have cable tv, big screen tvs, cell phones, etc. Sacrifice of the "toys" can easily free up money for buying insurance.
As for small business, cut the lawyers out of healthcare and costs will stay well under control. The government cannot guarantee it will keep costs down any more than private industry, historically it is never successful, and Canada is a perfect example at how costs are not controlled in a way that benefits the people. Also "Small Business Majority" is an Obama supporter, if they were truly representing small business, they wouldn't be donating money to support political parties. I think Arensmeyer would back up any recommendations the dems want.

Person 2:
The plan the Gov. is voting on "healthcare reform" is more about taking rights and controlling money. Most politicians voting have not read it! Our system may not be great as is, but adjusting it is FAR better than the "reform". Can you imagine being Punished by the government for paying cash for needed health care that they won't cover because bureaucrats (not doctors) decided that it was too expensive?

The other part is the many costs (taxes) levied on insurance companies along with hoops to jump through will get them out of the health insurance business quickly, leaving Only the Public Option. There is even a provision that won't let you go back to your "old" insurance company if you cancel - you must go with the public option - despite Obama's speeches (carefully worded).

It is all leading to eventual single-payer gov. run healthcare, just like Canada and Britian have - with waiting periods of up to years, just to get a gen. practitioner, among many other problems!

Person 2:
Healthcare coverage for everyone is a nice idea, but just look at the school systems (public vs. private). More and more money but less and less efficient. The "war on poverty" has not eliminated poverty, or even significantly reduced it. "war on drugs", etc etc.. Government involvement does NOT make anything more efficient. Obama (and congress) claims he can bring down costs. He is not in the business of insurance or health care finances, but he knows how to cut costs where all others in the business have failed?
Just think about it.

Person 2:
The proposed bill (if voted in) will open your medical records and financial records - and Require you to give credit info and bank access to the gov so they can extract payments for medical services.
Think of the eventual controls that a single payer (socialized) system will have. They will control your day to day habits, such as what you eat, smoking, drinking, driving, grilling, sleep? you name it - all under the idea that it Costs money for you to be unhealthy or risky!

This CNN/Fortune magazine article is pretty good on the basics:

Person 1:
An idea I read online this morning is a system that provides low interest they have for college students.

Person 2: If I had to pay for a medical procedure for someone in my family, even now, that was not covered I would not hesitate to borrow or mortgage or sell whatever I had to... Interesting idea.

Person 1: There was a lady complaining about how private healthcare was rationing a cancer treatment that her husband was trying to get. She felt that he may have lived had they not spent so much time fighting to get treatment approved by their healthcare company. My thinking is if you are going to die, you get the treatment and worry about how it will be paid for afterwards.
Another gov't comparison, the IRS. Press 1 because you owe them wait. Press 2 because they owe you money...I hope you like Muzak.

Person 2: the current legislation does not block you from returning to your previous insurance if you so choose and will not give the gov't access to your financial accounts. If it's in the bill, I'd ask you to point out where.

Re: mortgaging the house to cover medical bills--probably won't work.

"According to another published article, about 1.5 million families lose their homes to foreclosure every year due to unaffordable medical costs."

Robertson, C.T., et al. “Get Sick, Get Out: The Medical Causes of Home Mortgage Foreclosures,” Health Matrix, 2008.

Re: the article you mentioned:

--the mandated minimum benefits would be present because otherwise it's a race to the bottom. mental health coverage, substance abuse, Pap smears, mammograms, vaccines, etc are all essential services. I do agree, though, that you have to draw the line. These services could be based off the United States Preventive Services Task Force (USPSTF), which recommends evidence-based services.

--the idea of community ratings is based on the concept of cost sharing; I agree that it's a challenging set-up, but cost sharing will be needed. Remember that the healthy 24 y.o. could still end up having an accident or injury or a retinal detachment and require 10,000s of medical care (which currently has to be absorbed by the system)

--I guess it might threaten HSAs and high-deductible plans. However, those plans would not be excluded. Also if a public option has a lower deductible and better coverage (and is competitively priced) this doesn't seem so bad.

--In terms of keeping your plans vs. offering approved plans: is it really so bad to require insurances to cover certain essential/necessary services?

--The medical home is not a gatekeeper/HMO model. A complete misunderstanding of the model. The patient-centered medical home (PCMH) would have a primary care physician acting as your principle physician and coordinating and tracking care you get elsewhere. Rest assured--the physician groups promoting the PCMH do not like gatekeeper models; the idea is to ensure that patients have access to needed care and that physicians would be reimbursed for quality care, not for denying care.

--I'm curious about "the flexible, employer-based plans" that the article mentions: I guess they mean the current system, the one that is failing millions and limits the profits and growth of small business?

What value are these five freedoms to those who have no access to care?

Okay so I do not have a flat screen TV or cable or a fancy cell phone (mine doesn't take pics and is black and white and was free with my monthly plan) nor do I spend tremendous amounts at the bar or on "toys" or any of that. I live a rather modest life style and still can't afford health insurance. And I have to be honest even if I could afford it I'm not too keen on paying such high monthly premiums only to be dropped at the discretion of or denied care by a giant corporation that is so money hungry that simple compassion is no longer part of the equation. An example of this is SO's plan at work. Her co-pay went from $15 to $20 per visit to the first $3,000 having to be payed by her in turn discouraging her from seeking even basic health care because she simply doesn't have the cash to drop. A change for the worse in my opinion only serving to further discourage the "insured" to not use their benefits while the fat cat keep getting fatter by collecting monthly from her employer.

I don't think my situation is the exception here. We aren't talking about 20 somethings that could perhaps tighten it up and spend their cash more wisely. We are talking about everyday folks who are just a layoff or major medical situation away from being completely without health care. Situations can change quickly and even if you've got it good right now it can all be gone with one bout with cancer or one major car accident.

As far the low interest loan goes ... really? Let's put folks even further into debt by making them pay interest for being ill. That's if they are even still able work to pay off the loan to begin with. Chances are if they can't afford insurance they can't afford another loan. Also I see that as another way for the already engorged financial institution the get even fatter by preying on the sick.

Hear, hear!

A lot of evidence showing that cost shifting to patients reduces use of medical care. Even though the premiums are still being paid.

Friend: Person 2 I don't think you are alone in the thinking that you would do anything you could for a family member in need. Most people would. Some people don't have a house to mortgage or much to sell to make a huge impact on a looming medical bill. I know too many people who are working hard just to make to the next week hoping nothing serious happens to them. A good portion of the population is just a paycheck away from being homeless much less insured.

"My thinking is if you are going to die, you get the treatment and worry about how it will be paid for afterwards." – Person 1

Correct me if I'm wrong but it isn't up to her to get the treatment or not. I'm sure she would have done just that. Sad thing is doctors seem to be bound by the HMOs and if it not approved it doesn't get done.

I'm just saying is so terrible to have some compassion for your fellow human being and act like other civilized countries and provide at least basic health care your

"A recent study found that 62 percent of all bankruptcies filed in 2007 were linked to medical expenses. Of those who filed for bankruptcy, nearly 80 percent had health insurance."

Himmelstein, D, E., et al, “Medical Bankruptcy in the United States, 2007: Results of a National Study, American Journal of Medicine, May 2009.

Person 1: Life insurance is much the same way. You pay in, and if you don't die while the policy is in affect, you are out the money. You choose to not pay for insurance because you don't think it is worth it, then it is you who takes the risk. Society isn't responsible for paying just because you don't think it is a good return on your investment. Neither is any other kind of insurance that you buy unless your number comes up.
Making the insurance companies the villains is not realistic either, neither I nor Kristen have ever been denied treatment for anything, she had half her lung removed and the insurance company didn't give her any issues during the whole process. America was built on providing services and making a profit from it. Everyone who has 401k retirement plans has ownership in those insurance companies, that profit is shared by millions of shareholders.
I totally support the charging of co-payments. People abuse the system when there is not consequence, this is one of...

Co-payments are one thing, but a $3000 deductible (or a $10,000 deductible) basically means you will get no health care unless in a crisis. No preventive care, no check-ups, no addressing problems early on before they explode.

Person 1--I agree that society shouldn't pay for people's decision to defer health insurance. Fact is, we all pay every day. Costs are simply shifted to everyone else, with higher physician, hospital and insurance charges to those who are paying into the system.

Person 1:
the many failures in the Canadian system. If obamacare makes it through, I would hope someone has the wisdom to incorporate co-pays.
As for everyday folks, 5/6 people (to quote Mark) have insurance, 260 million people. They manage to pay for insurance, or their companies pay for them (can't be any of those big businesses out to make profits only for themselves).
I'm sorry if you choose to not pay for health insurance for yourself because you don't think it to be a good value, but I shouldn't have to pay more taxes for your choice.
I feel sorry for those who have been laid off, if obama spent the stimulus on job creation instead of bailing out everyone who gave him election contributions maybe the unemployment issue would reverse. COBRA is available to them, a perfect example of how crap government options are. A friend of mine who was laid off, her COBRA would have been $850 a month, she called Anthem, $325 a month.
As for the poor, the poor have Medicaid paying for healthcare.

Medicaid: successfully providing preventive care, vaccines, etc for underprivileged children.

Approx 50 million patients uninsured. I couldn't produce a #, but I would wager that most of them would like to have health insurance.

Me: Re: employer-provided health insurance:

Rapidly escalating health insurance premiums are having a profound impact on
business operations:

· The surge in health care spending over the last five years is a drag on
economic growth.
By cutting into operating margins, high health insurance premium costs are
reducing the capacity of businesses to grow by investment in research,
capital spending, product development, and marketing.

· High health insurance costs slow the rate of job growth by making it
more expensive for firms to add new employees or retain existing

Larger firms during this period of high health insurance inflation have been
reluctant to add new jobs. Smaller firms have been experiencing larger
annual increases in premiums over the last five years (15-20% annual jumps)
compared to large companies, making it more difficult to create new jobs1.
Health insurance costs are the fastest-growing business expense for

Just because you haven't been denied yet doesn't mean that it isn't happening to thousands everyday. I also didn't say that I choose not to pay. I said that I am not too keen on the idea that I could be dropped or denied care at the discretion of the insurance company who clearly has profits in mind before patient care. I completely understand that I take a risk everyday by not being insured. There is still a risk even if I were that I would be die at the hands of the insurance companies. Or just because I turn 64 I am dropped because of my age only to then have to pay even more just to maintain coverage all of this at a time when I may need it most. It's just dirty man.

(quick aside re: Canadian or UK health care: for all the issues that patients have w/ those systems--and there are certainly issues--no serious political movement is underway to undo the systems. They have been too successful at providing needed care.

Delays for services and for elective surgeries do happen, and the UK and Canada admit that. But patients can receive needed care.)

Person 1: I don't know about your finances, but I don't doubt the majority of people without healthcare could come up with the money to pay for insurance if they made some sacrifices. Maybe they have to work more hours at their job. Maybe they need to go back to school and get a better education so that they can get a better job that pays benefits. There is a certain level of responsibility people need to take for themselves. The government was not meant to be a babysitter for sheeple.
As to Marks statement about what the current legislation says, it has been written so vaguely at this point so that after it passes, it can be interpreted as the government sees fit. Ultimately the government plan is to expand control over the people of america, which means everyone will be forced into the public option. This has been well documented on the internet by independents.
Health Matrix? are they legit?

Person 1: Hey if the plan was so great it would have been passed already. He has the house, he has the senate...we can all agree that reform of the system is required...but obamacare is not supported by the majority of americans, is not even supported by many of his own party. He needs to back off and work on each piece in a bipartisan way that is very open to the public. This bill is not about helping americans, its about government control and who gets the money.

Friend: Yes we can agree that reform is needed.

Me: Part of the reason that reform is being slowed down: untruths told by opponents. Death panels, unplug grandma, etc: all shameless lies. Rather than have an honest debate (like we're having here), the sound and fury has drowned it out.

Politics of division: make sure that enough people get angry over things that aren't true, and you might drown out the potential good to everyone involved.

Me: If opponents to reform have a better option, I'd like to hear it. High-premium catastrophic plans and health savings accounts: not going to cut it.

Medicaid is only available to some poor adults--it depends state to state. Virginia is 47th in the US in providing Medicaid to adults: you could be homeless, on the street, eating out of soup kitchens and penniless: not good enough for Virginia.

Me: Person 1: in terms of "sheeple": how would you address the young adult who has a high school education, no money for college (and no role model to encourage higher ed), works a full time job at minimum wage ($7.25 per hour) and has no choices? Just supposed to work harder, I suppose?

If you make minimum wage, work 8 hrs a day, 7 days a week for 52 weeks: you will make $21,112 before any tax or deductions. Considering that the average employee's contribution to their health care premium is over $3000--how on God's earth can this work?

Person 1: There is truth behind the death panels and unplugging grandma...the people obama have working on his healthcare plan, the czars, all believe in eugenics.
"When implemented, the complete lives system produces a priority curve on which individual aged between roughly 15 and 40 years get the most chance..." E. Emanual
"Saving the life of one teenager is equivalent to saving the lives of fourteen 85-year-olds" P. Singer
obama said to judge him by those he as around him.
This isn't lies, read up on Emanual, john holdren, and the rest of the czars who shouldn't be where they are today...they were not elected by the people.
People aren't angry because they want to cause disruption to town hall meetings. People are angry because the government doesn't listen to the people any more. If you think obama is any more for the people than Bush was, that is a farce. Both parties need to go, and that is where americans are now starting to look.
The republicans do have a plan, the lib media
likes to say that the republicans have no answer, that they just say no, no, no...well they do...

Person 1: I went to college with no money. Millions of students out there right now go to college and will come out with debt...obviously they don't have money either. Yet they go. The work hard, take on part-time jobs to put themselves through school. There is no excuse, just a lack of ambition. Aww...poor ambition-less people...lets give them free health-care.
The solution to minimum wage jobs is to not work at them. Times are tough, you take a minimum wage job to put food on the table, and you continue to hunt for a better job. Maybe you take one college course a semester. Maybe you live with 3 other people to share costs to afford this. Regardless, you make sacrifice. Society doesn't make the sacrifice and provide you with everything for free, the individual needs to make the sacrifice to better his/her own life.

Person 1: Your example, $3000 is a tax deduction, so really it will only cost about $2000. You share a rented house with three other people so your rent is 1/4 what it was. You take a college class two nights a week, I'm sure at $21k a year you qualify for some assistance, at the very least a student loan which you don't have to pay back until a later date. You don't take classes like art appreciation, or african american history...they don't get you a job. inch by inch you work your way out of the pit you allowed yourself to get into. I didn't say to move out of your parents home when you finish highschool and try to live on your own working at McDs. There are consequences to being a schlump, and it isn't the role of society to reward it with free life enhancement. Responsibility starts with the individual.

Person 2: Mark, The bill uses the IRS to gain info and to enforce penalties and taxes. pages 195-196, SEC. 431 of HR3200 states that the IRS will provide taxpayer info for the purposes of Health Insurance Exchange Subsidies (Higher cost to people with more money): Identity, filing status, family members, adj.Gross Income and anything else the secretary sees fit. The employers are also required to provide info on request.
Here is the link to the Actual Bill:
It is not easy to read, so good luck.

Person 2: EVERYONE: I wish that everyone could get the absolute BEST healthcare. [Mark's wife] was obviously upset with the system, but she needs to look at the doublespeak about the proposal without emotion because this proposed bill is NOT the answer.
This is bad politicians using a vulnerability to TAKE from the people, not to give us anything. Making an ok system into a Terrible one will only cause more hurt and cost - even if the politicians are acting like they care.
And our system is ok. Just ask the droves of foreigners who come here for our cutting edge healthcare.
Gov. sponsored research produces less than 5% of the innovative drugs and procedures, where 'greedy' pharm companies provide all the rest. They are not the bad guys.

Person 2: We are not in a crisis as the media and politicians want us to believe, "Hurry we have to pass this awful healthcare bill before its too late"!
He is following in the Clintons template of 'make a crisis, then propose a big Gov. solution, pass the bill and then it is all better'. Funny how suddenly the media would drop the 'crisis' and onto the next one. This is a slow problem, despite the chicken little media.
When politicians are in a hurry to pass something, THAT is when we need to really examine!
Happy reading!

Person 2: Oh yeah, I almost forgot...We have had a high deduct. insurance with HSA for over 3 years. Yeah it is annoying to try to get through the deductible, but it is great for catastrophic events. AND all maintenance (checkups,basic Gyn etc.)is covered with $0 deductible from day one!
The GOOD part is that it is a little cheaper than HMO or other plans and you put the difference into the Health Savings Account pretax. When you go to the specialist etc. you pay out of that acct.. What you do not use that year, if any, is your money next year etc. If you are healthy, you build up a year or more of deductible and then the yearly is low and you are ready for bad events if they come (Janet). The idea is that YOU pay for care so you are more careful - reducing Unnecessary use of insurance money for small stuff - reducing costs for EVERYONE. I think it could work if given a few more years! NOT as painful as people think!

Me: Person 2:
--The gov't using IRS records they already hold is clearly NOT the same as the gov't having unfettered access to your bank account (as you stated).
--I'm tired of those who claim are system is "ok". It's not. Working in underserved communities w/ patients who struggle for access, I assure you that it is not a functional system.
--PhRMA companies buy up large amounts of gov't funded basic research (NIH, universities) and cherry pick the valuable bits and sell it back to us at great increases. Also, a lot of PhRMA "research" is to produce "me-too" drugs that offer little to no extra value.
--HSAs and high deductible plans can work--if you have enough $ to fund the HSA and cover the deductible. If you don't have either--and may won't--you're just as screwed as before.

Me: Person 1:
--Please, come to South Richmond and let my patients and their families know how easy it all as. Just work harder, go to college, and you will be well off! If only the people I care for could see how simple the process is. I assure you, with every fiber of my being, it is NOT simple. It can happen, but for many families and young adults it is not feasible.
--Good to see your answer to the cost of the premium is to make sure you have roommates to share the rent. Another high-level solution.
--I think we can tell what you think of these patients--my patients--by your language. "sheeple" "schlump" "There is no excuse, just lack of ambition." Do you have any concept of what it is like to be poor in these United States?

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