Public Option

I know a guy who was in a video...

Toons

In a comment on my previous post, a series of slides is recommended. I like the cartoon above even better. In simplicity there can be great truths.

Retort

Sooner or later, in any discussion of health care reform (to the extent that screaming and fear-mongering can be gotten past and actual thoughts exchanged), the issue of tort reform is raised. On that subject I'm of two or more minds. Neither a student of the various proposals nor particularly well-versed on the veracity of claims and counter claims about tortophobia adding to costs of medical care, I can only speak based on personal experience. Which is why I'm multi-minded. I've seen good and bad. I don't think I altered my practice style to avoid malpractice suits, but I can see why people would.

The central issue is this: there's a difference between malpractice and adverse outcomes. Most certainly, the one leads to the other; but the other does not imply the one. Were that distinction properly made and encoded in the law, the rest of the issue would become moot. If malpractice suits were about bad care -- actual errors, poorly thought-out diagnoses or treatments, willful neglect of patient needs; that sort of stuff -- I'd have no problem with them.

I was raised among lawyers. I've lived in their dens, eaten their food, learned their language. I agree with their claim that malpractice suits have, over the years, led to improvement in care, institution of protective procedures. And I absolutely agree there are bad doctors out there; lazy, lacking in judgment, in it for the money. Drinkers, drug users. Representing an overwhelmingly small minority, they nevertheless give us all a bad name; they are the cause of and the justification for the worst views the public has of us.

But, unlike the guy struggling to fix my freezer as I sit and type this (peering occasionally at what he's doing: my home improvement skills have largely osmosed from such viewings), I dealt with soft stuff. Every freezer of this type is exactly the same; the wires, the machinery, the outcome if you plug x into y. Not so of us humanoids. (I'm not saying what he does is less important; we're having to get along without freezing tonic cubes for our G and T's [a trick I highly recommend to anyone so inclined]. Or, judging by his grunts and mutterings, any easier. Just more predictable.) If he makes the correct diagnosis and replaces the parts properly, the outcome is the same for the same problem, over and again, on every like freezer. I've had some sub-optimal outcomes, despite (take my word for it, okay?) doing everything right. Not often. Not, thankfully, catastrophic. But the possibility is always there.

I've been sued, and I've written about it. It's humiliating, frustrating, depressing, and anger-inducing. I'd say that's entirely because of my certainty that in no case was malpractice, as I understand the term, committed. On the other hand, had I ever done something (or failed to do something) in a way that fell into that category, the last thing I'd want to do would try to defend it on a witness stand, nor try to prevent the patient from being compensated. Patients need a mechanism by which they can be protected from errors, and their injuries redressed. What form that takes is a complicated subject. The current system, because it fails to separate bad outcome from errors in management, isn't the proper mechanism. It wasn't my intent, in writing this, to suggest solutions.

My point, at last, is that I don't think tort reform, per se, will have much impact on the total cost of health care. Reducing errors will. Addressing inefficiencies and variations in treatments among doctors will. To the extent that docs order tests to cover their legal asses, such behavior would be reduced, asses covered, if there were guidelines that indicated when such tests were medically necessary and when not. It's true that there were times, when deciding a course of action based on clinical judgment alone (diagnosing appendicitis without a CT scan or ultrasound is a perfect example; taking a patient with a rigid abdomen to the operating room without the delay of additional testing is another), that I felt a slight breeze on my backside. Many docs are unwilling to do it; partly out of fear, but partly, also, out of being trained in the era of judgment coming in pixels. I guess you can't legislate judgment, but guidelines would help.

And yet it seems there's no discussing it without raising the specter of rationing and death panels. When President Obama suggests that investigating what works would save lots of money and improve care, he's exactly right. That's where the big bucks are spent, and wasted. Addressing it would solve much, including the need for tort reform.

The political party who has argued for reducing Medicare since it began, whose most recent candidate ran on cutting it, has now, for pale political reasons, resorted to demagoging attempts to do just that, as fascist terror. Without diminishing service at all, huge amounts of money could be saved by doing exactly what Obama proposes. Surely there are a couple of Republican senators and representatives who know this. But, clearly, the resistance is not about effective reform. It's about politics, and defeating the party in power.

The public be damned.

Stupid

Uuggggghhhhh.

Sorry.

I feel dirty, I need a shower, I may have to kill myself. Where are the death panels when you need them?

So Jon Stewart interviewed Betsy McCaughey last night, on The Daily Show. She's the one credited with raising alarms about the dastardly implications in the health care bill regarding end of life counseling. "Death panels," evidently, wasn't her exact term. "Disgusting," is what she said she wrote in the margins when reading it.

There was a point to which she kept returning (in between quite amazing dramatic gestures to the audience -- the kind when a stand-up comedian goes, "Am I right? Am I right? Huh? Huh?"). Medicare reimbursement is increasingly tied to performance standards, and it's an issue about which I've written a bit, and which, in its execution, is potentially problematic for all doctors. Nevertheless, her interpretation regarding end of life counseling was utterly, idiotically, cosmically ass backwards. Can you get it that wrong by mistake? Or must you be a willful liar? The lady, after all, was Lieutenant Governor of New York for a moment, which likely puts her in the upper four-fifths of the population in intelligence.

Doctors, she said, will be reimbursed, in part, based on the percentage of their patients who are given end of life counseling. Okay. And, she said, it will also depend on the percentage of cases in which the wishes were carried out. It's at that point that she went off the rails so grandly that, had I not been paralyzed with disbelief, I'd have reached for the remote. And shoved it up my nose. Aiming for my brain.

Her interpretation -- this former politico and self-styled patient advocate -- is that doctors get dinged if their patients change their minds. Really. That's what she said and, apparently, believes. (Okay, she may not believe it: she is, after all, a Republican hack trying to derail health care reform.) You sign an advance directive, that's it. No changes. Any doctor who allows changes gets penalized by THE GOVERNMENT. The lady is an idiot. And, sadly, Jon Stewart didn't call her on it.

Here's the thing: advance directives are for the time when you can no longer make your own decisions. By definition, that means as long as you have the ability, you can change your mind any time you want. In the hospital. In the ICU. Anywhere, anytime. Advance directives are not in effect until you are no longer able to express your wishes. What the bill is doing is making sure doctors follow the patients' expressed wishes when they're no longer able to express them. If a patient has said they want everything done, the doctors must do so. If they've said they don't want to be put on breathing machines, the doctors must honor that request.

It's about following the patients' request. It's about protecting the wishes of patients. I repeat myself. But the lady blew my mind. She couldn't understand her way out of a paper bag.

So this is where we are. This is the level of debate. In a matter as important as this, it's really appalling and disheartening to watch. It's not as if the issues aren't worth discussing. Tying reimbursement to adherence to certain standards is a tricky issue. But if we're going to have the discussion, let's have it with at least a toe still attached to the fundaments. Same with advance directives.

As long as people like that lady get air time without proper rebuttal (in fact, as long as idiocy that deep gets air time at all), we'll never have the kinds of discussions that we need. And deserve.

Bureaucrats

Among the many themes of dissent which have gained traction in the health care debate is the canard that we don't wont some government bureaucrat between us and our doctors. Funny thing about that: the only payer entity with which I never had a problem getting authorization for care was Medicare. Here's the sort betweenness I routinely encountered from private insurers:

In the fine print of nearly every private plan are exclusions for "pre-existing conditions." Okay. You had breast cancer, now you can't get any insurance to cover issues related to it. Fair enough, right? Guy's gotta make a buck, right? I mean, it wasn't their fault you got it, right?

But how about this: more than a couple of times I had patients with colon cancer who were denied coverage because of a previous history of.... hemorrhoids!! Yes. Hemorrhoids. Similarly, people who'd had, say, a rubber band placed for hemorrhoids -- a two minute, hundred buck outpatient procedure -- could not get future insurance that would cover ANY disease of the intestinal tract. Band on your butt, screw your stomach. Exit your esophagus. Not, I suppose, that a private insurer has to have any reason for something like that: their goal, after all, is to NOT spend your premiums on your care. Message: if you have hemorrhoids, live with them, baby.

There's more. Many patients of mine whose gallbladders I removed were informed by their insurers that they'd no longer be covered for any disease of their internal organs. A lot of territory excluded, that.

And, as everyone knows, if you lose your insurance because you lost your job, and if you've had any sort of serious illness, you are simply SOL finding new coverage. Imagine the frustration, as a physician trying to help, of dealing with insurance companies as they apply their exclusionary rules. Their rationing. Their death panels.

Yet there they are, those sign wavers, insisting that it's Hitleresque to demand changes in all this. For his attempts, Obama gets branded a Nazi. While the right wing screams, the left wing caves. Advance directives? Gone. Public option? Fuggeddaboutdit. Studies to find out which kinds care work and which don't? Nuh uh. Too... too... I don't know... logical?

I repeat: Medicare, which is in my mind the best paradigm for a public plan, NEVER refused coverage for cancer (or any) care. Not even for grandma. Those government bureaucrats? Not a problem. It was, as anyone might predict, the "market forces" guys who stood between me and my patients.

There is, of course, this little paradox: those people who hate government intervention generally are quite happy with Medicare. Those who point out it's running out of money are those most likely to recoil at suggestions that we ought to find ways of saving money in the program. The ones who think Medicare is shameful socialism would holler "they're trying to raise your taxes!!!" if anyone suggested premiums be scaled to one's financial status.

Is there a more clear example of why we're failing as a country than the debate over health care reform, and the arguments over Medicare in particular?

One Small Step

If anyone here reads Andrew Sullivan's blog, runs across this post, and finds anything familiar in the writing, there could be a reason... Anonymity doesn't do much for blog traffic, but any way to spread the word...

The word, of course, is the extent to which health care reform is aimed at doing things that will be helpful. Even -- especially! -- for those very people who yell and weep and carry guns to meetings, spouting verbatim the insane ravings of Glenn Beck and Sarah Palin while having not the slightest idea what they're really talking about. "Keep government out of Medicare," they say. "Socialism."

The "socialism" trope may be the most laughable (were it actually funny): all of the proposals on the table fall over themselves to maintain the death-grip insurance companies have on us. (Talk about "death panels!" What is it when insurers deny coverage?) None talks about nationalizing the health care delivery system. Not even Medicare is socialism. Single payer -- which in my mind is the only option that makes sense, and which, like Medicare is NOT socialism -- is, clearly, off the table.

There's no possible health care reform package that will satisfy everyone; nor, given the way Congress works, one that will be free of pork-fat, undue complexity, or unexpected consequences that will need to be addressed. Still, what the various iterations seem to have in common are regulations to prevent rescission, to create portability, to remove limits on lifetime coverage, to banish denial for pre-existing conditions. Is it really possible that any of the screamers are against those reforms?

Cost is most certainly an issue, and there is a multitude of ways to address it. Starting, from the doctors' part, with the sort of thing mentioned in that Andrew Sullivan post. Only the surface has been scratched there. And, long after I'm dead, assuming the country still exists, I predict single payer will have come to pass, and people will be glad for it. Even the gun-totin' America lovers.

Signs at the meetings -- ignoring the ones showing Obama as Hitler, a completely ludicrous meme hatched and promoted at Fox "News" (sic) and ingested without chewing by its self-pitying listeners -- point out that Medicare is "bankrupt." While not yet true, it's a point worth considering. To the extent that it hasn't enough money, it's not the fault of Medicare, which spends far less on non-medical expenses than any private insurer. It's because of funding. It's because of the holdover idea from the Reaganomics that you can have what you want without paying taxes.

So, what if everyone were covered by a Medicare-like program, and no one paid premiums; or if there were the sorts of premiums and co-pays associated with Medicare? Currently I pay $14K/year in premiums for me and my wife. Would I be happy to have taxes raised in another area, even, say, by $10K/year? Who wouldn't take that trade? By getting rid of the 30% skim by insurers, that math works right away. And by taking seriously -- instead of demagoging as "death panels" -- the idea of finding cost savings in more efficient care, much more than that will be saved.

And yet, they rave and froth. Getting crazier and scarier. Arguing, in effect, for maintaining a system in which their premiums have likely more than doubled in the last ten years, which covers them sparingly, cutting them off when they need it most: sick, out of work. And they are ready to draw weapons over a plan to pay for help writing the very instructions that will keep them in charge of their care when they're unable to make decisions for themselves.

Who'd have thought people so in need of health care reform could be whipped into a froth by people who lie so freely and make easily refutable claims? I remain unable to understand. And bereft of hope.

Rationing. There. I Said It.

Thirty percent of Medicare money, it's said, is spent in the last month (or is it six months?) of recipients' life. It shouldn't be surprising: people who die are generally sick. Sick people -- especially ones that die -- require more care than healthy people, or people who survive an illness. But it gets to the most thorny of issues when tackling health care costs. And it's a perfect example of why real reform is next to impossible: our politicians are too venal and stupid, special interests are too powerful, media are too superficial, the issue it too freighted with grayness, and the public is too easily distracted for there to be a meaningful discussion.

Notwithstanding the truths just enunciated, I have a few things to say. A proposal, too.

Absent having all the money in the world to spend on health care, I think it's fair to say that everyone is in favor of rationing. If all we had was a million bucks, would anyone choose to spend it on ten demented ninety year olds with advanced cancer and a 5% chance of recovery, instead of ten ten year olds with leukemia, with an 80% chance of recovery? So, like the old joke, we're not really arguing about rationing; we're haggling over details. Not to mention the fact that rationing, so loudly decried by the Foxoid among us as possible under "Obamacare" (whatever that is) is already happening with private insurance: of the dozens of plans offered by each of the twelve hundred insurers, how many cover all things for all people with all conditions under all circumstances? How many people get dropped after an illness, or refused in the first place? Wouldn't it be better to have such decisions made in a system open to public and medical input? (Along those lines, here's a pretty good, and humorous, commentary on the reality we currently face, still defended most arduously by the nay-sayers of the right-wing persuasion.)

End of life care presents us with some of the most difficult decisions we make, as families, as patients, as physicians. Likewise the related situation of "futile care." In neither case are there clear criteria to guide us. The exact same operation -- say, bowel resection for perforation -- would certainly be futile in that ninety year old (let's add some heart and kidney disease to make it easier), and entirely reasonable in a thirty year old, even if that person presented in septic shock. In the latter case I wouldn't hesitate for a second. In the former, I would try (and have, many times) to present for consideration the option of providing comfort care only. I won't psychoanalyze myself, but I hated doing operations wherein I felt there was virtually no hope of survival. (Need I mention that I made more money when I did operate than when I didn't? Yet I tried like hell not to, by presenting as candidly and openly as possible what I thought the situation was.) Not every surgeon would have done so.

I was always scrupulous about cost in my practice, from the little things to the big ones. Saving a few bucks on every case by not demanding different suture for every step when it made no difference: it adds up. So does thinking twice before heading down the road to futility. But it's neither universal, nor easy to know the signposts. Ought there to be some guidelines at the end of life, or should it be up to serendipity? I don't want to take judgment out of the equation; but not everyone has the same capacity for it. Which is part of the problem.

I can't back this up with any data, but when their grandma was dying, it seemed to be those who'd been with her the most who were the most able to let go. It was the out-of-town shirt-tail relative who blew in at the last minute who seemed to demand that "everything" be done. In those circumstances when it was insisted I go for the one/million shot, I've wondered if the same decision would be made were the family responsible for the cost.

So here's my proposal, in the context of the brouhaha over the idea of studying what works, and not paying for what doesn't: let's lay the money on the table. If a family wants to go ahead with an operation or other intervention, for which the odds of success are very long, or which is judged ineffective based on research (let's not get into details for now), here's the deal: if it works, Medicare (or is it Obamacare?) pays. If it fails, the family pays. Cash (credit card?) up front. Takers?

I see this health care "debate" as the quintessential test of our democracy. The need for reform is clear; the trajectory is, without doubt, toward disaster if changes aren't made. And yet, here we are, bogged down in disingenuous rhetoric, in overt efforts to stop it for purely political reasons. Trading amendments and concessions to various profiteers like bubble gum cards. Watering down the most serious proposals like potted plants. Media covering it lazily (all of them), sensationally (most of them), or entirely falsely and politically (you know who.) Advertisements and talking points designed to frighten, inflame, misinform. Citizens unwilling to think about it carefully. Faced with a crying need and a failed future that is not seriously in doubt, we seem unable to have serious debate, to argue on the merits, to legislate the sorts of changes that are needed. How can other countries have done it, and not us? And what does it say about our political system?

Can a nation of half-educated people, unable or unwilling critically to evaluate data; a media industry degenerated into selling soap over meaningful reporting -- and, worse, owned, operated, and scripted by people with overt political agendas; legislators elected for their dogmatism above all, the less serious the better; political parties more interested in power games than doing right -- can such a political system meet real and serious and undeniably needed challenges, or not? We'll know pretty soon. In fact, I'd say we already do.

Gotcha. Not.

From a commenter:

I think as long as Obama admits that he wouldn't subject his own family to the limitations he proposes for everyone else, his plan will fail.

Regards,
A Better Angel

I assume he/she refers to comments by Obama during the recent ABC News "town hall" held at the White House, in which there was this exchange, edited selectively in many "news" sites:

"Q: If your wife or your daughter became seriously ill, and things were not going well, and the plan physicians told you they were doing everything that could be done, and you sought out opinions from some medical leaders in major centers and they said there's another option you should pursue, but it was not covered in the plan, would you potentially sacrifice the health of your family for the greater good of insuring millions or would you do everything you possibly could as a father and husband to get the best health care and outcome for your family?

OBAMA: [....] I think families all across America are going through decisions like that all the time, and you're absolutely right that if it's my family member, my wife, if it's my children, if it's my grandmother, I always want them to get the very best care.

Predictably, this has been jumped on by detractors and touted in pretty much the way the commenter did: Obama's plan is good for your family but not for his, says Obama. Since we all love our country and don't wish our President to fail, I'm sure it was just an honest misunderstanding. Like my snippet above, most of the criticism leaves out the President's next sentence:

...but here's the problem that we have in our current health care system. Is that there is a whole bunch of care that's being provided that every study, every bit of evidence that we have indicates may not be making us healthier.

Which, of course, is the most important thing he said.

First of all, the wording of the question was, well, questionable. It's a false premise. It implies there are "plan physicians." It implies that treatments recommended by "medical leaders in major centers" wouldn't be part of "the plan." There's simply no reason to think either is true. There isn't, as far as I know, a proposal to separate "plan physicians" from others. And there most certainly is NOT an implication that therapies that carry the weight of "leaders" in "major centers" would be off the list. The opposite is true.

And it's exactly the point Obama was making. But it's neither sound-bite worthy nor easily explained; and, as we've seen, it's very much selectivequotable and outofcontextable. (Incidentally, that he got tough questions like that sort of shows the right wing fury (ie, Fox News) over the "unprecedented access" ABC was granted was so much hot air...)

Among the many ways to control health care costs is to establish what works and what doesn't. As I've written, severally. Patients and families, as President Obama said, face such dilemmas all the time. "The very best care," he said. Exactly. Would that it were always as easy as the example that the questioner (a doctor) gave, in which there would be general agreement from the creme de la medical creme. (It'd have been better if Obama had pointed that out: again, showing the session was hardly planned and canned.) On the contrary. It's often a decision involving futile care: the operation with a one in a million chance of helping; prolonging life in the ICU; trying dangerous drugs with virtually no chance of helping. Or -- and one assumes this would not be covered, since it currently isn't -- heading to Mexico (or, like Farrah Fawcett, to Germany) for entirely bogus treatments.

These sorts of things are, in my opinion, way too difficult for our political system, as currently manifested, to handle. Rather, at best (if that's what to call it), we'll get a plan to pay for insurance for those who can't afford it, leaving the excess costs of insurance untouched and not tackling effectiveness in any meaningful way at all.

But, perhaps, we could at least do it or not, without deliberately taking out of context what the President said.

Yeah.

Right.

Progress

Kodak announces it will stop making Kodachrome, and I don't care. I'm down with digital. I mention this so as not to sound like a Luddite in the following paragraphs.

I don't know if we'll get health care reform or not; nor, if we do, whether it'll be in any way significant. Unlikely. Meanwhile, there are examples in surgery which illuminate one aspect of the problem of skyrocketing costs. Technology, in a word. Technology as selling point; technology as sexy; technology for its own sake. Unlike my digital camera, medical technology includes much about which it can be asked: "Huh?"

Previously I've expressed an opinion on "NOTES" surgery. More recently, I opined about robotics. I've also described the way I did gallbladder surgery through a single small incision, as an outpatient, with recovery times the same as laparoscopy, at significantly less cost. The latest hotness is single incision laparoscopy. The linked article describes a half-inch incision. Maybe. What they stick in is this baby, which, according to what I've read, requires a 3.5 cm incision, or about an inch and a half. In total, that's at least half again the total length of incisions made in standard laparoscopy, for removing the gallbladder, anyway. No less painful, one would assume; although the pain isn't that great, usually, in either case.

Now I must admit I've neither seen nor done it. As I've said about laparoscopy and robotics, it's fun to do, and I have no doubt this wrinkle is fun, too. So far the operative times are longer than "regular" laparoscopy, which equates to more expensive. In that article, the recovery is no different from standard stuff. Without knowing for certain, I'd say there are also issues with exposure and perspective, since the camera and tools are all coming in at the same angle. That, one might predict, adds up to higher risk. Time will tell.

The other day I read an article about a kid who had his spleen removed this way. Nice scar in the belly button. Humbly, the surgeon says it's not about fame, or being first. It's about preventing the trauma of a scar. The cynic in me says it's about referrals. But what do I know?

Here's my point, about which time might well prove me wrong. In my opinion, NOTES, robotics, and single-incision laparoscopy, so far, have one thing in common: dubious value compared to other options, more expense, and possibly more risk. For what? In the case of robotics, marketing. In the other two, marketing and cosmetics. These are examples, it seems to me, of therapies which, if effectiveness research becomes pervasive and meaningful, may well be taken off the list of covered procedures. And then what? Well, for one thing, the disconnect between reform and having it all will be illuminated. Maybe, rather than disallowed (which, realistically, is unlikely) the extra costs of these operations will need to be paid by the patient. Surgery which is purely cosmetic, after all, is never covered by any payers.

In any case, this is the sort of thing that doctors and patients alike will need to face if and when real cost control is effected. It won't be pretty, even if the data are there. Because when have data had anything to do with anything?

Reform School

What if every American of a certain age knew they had medical coverage; what if all they had to do was register? What if, in this program, they could choose their doctors, who would be privately or self-employed, not government workers? What if the hospitals they went to were the very ones they go to now? What might you call such a program?

Medicare.

And what if this coverage were extended to all Americans? What might you call that?

Single-payer.

For those who have insurance, the only thing different would be the paperwork: it would become far less, or cease to exist. Neither the care nor the people and places providing it would change. From the point of view of the consumer, I simply see no advantage to having multitudes of companies standing between them and care, sucking money out of the system which goes into the pockets of executives, investors, and into the paychecks of tens of thousands of workers filling out forms at both ends of the transactions. No one -- NO ONE -- is talking about a national health service, ie, a plan whereby everyone goes to government-run hospital, staffed by government employees. (Well, that's not entirely true: several in Congress are comparing the so-called "public option" to the Department of Motor Vehicles. But that's completely disingenuous. The comparison, as I've said, is to Medicare.)

I'm not saying there are no arguments to be made against that "public option," or to a single payer system that enrolls everyone. Many doctors worry about losing control over reimbursement, having to accept ever-decreasing payment for service; they fear the monolithic. It's not without reason, or precedent. Funny thing is, as I've said, Medicare is already pretty much calling the shots: insurers largely take their reimbursement cues from them. Moreover, I've seen several situations in which an insurance company plays docs against one another: fearing losing their patients who are covered by a particular company, they cave to the demands to accept lower fees. It works particularly well in towns that have several competing physician groups.

It's also been a repeated theme of mine that endlessly cutting reimbursement to "providers" is a policy doomed to failure. We're about as low as it can go, if there's an expectation that smart and dedicated people will take up the caduceus. Rather -- and President Obama at least speaks the words -- the real savings will be in identifying those treatments that are the most cost-effective; and, even more importantly, finding those docs that provide the best care at the lowest cost and spreading the word.

The concept is ripe for demagogurery. "Do you want the government to get between you and your doctors?" they ask. As opposed to, what, a high-school grad in an insurers cubicle, telling the docs what they can and can't do? Like it is now? (In the linked article, it would also appear some want to prevent -- by law!! -- research into what treatments work best. To me, that's pretty hard to explain. How awful could it be to be told you can't have one operation that has been shown to be inferior to another?) (Okay, I recognize the potential problems. But if an idea is a good one, surely there's a way to implement it with safeguards.)

Reforming health care, it seems to me, is a perfect metaphor for everything that's wrong with our political system. While faintly acknowledging that for tens of millions it's not working, some in Congress nevertheless want only to maintain the status quo. Their efforts, unashamedly, are mainly limited to coming up with loaded (and disingenuous) phrases calculated to obfuscate. Given the complexities, it would be daunting even for legislators committed to comprehensive and effective reform. Would that we had some.

I'd bet very few people feel loyal to their insurers, per se. They may be loyal to their "providers" and to their preferred hospital. (Sort of. I read a study a few years ago that put the price of loyalty at, as I recall, about twenty bucks: ie, if switching docs meant saving more than that per month, it was hasta la vista, dockie.) What is the argument, from the consumers' point of view, of having insurance companies in the middle of the system? Where, specifically, is the value-added?

I fault the whole gang: Republicans, Democrats, and those in the White House. I can think of no reason why single-payer isn't on the table, except for the fact that it has so little support in Congress. But why? Whose goose is being greased? (If that's the term...) If a plan were to provide the same care we're now getting (or, hopefully, better), using the current infrastructure of doctors, nurses, clinics, and hospitals, while costing less by keeping more money in the system, why would that be bad? Because some call it.... SOCIALISM? Might not the result be more important than the name?

Some who've traveled these parts before will know I've made some suggestions. Funny thing: President Obama seems to have read them and bought everything but the single-payer part. He talks about identifying best practices; he talks about a larger role for the Medical Payment Advisory Commission. The latter, of course, is a double-sided axe; how acceptable it might be to physicians and hospitals would depend on its makeup and its responsiveness to reality. But it's the idea that is a good step. Cautiously endorsed.



[Acknowledgment: I know I said recently I didn't want my return to this blog be by way of the politics of health care. But I find myself unable to cast it out. I think I may have to get a little rubble off the desktop before I can find my way back into the mind of a surgeon.]