Happy Halloween!

Halloween is my favorite holiday besides Christmas.

"Harry Potter"-esque magic potion. Total supply cost: $15 or so. Glows in the dark, bubbles, puts off fumes, and perfectly safe to drink. Putting it out on the porch for the trick-or-treaters tonight. Good times. (Photo credit to my highly talented sister-in-law Whitney.)

My family (most of us) love Halloween. My mom being the exception. So, mom, here's a halloween production I think you'll appreciate.

Try JibJab Sendables® eCards today!

Health Care Reform: Summary

Some suggested I should make a short version of this so people will read it. Here it is.

I think that we should scrap the current system entirely, and remake health care reform like this:

1) Personal Health Fund accounts held by the federal government and funded by individuals should replace insurance as the primary means of paying for non-catastrophic health care costs including clinic visits, drugs, routine surgeries, pregnancies, and minor emergencies. When the money is exhausted, basic health services should be funded out of pocket. This removes much of the moral hazard associated with our current system, and gives persons incentive to choose cost-effective treatments (generic drugs, physical therapy) whenever possible.

These funds would be created by pulling tax-free earnings from individual's paychecks. Currently, over $1.5M is spent on health care per person over the course of their lifetime with personal and employer health care insurance premium contributions. Put that back in people's pockets in the form of PHF's that people can use however they and their doctor see fit. Indigent, unemployed, or disabled persons would have payments placed by the federal government through tax dollars so that these individuals are also spending money from a limited, personally controlled fund. By David Goldhill's math, this amounts to $12,000 per year for a low-income family of four if we abolished Medicaid and instead provided the health dollars to them directly.

This system would redefine 'coverage' to include whatever you and your doctor deem an appropriate treatment at a reasonable cost (it's your money, not the insurance company's). It would put competitive pressure on health care providers and hospitals to provide better health care at lower prices, because under this system people have much more stake in what they pay for, and how much they pay for it.

2) A publicly-funded 'catastrophe' insurance to provide coverage for all burdensome or disabling health conditions that are beyond the control of the individual to avoid or fix. Conditions such as systemic lupus, crohn's disease, rheumatoid arthritis, schizophrenia, bipolar disorder, paraplegia, quadriplegia, parkinson's disease, multiple sclerosis, congenital conditions such as heart disease requiring surgery, mental retardation, familial cancer syndromes, cystic fibrosis, severe trauma and others would have coverage from this public fund. Note that this fund would NOT cover avoidable conditions such as heart disease, diabetes, lung cancers from smoking, etc.

3) Private insurance for additional coverage beyond the catastrophe fund, but with restructuring of the current system. Insurers should be able to charge based on individual risk factors for disease that can be controlled by the individual such as BMI, smoking, drinking, illicit drugs, medical compliance, abuse of the ER, unsafe sex practices, and other lifestyle considerations such as diet and exercise. They should not be able to deny coverage based on pre-existing conditions (the financially worst of which would be covered by the 'catastrophe' fund anyway) or on race, gender, or socioeconomic status. This private insurance would cover things like non-catastrophic emergency care, expensive preventable chronic conditions such as diabetes, non-essential surgeries such as hip replacements, and expensive treatments with small chance of success like some chemotherapies for recurrent cancers (first set would likely fall under 'catastrophe' coverage).

Also, most of these insurance covered treatments should require a percentage-based payment from the patient's PHF, thus ensuring that we don't go back to our current state of spending other people's money on health care (again, 'moral hazard.')

4) Tort reform that provides lawsuit immunity to physicians except in cases involving gross negligence. Other malpractice claims would be put before a panel of physicians empowered with the ability to enforce disciplinary actions on the malpracticing physician such as suspension or revocation of medical licensure, remedial training, or fines. Patients injured by medical malpractice would be eligible to receive care financed from the 'catastrophe' fund. Thus, malpracticing physicians are held accountable, and patient's needs are met.

So that sums it up. Under this system, everyone gets access to primary care via their PHF money, kids are covered by PHF money provided by parents, the 'uninsured' would still have PHF money provided by the government as well as catastrophic coverage, overall health costs will go down as people are forced to be cost-aware (limited funds) and providers are forced to be cost-transparent to compete for business. Additionally, Americans would re-learn that being unhealthy is expensive, generating increased responsibility for personal health via financial incentive.

The downside? Huge transitional costs as people are taxed to fund the current medicare system (which would eventually be phased-down or phased-out entirely-- but you couldn't do it immediately and leave non-PHF seniors with no coverage at all) while simultaneously being required to put PHF money away for their own personal health care, resistance from hospitals and drug companies who benefit from the price-opaqueness of the current system, and the unwillingness of the American people to abandon the current system where people with good insurance feel extremely safe. (Because they're not spending their own money if something happens to them.)

Comments? Thoughts?

Health Care Reform: Solutions I like

Background to all of this can be read in my first, second, and third posts on health care reform. Think I'm writing about this too much? I do too.

I've touched on why health care in America is expensive, inefficient, and unfair. Fortunately, as some random guy on the internet with access to free blog publishing should, I'm going to tell the world what I think we should do about it.

And, because I feel like it, I'm going to do it by comparing two systems: health care and transportation.

In terms of transportation, most people in America own one or more private automobiles so they can get around. This isn't a bad place to start when explaining how we should run the health care model. People have car insurance, and people pay for their own gas. People who drive recklessly get penalized for it (assuming they get caught or get in accidents) by paying higher premiums for insurance and/or getting ticketed by law enforcement officers. If you lose your license or can't afford a car you can still get around... you just have to ride the bus. Overall, there's a high level of responsibility in this system. I think that's healthy.

In terms of health care reform, we need to move more towards that kind of system in order to keep the level of quality we have and still control prices, while affording freedom to manage our own health and choose our own doctors. So here's the three-part (and a side-note) system I propose*:

Part I: We should implement a system of personal health funds for every individual as the first-line of health insurance. A PHF would be financial account tied to your social security number, and held by the federal government. These PHF's should be fed from individuals paychecks, tax free. This money can then be used to purchase things that people need for basic health maintenance like medications and doctor's visits, and even minor or routine surgeries like broken bones or getting your appendix out. Dental care and vision checkups could also tap into this fund. When the money is gone, you have to foot the cost out of pocket (though you could still pay for it tax-free).

"That's terrible!" you think "What about the poor people or the unemployed who don't have money to put in an PHF? What about the people with terrible, chronic health problems? What about the people who need semi-emergent major surgeries or have complications like post-surgical infections? What about the elderly who have extreme health costs because of age? What about all of the people with unavoidable and expensive conditions like Crohn's disease? Or those who are born with genetic diseases? There's no way this would work for them!"

Hold on. Take a deep breath. Hear me out, here. We can take good care of them, too. Better care than we do now, I think. Keep reading, and see if you agree with me or not. (No obligation to. If you don't, leave a comment and let me know, eh?) So why do it this way? Because it ensures everyone has access to care, and the means to pay for it if they're responsible with what they have.

If people are spending their OWN money, they're careful with it. They care how much things cost. They don't just want the most expensive or most radical treatment available. It also encourages long-term responsibility for your own health maintenance because being unhealthy is -- as America is learning -- extremely expensive. That's something that people will only really seriously care about if they're dealing with it firsthand.

Conversely, how long do you think it'll take drug companies, hospitals, and high-paid medical specialists to start lowering prices if all of their customers suddenly start asking how much things cost? How many irate patients with large bills would it take for physicians to start seriously considering whether or not they should have ordered all of those lab tests? Not very long, I'd argue.

Some people point to elective, non-covered surgeries like Lasik to showcase this effect. The price of Lasik has dropped dramatically in the short time since the technology was developed largely because providers have been competing with each other's prices. How much does an appendectomy cost at the hospital I work at? I have no idea, and I'd argue most doctor's who work there don't either. We never see the cost of the treatments we prescribe until someone without insurance can't pay for it, or an insurance company balks. That's got to change.

Another benefit of the PHF's is that anything you need is covered -- as long as you have the money for it. This will remove the insurance company's meddling "That requires prior authorization so we're not covering it!" and "We don't cover that because it's too expensive!" cards. If you're willing to foot the cost -- and if your doctor is willing to write you a prescription for you to do so -- it's now fair game.

Part II: Catastrophic coverage for everyone, because it's just not nice to let people who are truly unlucky (vs. irresponsible) go bankrupt for health-related reasons. So what constitutes a catastrophe? Basically, it's a situation that adversely affects your life to the point where you can't pay for it either because you're disabled, the costs of the treatment far exceed what we would reasonably expect the average person to pay, or the preventative costs of any circumstance beyond your control that has high potential to put you in either situation in the future. This covers things like:

1) Mental health issues such as schizophrenia or bipolar disorder.
2) Severe trauma such as car crashes, severe burns, or gunshot wounds.
3) Chronic and debilitating conditions with no known prevention. Crohn's disease, lupus, rheumatoid arthritis, paraplegia, cerebral palsy, multiple sclerosis, and others all fall into this category.

This is probably going to be expensive, but I just don't see another reasonable option, here. The fact of the matter is, a lot of this is already picked up by the general public directly (Uncle Sam pays for dialysis, no questions asked) or indirectly (the uninsured person in a car accident) in the form of hospitals making up for obligatory free care by charging people with insurance more. Besides, coming down with a significantly life-altering medical condition kind of stinks, don't you think? I feel bad enough for people like that to collectively give them a portion of my paycheck.

Part III: Private insurance for everything else, including elective surgeries, expensive or advanced drug therapies, non-emergent complications of common conditions like diabetes, heart disease, and obesity, cutting-edge imaging studies such as PET scans or non-emergent MRI's, and expensive treatments with little chance of success or only marginal benefit such as some types of chemotherapy.

What's the point, you might ask? What good is insurance if true catastrophe's are already covered by the government? Well, a lot, if the cutoff for the government catastrophe insurance is quite high-- say $25,000-$50,000 or so. The fact of the matter is, as a society we can't pay for everything for everyone. It's just not possible to do-- which is why the Europeans ration care. (Which I don’t like the idea of.) So we may need to set the catastrophe insurance level high enough that this type of system is sustainable, and that may mean increased individual risk when compared to a single-payer, universal high-coverage system. It also means increased flexibility, personal control, and broader options available for those who want them and can pay for them. And it controls costs by free-market prices, not by restricting care.

My ideological preference for this is based in the idea that an individual can either be safe or free to choose to do things his or her own way, but not both. One necessarily precludes the other, simply because not all persons will choose to do things safely.

Despite being insured, everyone should be required to pay a certain percentage of the costs out of pocket or their PHF (say 15-20%), and insurance companies need to have a brand new set of rules laid out regarding who they can deny coverage to, and who they can raise or lower rates on. Specifically, insurance coverage should be priced based on the same types of controllable criteria that car insurance is.

Being medically compliant should lower rates, just like drivers with clean records (no accidents or tickets) have lower rates. Having a healthy lifestyle, including avoidance of smoking, drinking, drugs, and high-risk sexual behavior should lower your health insurance rates. Regular exercise and healthy eating should lower your rates as well.

Conversely, rates should go up for people who have high-risk or unhealthy lifestyles. Rates should also be increased for people who are noncompliant (i.e. don't listen to their doctors) or who abuse the system (i.e. frequent ER visits for non-emergent problems). Things that insurance companies should NOT be allowed to modify rates for include race, genetic conditions, economic class, the region you live in, or (the biggie) pre-existing no-fault conditions. The rationale for this is that you should largely be able to control your rates through your behavior, just like with the current car-insurance model.

So this will translate into an insurance profile that looks something like this: "55 year old male, compliant with medications and doctors' advice, 3 emergency room visits in the last year, BMI of 28, smokes 1 pack per day, 40 year smoking history, drinks alcohol moderately(2-3 drinks on most weekends), no history of street drugs or STD's, past medical history of diabetes, high blood pressure, and coronary artery disease.”

This resembles "25 year old male with one recent speeding ticket (73mph, speed limit of 65), one accident in the past year, drives a Honda civic."

In other words, the insurance companies don't know (or, at least, aren't allowed to take into consideration) that you have lupus. Or a heart disorder that you've had from birth. This gives the insurance companies enough information to put you into a general category and assess a rough risk-to-profit picture, but not enough information to deny you coverage because you have a struck-by-lightning style unlucky health history of being born with only one lung. Of course, people with diabetes and heart disease will be more willing to sign up for this sort of thing, but that’s to be expected. Like people who drive Ferrari’s, they’re higher risk.

Then, just to make sure that the insurance companies don't monopolize and price gouge, you do two things: eliminate the tax break for employer-based insurance (or even better, add on individual tax-breaks for purchasing your own), and open up state borders to insurance companies in other states. Again, this is how it works with car insurance -- and as a result the insurers compete with each other for customers via advertising (the Geico Gecko, anyone?), discount rates for people who drive safely, and lower prices overall.

So now let's fill in a couple of holes (I’m sure I’ve missed some. Feel free to point them out.)

1) Poor or disabled or temporarily unemployed persons would have payments put into their PHF's every month from the government, just as though they were working. These payments would ensure that there is funding for the economically disadvantaged when they have health problems, and would also allow access to primary care. This is, essentially, the 'public transportation' portion of the primary care part of the equation, and I'd argue it's much better than the 'no insurance at all' model that we have today. (Remember that catastrophic costs would be picked up by the taxpayer's buck.)

Admittedly there's still risk involved, but for better or worse that's how almost everything in life works. The downside to this is that someone who doesn't have supplemental insurance and who isn't frugal enough or who has an unexpected high-cost health problem not qualifying as a catastrophe (e.g. appendicitis) could be in some debt. Again, this is not unlike other aspects of real life.

2) Disabled persons would have the cost of medical care related to their primary disability covered by the program. Depending on the degree of disability, other health care issues may or may not be covered. For instance, the person with mental retardation would probably have the cost of their diabetes treatment covered if they're not competent to care for themselves adequately, whereas the person on disability because of chronic severe back pain probably would not. While it stinks to have low back pain and I feel for those people, I'm not going to give them free care for things that they (and most everyone) should take a personal stake in paying for and controlling. (Keep in mind, they'll have PHF's, too.)

3) As above, insurance companies can compete across state lines. Also as stated above, the current health-insurance tax breaks need to shift to being individual based instead of employer based.

4) Chronic, expensive, but preventable conditions such as diabetes and heart disease should be managed with personal money -- not public money. The PHF should provide sufficient funds to cover basic (i.e. not necessarily the best, but reasonably effective) and inexpensive treatments. Currently, you can get a broad list of high-quality generic prescription drugs through Target and/or Wallgreens for 3-4$/month per prescription. In America, that's pretty darn affordable to anyone but the absolute poorest of the poor. And even then, one has to ask what're they spending the money that they do have on? If the PHF system were implemented, more and more drugs would be added to this list -- probably rapidly. Additionally, the size of the market share lost would force drug companies to choose between the current high-price/low volume profit model to a high-volume/lower price model.

5) Last but not least, Tort reform. I like Krauthammer on this one. Have a panel of physicians sit together and decide whether or not to strip the medical license of those persons deemed sufficiently negligent to do so. That’ll get a physician’s attention—I promise. Meanwhile, persons injured by physicians (an unfortunate risk that’ll never be completely eliminated) should be compensated out of the ‘catastrophe’ fund I’ve detailed above.

*Very little of this is truly original. It's mostly a hodge-podge of things I've picked up from reading multiple-people's opinions. A lot of it from David Goldhill, though I don't agree with all of his ideas.

Capitalism

I wish I'd written this. It gets to the reasons behind the current convouluted financial situation. It emphasizes what I think are the real reasons, and which are simple enough for just about anyone to understand. And you don't even have to know what the term "toxic assets" means.

Great article. I couldn't agree more.

Health Care Reform: Reasons Behind Excess Costs

This is the third bit of ranting on health care reform that I've written. Parts one and two should probably be read first.

Why on earth is health care in America so expensive? This is the question we should answer before we try to make it cost less, don't you think? So let's look at the system through the eyes of someone with health insurance: our imaginary friend Bob the Engineer.

Bob, like most people, gets health insurance from his job. He has some choice in his health insurance, and can pick from a couple of different plans. These plans are (only semi-hypothetically) a high deductable but low monthly payment plan, a low deductable but high monthly payment plan, and a catastrophe-only HSA-based plan (also low monthly payment).

These plans are all through the same insurance provider-- someone who has bargained with Bob's employer ("Transparent Aluminum Engineering") to be the exclusive health care provider to all of the employees in the company. Because Engineering is a competetive field, Bob has good health insurance coverage. In fact, because Bob is risk-averse, he decided to purchase the low deductable plan with a high monthly fee.

Bob also drives a 2004 Acura to and from work, and has car insurance for his vehicle. I'll come back to the car later.

Bob has asthma, and needs to buy two inhalers per month at a total cost of about $300. It's not a problem because -- fortunately for Bob -- the inhalers cost him about $20 apiece and his insurance picks up the rest.

Then, one fateful day, Bob gets in a car accident and gets taken to the ER by ambulance with a perforated bowel from his seat belt (I've seen this). He has his surgery, gets admitted to the hospital floor, and goes home after about 4-5 days feeling pretty darn good.

A few weeks later, the hospital bill comes in the mail -- Bob (like most people) checks to see how much he owes. It's about $2500. Expensive, but manageable since he has a good job. The rest of the bill, of course, gets picked up by his insurance and so Bob doesn't really care that the total costs for his care were right around $35,000. Good thing he got the low-deductable plan, right?

The next week at work, our accident-prone friend manages to inhale the eraser of his pencil when he sneezed and coughed at the same time. He's having a bit of trouble breathing and he's coughing uncontrollably so he gets shipped to the ER again to have things taken care of. Upon arrival to the ER, he's taken care of by a new ER doc who's slightly paranoid about getting sued. So, after Bob gets a chest X-ray which shows the eraser (apparently it's radiopaque) in his right mainstem bronchus, the ER doc checks out Bob's info. She see's that he has great insurance, and decides that she should cover all of her bases to make sure that she hasn't missed anything. She begins ordering tests for tuberculosis, pneumonia, blood counts, chemistry, and Bob's thyroid.

She also discovers that Bob skipped breakfast this morning and hasn't had anything to eat today (besides the eraser, which doesn't count) and orders a fasting lipid panel on him because if he DOES have high cholesterol, she doesn't want to miss it.
Meanwhile, Bob leans over the side of the bed in a raging fit of coughing, and manages to hork up the eraser on his own. Phew. That's a relief.

After hearing the good news, the ER doc, just to make sure that Bob does NOT still have eraser in his lungs, orders a CT of his chest. Nevermind that the eraser was in one piece when it came out, anything that remains will be too small to find in his lungs anyway, and you can see the eraser on a plain chest X-ray just fine. The chest CT helps both Bob and the ER doc feel better about getting the eraser out of his lungs.

The CT shows no eraser in his lungs anymore. He's cured. On top of that, all of his laboratory tests come back negative, so that's good news too. He goes home without further incident.

Now, Bob gets another bill in the mail for his ER visit the next week: $8,000 total, including the CT scan and all of the lab tests. He was there for about three hours. Pretty expensive, but Bob doesn't care -- his part of the payment is... free. Completely free. Because he has AWESOME health insurance and has reached his deductible for the year, anything beyond the first $2500 is picked up by his insurance company. Bob's life is awesome. And the ER doc got sued by the guy in the room NEXT to Bob's -- but it was okay for her because she'd ordered all of those tests for the guy next door, too!

And life rocks for everyone. Except... not really. We spend one out of every six dollars of work that our country makes (1/6th of GDP) on health care.

So why do we spend so much money on health insurance in this country? Because, at almost every point in the system, strong incentives exist to spend more money, with very little incentive to spend less. Let's recap:

1) Bob's company gets tax breaks for all money spent on healthcare. Imagine how many corvettes there would be on the road if companies could buy cars for employees with tax-free money. Why wouldn't they? The employees love it, and it'd be cheaper than raising the employees salary to pay for it themselves. A pre-tax $10,000 per year health care plan is worth MUCH more to Bob than $5,000 cash is post-tax. Besides the fact that half of the money goes the government, buying insurance as a private individual is much more expensive, if not downright impossible.

2) Health "Insurance" isn't actually the same type of thing as car insurance. Bob has car insurance, and hopes he never has to use it to replace his car. It doesn't buy gas (a long-term, constant expense not unlike Bob's asthma inhalers), he doesn't make an insurance claim when he needs new tires (but he would if his wife had a baby-- nevermind that they had 8-9 months to plan for the expense of having the baby) and -- for the most part -- Bob hopes that his $100 per month to his car insurance company never, ever comes back to him. He's buying peace of mind, not car maintainance. Yet, with health insurance, he's buying all of his healthcare -- no matter how much it costs -- for one, neat, clean monthly fee.

3) Due to reason number 2), people feel entitled to get whatever they need (or want) for their own health maintainance without paying extra for it (other than miniscule co-pays.) This entitlement encourages employers to purchase plans with extreme coverage -- like Bob's, where he doesn't pay a dime beyond a certain amount -- because they're attractive to employees. Nobody wants to be told that health care should cost them more because they're overweight, don't exercise, go to the ER often for things that aren't emergencies (or for emergencies that could have been avoided), and don't take their medications like their doctor tells them to. Yet, if you drive recklessly, crash your car, and don't obey the traffic laws like the police tell you to, nobody's suprised when their auto insurance goes up. I bet if you got auto-insurance through your job and they paid your speeding tickets, you'd drive a bit more recklessly, don't you think?

4) Because of reasons 2) and 3), most people in America (>80%) have good health insurance with broad coverage. This means that hospitals have no need to compete with each other on prices -- their individual customers don't really care what something costs, because (it seems) someone else is picking up the bill. If you need an MRI for your back to see if you need surgery, do you shop around for the cheapest place for a scan if you have good insurance? No. Why should you? It doesn't cost you any more no matter where you go. So you choose the closest, or highest rated hospital that your plan covers. You choose the Ferrari of health care because... well, you can. (The actual term for this sort of situation is called "Moral Hazard.")

5) Doctors are encouraged to spend money to protect themselves from lawsuits. On average in the US, every single doctor is sued multiple times through the course of their career. In medical school, I was taught to play defensively in the medical field -- document EVERYTHING extensively, order whatever tests I need to MAKE SURE that I've covered everything that could possibly be wrong and write my notes such that anyone (i.e. a patient's lawyer) who opens the chart to see if I am a potential target for a lawsuit knows that I have covered all of my bases, and that it'd be more trouble than it's worth to try to sue me.

5b) Some estimates out there say that 25% of all health care costs go to defensive medicine and malpractice. I believe it. I've seen an ER doctor order a CT scan of a child's head (probably $1000) when she was clinically fine (she HAD hit her head and had a goose egg-- but I did too when I was a kid, and I never got a CT scan). The doc's reasoning? "I'm near positive that little girl is fine right now. But if she goes out the door and hits her head again and THEN she has a brain bleed, I could be sued for missing it the first time because I can't prove that she doesn't have one now. And who knows if her parents will tell the truth about her hitting her head again?"

5c) Malpractice insurance is sought after by doctors because the hypothetical malignant mother of the child in 5b all too often wins a lawsuit and is awarded millions and millions of dollars. I don't have that much money, and I don't want to go bankrupt because I tried to help someone and possibly made a human mistake and they sue me. So I'll be buying malpractice insurance at whatever price they ask for it until this problem is solved.

5d) I'll also be spending endless hours charting things in immaculate detail so I'm protected if I DO ever get sued. Time is money. Lots of time charting is expensive. In summary, we have a system that rewards those that spend more, removes responsibility for paying for things from the individuals receiving the services, and removes cost-accountability from doctors working with patients. No wonder it's so expensive.
The good part of it -- the reason it persists -- is because the American people like to feel safe. We like knowing that no matter what happens, we're going to be okay and someone's going to pay for anything and everything we need. I can appreciate that. We just need a better way of doing it.

Health Care Reform: Expense

**Before I get too much futher, I should admit openly that I certainly hope to hear from people who have different ideas and opinions on this issue than I do. Intelligent debate is something that we have far too little of in the media right now, so I have to try to get what I can in places like my blog. Let me know what you think, eh?

One of the great problems in today's healthcare system is that a major health problem has the potential to consume your financial life. If you're in a serious car accident and require multiple reconstructive surgeries, hospitalizations, and rehabilitation, it's not very difficult to run up a million dollars or more of medical bills. Very few people could afford that, and no insurance company wants to bear the costs of such ruinously heavy expense. I don't really blame them.

It's for reasons like these that I do support a limited form of universal coverage. In fact, the government already pays for certain medical treatments no-questions-asked, such as dialysis and hospice care. I think that's a good thing. While having Uncle Sam foot the bill for certain extremely expensive circumstances certainly won't help with the overall cost of health care (i.e. 1/6th of GDP), it'd certainly remove much of the burden from individual families that have a disproportionate healthcare need. I think this is an enlightened position to take -- bearing certain burdens as a society benefits us as a whole.

Now, what do I think falls into the category of "The Government should step in?" A very few things:

-Chronic mental health issues such as schizophrenia

-Catastrophic events such as life-threatening trauma, ectopic pregnancies, strokes, and possibly other emergency surgeries or services.

-Chronic, severe, unavoidable and debilitating medical conditions such as lupus, crohn's disease, multiple sclerosis, and parkinson's disease

Now, what do all of these things have in common? They're conditions that can render a person unable to care for themselves or their families, are extremely expensive, and (call me a cynic) they're very difficult to fake and are extremely unattractive in terms of lifestyle change. i.e. very, very few people would intentionally drive their car into a brick wall at 60mph just so they could have a free trip through the hospital as a spinal cord injury patient. Therefore, the potential for abuse of this part of the system is very low.

Now, you ask, what about other, equally debilitating conditions such as type II diabetes, high blood pressure, heart disease, and obesity?

Minimal public coverage only. I oppose bailing people out of situations that they could have avoided themselves had they taken the opportunity to do so. It's expensive, and a losing battle. Human nature is such that fixing a problem for someone else that they could have fixed themselves rarely actually fixes the problem.

That may sound heartless at first, but it's not. It's practical. Not only are these conditions extremely common and extremely expensive to treat, they're avoidable. Really, they are.

Besides that, these people are hardly without options. Currently, you can get generic blood pressure, cholesterol, and diabetes medications for $3-4/month each WITHOUT insurance at Target or Walgreens. It's not state-of-the-art, cutting-edge stuff, but it works pretty darn well and it's dirt cheap. If you can't afford 50 cents per day to get the five different medications that you need, you should spend less of your money on whatever you're spending it on. Ditch your cell phone, maybe?

Now, here's one other thing that I DO support -- universal access to primary care physicians, physician assistants, or nurse practitioners. In fact, I think NP's and PA's are awesome. I see an NP instead of a doctor at least 80% of the time I head to the doctor's office, and they know their stuff and do a good job. (At least, they do where I go to get my primary care.) They're also much cheaper than doctors.

One of the primary reasons that I support universal primary care is so that ER doctors can, with confidence and impunity, begin kicking people out of the emergency rooms who don't need to be there, and sending them off to follow up with a primary care provider. Rationing ER visits is, I think, absolutely appropriate. If we, as a society, start kicking people out of the ER who go there inappropriately, people will learn to stop going there inappropriately.

The above health care subsidies benefit the rest of us who don't go to the ER inappropriately, but occasionally need hospital care.

I work at a hospital that services the inner city of Milwaukee. I have seen a LOT of people come into the emergency room who don't need to be there. They get treated there, because they don't have anywhere else to go and the ER doctors are bound by duty (Hippocratic Oath) to treat these patients as they will not be recieved elsewhere. They plug up the ER and take up resources that they don't medically need, and it's extremely inefficient. There's also a lot of trauma (gunshots, stabbings, car crashes) that gets routed to the hospital, and much of the time those people don't have insurance to pay for their extremely expensive life-saving care.

So, when my friend Eric got sick with the flu, got dehydrated, and ended up going to the ER so he could get some IV fluids in him (he got three liters of saline before he was fully hydrated again), the emergency room charged his insurance company over $3,000. Maybe $300 of that was actually Eric's care, by my estimation. (Ten minutes of the doctor's time + 3 bags of sterile saline at maybe $10 a bag + IV and tubing for another $20, plus the ER bed, nurses time, etc.) The rest of it went towards the surgery for the hypothetical guy in the next room over who'd been shot in the lung and had to have an emergent pneumonectomy.

If that guy who got shot would have been covered by Uncle Sam, the hospital wouldn't have had to gouge Eric to make up that cost and stay in business.

The pro's of the above scenario are that we meet the criteria of expanding coverage for the uninsured as well as decrease the individualized costs of heavy health burdens for victims of serious illness, injury, or disease. So that's good.

The cons are that it expands the government's share of the healthcare pie, and will end up INCREASING the amount of money spent on healthcare by the federal government, which translates to increasing taxes. Because I hate taxes, I'd better come up with something soon that'll cover some of the above proposal's gargantuan costs. Never fear. I have more verbose, only-semi-original opinions on all of this stuff. Stay tuned.

Health Care Intro

As an MD, I feel like I should blog about my thoughts on this, so I'm going to. (Sorry, Ronnie. No post about the new house just yet.)

American healthcare is excellent by any standard-- we have the most advanced drugs, tests, treatments, and we come out with new innovations at an astonishing rate. We have the longest life expectancy after being diagnosed with cancer or other serious illnesses, have shorter waits for surgeries and diagnostic scans, and are generally (80+ percent of folks) satisfied with the healthcare we get.

America's HEALTH, however, is not excellent. As a macro-generalization, Americans have unhealthy eating habits, poor exercise habits, and are overwieght. We also do our fair share of drinking and smoking, which are bad habits to get into if you want to live a long, healthy life. Not only that, we're busy and stressed and yet impressively physically inactive all at the same time.

Americans are also rich compared to people in other countries. We have an incredible standard of living, far surpassing what it was even 50 years ago here. We arguably have more disposable income now than at any other time in the history of humanity.

Thus, unsuprisingly, we spend more on healthcare than any other industrialized nation, and (also unsuprisingly) we learn the hard way that we can't buy our bodies back into good health.

This has sparked a national debate about what we need to do as a nation to cut costs, expand access, and keep the same level of care that we have now.

The Current System has the following traits:

-Excellent health care

-Innovative technologies

-High levels of choice in providers

-High satisfaction ratings

-Short wait times

-Extremely expensive

-Highly inefficient

-Uninsured persons have minimal/no access to care

President Obama's health care plan would attempt to fix the inherent problems of high expense, lack of efficiency, and uneven coverage.

'High Expense' refers not only to personal expense -- people who come down with major health problems with or without insurance can very easily end up bankrupt as they try to save themselves or their loved ones -- but also national expense, with health care taking up approximately 1/6th of the United State's GDP.

'Lack of Efficiency' comes into play as extremely expensive interventions are employed for only incremental benefit over less expensive alternatives. It also comes into play as health insurance companies require a high overhead to run, and when doctors order uneccessary tests. It's also inefficient and expensive for people to use emergency rooms as primary care providers.

'Uneven Coverage' refers to the ability of those with health insurance to get almost any treatment, test, or surgery that they need (or even want), while those without insurance lack basic fundamental health care.

So, the question then becomes "How do we, as a nation, decrease expense, increase efficiency, and increase coverage?"

I think it's at least theoretically possible, though I disagree with the 'big government' proposals of the current administration. The next couple of blog posts will discuss what I think we should do about the problems.

America vs. China (eating)

So my mother in law asked me how the Chinese people stay so thin, given that they fry so much of the food they eat. It was a great question, and I've been thinking about my answer for two months. Here is my (verbose, as usual) answer, neatly categorized into sections:

1. Meat. Meat in China is made from the same animals as it is in the United States. Beef, Chicken, Pork, and seafood are the mainstays. However, the meat in china is in much smaller portions than it is in the US. (Read: no steak.) Also, it's not uncommon for the meat to have bones in it. This actually matters, because one of the factors in how much you eat at a sitting is how fast you eat it. If you eat slowly, you get full on less food. Taking meat off the bones takes time, so you eat more slowly.

2. The Fat is different. Chinese cooking routinely calls for vegetables and meats to be fried, either together or separately. Unlike America, however, they usually use a light vegetable oil to fry things in, rather than using butter. Butter is flavorful and fattening, and tends to stick to the food a little better than a light cooking oil will. Also, soaking something in light cooking oil tastes kind of gross (while anything soaked in butter will probably taste great) so there's incentive to minimize the oil left on the food after frying. Also, they don't bread the things they fry (i.e. give it a carbohydrate coating to soak up extra grease.)

3. Dairy products. Asians don't eat dairy products like Americans do. In fact, a good chunk of asians (90% in some places, if you believe Wikipedia) are lactose intolerant. Cheese, butter, and milk are therefore all much more rare than here. Dairy products are designed by Mother Nature to be helpful in doubling the size of young mammals in the shortest time possible so they can get big and strong. Grown mammals in America, however, absorb dairy almost as well as infants -- and if you consume a lot of dairy, the high-fat, high-protein, easily digested and easily absorbed foodstuff will help you grow in size as well.

4. Chopsticks vs. forks vs. hamburgers. Asians use chopsticks. Anyone who's eaten with chopsticks knows that you have to take smaller bites than you do with a fork, knife, and spoon. (Heck, if you feel like it, you can put a whole steak on a fork, right?). Thus, when using chopsticks, eating takes longer and (as mentioned above) you eat less per sitting. Some American meals are designed to be eaten with no utensils at all, such as hamburgers and other sandwiches. This translates to having the ability to take HUGE bites of stuff and pound it down your throat as quickly as your esophagus can carry it (no bones in a hamburger, either.)

5. Vegetables aplenty vs. scarce veggies. Americans don't eat as many vegetables as asians do. The core of most Chinese meals is rice with vegetables and a bit of meat for flavoring. Americans prefer thicker, hardier, usually higher calorie starches (bread or potatoes --baked or mashed -- with butter are very common) than rice, and usually the vegetables are marginalized in American meals. (i.e. the teeny portion of peas sitting next to the 16 oz steak, or the single lettuce leaf on the hamburger)

6. Rice is filling, but not for the calories it gives you. Rice expands in your stomach, so if you eat slowly (i.e. with chopsticks and meat with the bones still on) the rice has time to expand in your stomach and help you feel full. See the mashed potato comparison in number 5 for the American starches of choice, which do not expand.

7. Smaller bowls vs. large plates. In China, they use rice bowls.

See how much food you can put in them? I bet you can't fit a steak (okay, maybe a small one). It's very common to go back for seconds, or even thirds or fourths in China, but the basis of your seconds, thirds, and fourths is mostly rice with a bit of vegetables and meat on top to flavor/texture the rice. Filling up your bowl takes time (see 'eating slowly,' above) but more than that, you're much less likely to overeat just because you feel obligated to clean your bowl out so as not to waste any leftover food. In my case, I routinely clean my whole plate so as not to waste food, and then my wife has me finish of HER plate so SHE doesn't waste food. Of course, we both took way too much food to begin with since we were hungry when we sat down to eat.

8. No cups of liquid during dinner. The Chinese don't wash anything down with a swig of milk, soda, or even water. They drink after they've eaten. This decreases the amount of calories you take in because your stomach doesn't start emptying quite so fast -- you haven't helped it by dissolving all of your food in added liquid. Interestingly, this is one of the hard-and-fast rules that patients who undergo gastric bypass are told to live by. If you wash all of your food down, you get it out of your stomach faster and therefore the fact that your stomach has been artifically bisected and put back together to be a quarter of its original size doesn't slow you down. i.e. you might as well not have gotten the surgery.

9. Liquids at the table are low cal (brothy soup) vs. high-cal (soda/milk/juice). While they don't have a glass at a place setting, there is often liquid available if you need it in the form of a brothy soup. It's usually pretty bland, with a small chunk of meat and (again) some veggies of one kind or another.

10. Low sugar sweets. There is no such thing as "too sweet" for desserts in America. When I was in Taiwan, I gave an american Starburst candy to a chinese friend of mine, who could barely chew it. I suspect it gave her physical pain to choke it down. When I asked how she liked it, she said "Waaay too sweet." In America, we load up our desserts and candy with so much processed sugar that it's really quite impressive, and unpalatable to those not accustomed to it. Moral of the story? Eat less sugar. Cut the sugar in dessert recipes by 1/3 or more and you'll probably still be able to eat it no problem.

Anyway, there are probably more dietary reasons that I can't think of at the moment. And, of course, this leaves off the lifestyle part of the equation, which Americans also lose out miserably to the Chinese in terms of health. (In Beijing, by about 6:30 in the morning the parks are FULL of old people doing Tai Chi. In America, people consider themselves as having exercised if they simply go walking in the park.) But I don't want to rant about that tonight. It's late.

(Note: both pictures shamelessly pilliaged from the internet without permission.)