Please show us the medical mediocrity of not-for-profit and single-payer systems. http://www.photius.com/rankings/healthranks.html

Show us how embracing health care as a right has diminished the health care systems of the other, modern industrialized countries.

Show us how having too much government involvement has created runaway costs, less than universal coverage, and failed to motivate excellence.

Obviously, the international standards have no bearing on your perspective and the weight of evidence takes a backseat to your economic dogma. In the words of our founding document, where is your respect to the "Opinions of Mankind"?

15% left out is not admirable, even 2% of our nation, 6 million people, would be too many. What if only 1% of planes crashed or 1% of drivers were in fatal accidents or 1% of all houses burned down? Hey, we're still 99% good, right?

The bills are bad because they fail to act from an ehtical and moral perspective. They cater to the profit motive and, therefore, increase our contribution to profits. There is no motivation for the access providers to control costs because they can profit without efficiency. There is no motivation for providers to control costs because their appetites reign over human dignity and compassion in our twisted and unique economic and social values.

The AMA has come out in support of the healthcare overhaul in the House...

http://www.reuters.com/article/companyNewsAndPR/idUSWBT01330720091105

The AMA, which only represents a small number of doctors, voted with the insurance companies who will not be touched by this bill.

Health care is administered, traditionally, in the doctor-patient interchange, complicated of course, by third parties, endless formularies, gatekeepers, etc., etc.  It isn't easy to make a living, or pay off your educational debts, or even have a family life, if your mixture of private paying patients, private health insurance patients, Medicare, Medicaid or charity patients doesn't add up to a mix that ensures the viability of your practice.  

But "mediocrity" is a fighting word!  I don't consider the demographic I choose to serve as deserving of mediocrity, and I choose to give them my best effort, and to fight, on their behalf, and on behalf of my concept of medicine as a profession, for the most cost effective medicine as is possible for every inhabitant of the United States.  I see that as an extension of my self-definition as a physician.

What is proposed will cost more than current estimates.  It always does.  That's why Single Payer is a necessity, or at the least, non-profit insurance companies administering health care at cost, as in France and Germany.

The inference that the system creates mediocrity ignores the responsibility of the individual physician to stand up to how he choses to practice, what he choses to earn from the practice of his skills, and how much effort he puts into advocacy for his patients and his profession. 

Michael - Your blog looks to be very, very interesting, and I hope to find some time.... I'm sure you can understand that ephemeral wish.... to read and learn.  Thoughtful writing from physicians is none too common, so I want to congratulate you for your endeavor, even before I attempt to digest (a sense of humor, I'm sure) and respond.

40% of insured people in this country have government insurance and even my dad who would vote for Nixon if he was exhumed admits it works pretty well.  I'm not advocating Medicare for all but I'm not convinced it our government could not run a single payer very well cutting 30% or so off care costs because of savings in administrative costs alone.

Rick,

40% seems high but, yes, the track record of Medicare is sound and they cover the segment of the population running up the highest hospital costs.

It's a relief to hear someone observing reality. We can build a better system or, at least, extend our successes in Medicare to all people.

Michael, you said "Just because the system is flawed, doesn't mean we have to embrace a single payer government takeover of the system."

I've discovered it's way more than flawed. As the good doctor says in this thread, they don't want to have to deal with the complexity of insurance billing, what's covered, what isn't. They have better things to do than push papers. You should agree since you claim to be striving for excellence.

Please go to moneydrivenmedicine.org and watch the video. It will open your eyes the way it opened mine, that we need to get profit out of our healthcare. We need to do as well or better than other countries who are providing better care for less cost. That should appeal to your sense of competition. We are #37 in the world!

Harold, A pleasure to dialogue with you once again. We would all welcome your utopian society where every resident, legal and otherwise, could enjoy Rolls Royce health care, an Ivy League education, a job, prosperity and a happy life. This is not possible.  You seem so angry and admiring of other nations' health care, that I wonder if you were ever tempted to move.  You suggest that those who oppose Obamacare or single payer are immoral and unethical profit seekers.  Physicians must be quite different in your community than in mine.  My colleagues, by and large, work hard to help patients as best we can, and for the right reasons.  While I am not devoid of human frailties, I strive to practice medicine at the highest level of personal integrity.  Sure, I get paid for it, but that was always a secondary phenomenon in my practice.  Claiming that those of us who oppose Pelosi & Co. are ethically challenged is as absurd as the charge made against Democrats who opposed the Patriot Ac that they are less patriotic.  www.MDWhistleblower.blogspot.com

Dismissing Harold's values as utopian is just about as silly as wondering if he were ever tempted to move. And I didn't hear him call anyone ethically challenged, rather he just stated his belief that health care is a human right, which it should be and unfortunately is not in this country. His comments speak to the issue of greed and a lack of concern for your fellow man . Your response seems quite harsh; could it be you have a guilty conscience?

The reality IS that some providers have taken the bait presented to them from the medical paradigm created by the health insurers and they have contributed to the problem as well. In addition, patients who overuse the system and expect medical perfection from a profession that is not designed to deliver perfection also strains the system. Until we all wake up to the responsibility that wainbale system of health care we will never have it. Taking what we don't need, allowing health care to be reduced to a system of reimbursement rates, and not seeing the obvious need for a simplification of our system of health care administration are obstacles to real reform. Gillian is right and you would be wise to consider what she has to say. Harold is a champion for the people and your responses to him are offensive.

Michael,

Having visited your blogs, I see a lot of frustration on your part but not enough of it aimed at the parties which interfere with you and your patients. You seem to accept that there will be interference and you'd rather it be the accepted profiteers and not the government. Rest assured, the bills under consideration will not change that and they will, as you fear, add another party to the mix.

"We would all welcome your utopian society where every resident, legal and otherwise, could enjoy Rolls Royce health care, an Ivy League education, a job, prosperity and a happy life. This is not possible."

Nothing is perfect but, in my experience, in order to improve you have to set your goals high. If we aim for what ought to be, we will come closer than if we aim to settle. So, I don't expect everyone to have Rolls Royce healthcare but the clunkers have to taken off the road. The weight of evidence shows that, given a principle that health care is a right, nations develop better systems. The opinions of perhaps 75 -100 million American voters dead set against this principle does not hold up against the billions who acknowledge it.

"You seem so angry and admiring of other nations' health care, that I wonder if you were ever tempted to move."

This is my country, my people. I would not try to change it if I did not love it. I'll stand with Jefferson: "Dissent is the highest form of patriotism.", Murrow: "We must not confuse dissent with disloyalty. When the loyal opposition dies, I think the soul of America dies with it." What I cannot abide is the "my country right or wrong attitude" marketed as patriotism. To say that we are correct though we stand in the minority against the opinions of mankind because we are better because we are Americans is nonsense. I think Chesterson said it well: "‘My country, right or wrong' is a thing no patriot would ever think of saying except in a desperate case. It is like saying ‘My mother, drunk or sober."

"You suggest that those who oppose Obamacare or single payer are immoral and unethical profit seekers." 

First, let me say that I oppose what you label Obamacare as a tool of profit. Oppose it all you like. As to single-payer, the only parties threatened by single-payer are precisely those entities who would no longer receive their desired prices. That doesn't mean they will not cover costs and make a good living as they do in nations which have such systems. If desired price is all that stands between a person in need and care, then it is immoral denial of human rights and desire for profit that is the problem.

"Physicians must be quite different in your community than in mine.  My colleagues, by and large, work hard to help patients as best we can, and for the right reasons.  While I am not devoid of human frailties, I strive to practice medicine at the highest level of personal integrity."

I am very happy with my primary physician and firmly believe that primaries are short-changed, underpaid in our system. The value of primary care in easing costs up the line is demonstrated in the nations which top the WHO's list. They know that they cannot bear the social cost of poor primary care. Our system is driven by high-cost treatment.

I am sure that you and nearly all other physicians are performing wonderfully. But the system is not the sum of physicians. It extends to the research supporting their methods, best practices, hospital care, pharmaceuticals, patient education, facilities management, surgical practices, and the means at patients' disposal to avail themselves of services. None of this will be improved on under the bills in Congress. All they've accomplished is keeping everyone in the system, patients and doctors, in their places, subservient to higher desires for profit and not the welfare of our society, the rights of all people.

You ought to despise not the government's, our common and collected, involvement in health care but the government's betraying it's proper role and colluding against our common and collected interests in supporting profit over people. What I want, what I will fight for, is a single-payer system where there is no broker between us and needed care.

Harold, I am convinced from our prior communications that you are motivated for the right reasons.  Jefferson is a heroic figure for me also, but I am sure we are both aware that he suffered from deep moral lapses and behaviors.  It is easy to be selective when presenting supportive viewpoints.  While there is greed in every industry, except perhaps in a convent, attacking too broadly offends honest and honorable practitioners.  How was I to interpret your comment:  "There is no motivation for providers to control costs because their appetites reign over human dignity and compassion in our twisted and unique economic and social values."  As you have kindly visited my blog, you know that I am not a 'tea party' attendee or Sarah Palin devotee. I do my best to serve as a spirited patient advocate providing medical care as best I can. You suggest that we set the bar at an ideal level, with the hope that we can approach it.  I have no quarrel with this, but do believe it has a 'utopian' aroma.  It is also reasonable to strive for what is achievable, rather than what would exist in an ideal world.  With regard to health care as a right, you know from my blog that I have struggled with this issue, and did not offer a firm rejection of the premise  that health care is a human right.  For me, it is a more complex issue that it is for you.  I'm more interested in extending actual health care than I am extending a right to health care.  If you have no insurance, you would rather have medical coverage than simply a right to it.  I am quite sure that we want the same outcome, but perhaps by different pathways.  I realize that this is a liberal blog site and I hope that a diversity of opinion is welcome. www.MDWhistleblower.blogspot.com

Extending health care will never occur unless we extend the "utopian notion" that health care is a human right. Even if the pure sciences there exists "ideal" laws, theories that advance knowledge and result in physical realities. We live in  society that represents the "ideal" of democracy. I think we really have to ask ourselves what is  more important, what expands the purpose, what is a better expression of our humanity: democracy or capitalism. Capitalism is a system that helps sustain our market and allows democracy to (hopefully) flourish. We are currently experiencing and witnessing a reversal of this relationship and as a result people are suffering. Michael, I think this is really the issue here and it is manifest in every facet of our society and government. Until we truly awaken to the fact that people are being brutally used as a means to an end we will all suffer the consequences. You strike me as a thinking person and that is rare in this age. Don't let anyone tell you "it can't be done". Most of what is good in this world and the advances in science have originated in the minds of men and woman who have been told, "it can't be done". 

The world needs all kinds of people; those who dream, those who do, and those who do both. We all advance when we give honest unbiased appraisals to a social hypotheses. The data for profit driven health care administration is not favorable towards supporting the vision of a sustainable system of health care funding. A medicare for all type public option is a commonweal approach that has a very good chance of working. We are not letting it happen because a particular industry feels threatened.  This industry has done nothing to afford Americans affordable, equitable health coverage. We need to limit their power and influence in the market because it is actually now killing people. Changing the rules on them while allowing them to retain market share is not the reform that will solve people's basic problem of affordability. 

Well, if my aspirations are utopian, then I guess all of the EU is living a utopian dream while I'm stuck in this nightmare.

Michael, I only want what is attainable. Other nations have attained higher because their fundamental goals are different. Rather than persist in trying to get the right results out of an idea which has failed to deliver in this or any nation, I'll go with what works. This is where I think our pathways diverge.

I will accept objective evidence that private, for-profit insurance in the American mode works somewhere in a modern industrialized nation to provide universal access to a top-notch system of care. We're past time to talk about what COULD work or COULD make it work when we have before us a world of solutions that DO work.

If our founders feared to shake the world and upset the given order, we wouldn't be here. We do them a great honor by facing the need for deep reform and social changes.

God forbid we aim for Utopia, for crying out loud. That would be just too "socialist". (sheesh :)

Harold, don't you change a thing, you are thinking correctly, it's the only way to get where we want to go, to dream of it, envision it, and make it real.

Harold and Lauren, It is clear that we agree on what matters. We all desire a system where all inhabitants of the world could have access to decent health care.  Indeed, there is no daylight between us on this issue. The challenge is how we can approach this idea, realizing that we cannot achieve it.  We would need a fortune of money, political cooperation from world governments and organizations, medical capacity to provide these services and various stakeholders in the medical establishment who would be prepared to sacrifice their own interests and livelihoods to serve the greater good.  Not exactly a slam dunk. www.MDWhistleblower.blogspot.com

A good place to start (because remember, we have people UNABLE to feel SAFE going to a doctor for FEAR of financial ruin) would be to open up Medicare for anyone who wants to BUY IN. Yes, thats right, a robust PO is a good place to start to see if we can have this wonderful idea of a public private partnership or if Single Payer is the way to go. 

Do we need to reform the way care is delivered, the crap we allow in our foods, the shitty air, the lack of time for people to devote enough time to their physical well being to even exercise???? Do we need to educate the population? Yes, of course we do. Health is more than just patching a broken fence post, but when people cannot access medical care because of finances AND because that situation is promoted by huge corporations who as far removed from the patient and provider than you could possibly imagine, then Doc Mike, something is horribly wrong.

When you see a person bleeding, you apply a tourniquet. We need to stop this bleeding. We CAN institute immediate changes to protect PEOPLE while we take a bit longer to figure out "the best way". And the best way may change as time goes on, maybe it needs to be designed to be more dynamic. But we will never know if we allow the interests that have profited from the system and who are literally controlling the system to continue to treat human life as a means to an end.

If people have to pay a large amount to a private insurer and then the taxpayer will be subsidizing that premium......am I the only one getting that??

Reform doesn't have to cost so much. It will if we insist on keeping the private for profit guys in the game and the fact that our legislators have bent over backward doing so is absolutely frightening.

Lauren--No, you're not the only one who gets that we'll be handing over our wallets to the private insurance industry. That this status quo is where legislative deliberation starts is very frightening.

http://healthcare.change.org/blog/view/faulty_math_in_cbo_senate_healthcare_bill_analysis

well, thanks for that info, I'm adding Sweden to my "country's to defect to" list. :)

Thanks to you, good Doctor, for speaking up today.

Dear CherokeeGirl,   I suspect that your reference to the 'good doctor' was to Laurence and not me. All of us desire the same outcome. Those who advocate a European model may soon approach this if Obamacare is passed and develops toward a single payer system.  I am skeptical that is will deliver on its promises.  I expect wild cost overruns and underperformance of the health care system.  As for removing profit from medicine, why stop with my profession?  Why can't we extrapolate your argument to all profession who work for profit and face potential conflicts of interest?  Lawyers?  Accountants? Car repairmen? Retailers? Dentists? Businessmen? Venture capitalists? 

Doctor Kirsch, that's an excellent question. We have public and private universities, and I think that serves our country well. We have parks and libraries and other valuable services provided to us, not to mention the National Parks, which we all share.

As to profit in our care, I am a new zeolot for Single Payer, because I see how profit in our care is KILLING PEOPLE. Is that important to you and do you see the distinction between that and lawyers?

I must admit, your question has me thinking. I would say that if the profession provides services to the public good, and that profession abuses their monopoly and harms people, when they show that the dollar is valued more than the human, THEN I think all we have to turn to is the government.

I guess you could say that I look at it this way. Your fear of government takeovers and Obamacare (which is a disrespectful term, btw, to progressives) is the same as my very real and present fear of large corporations hurting our people. I guess that's the bottom line for me.

We already have federal funding for Lawyers for low income people, thank goodness. Are you against that too?

I have always been ill at ease with the notion that I am profiting from the illness of others, but, indeed, I am.  The living I earn is a fair living in my eyes, and I don't feel that I've achieved the material comfort that I have in a zero sum game.  Always, I've known what I should or shouldn't do relative to patients, because I've been guided by what is probably a pretty strict interpretation of my membership in a profession.  My conduct has been filtered by the notion that I am entrusted with knowledge to be used to the benefit of my patients, and that I must not exploit their illness for my material gain, yet I should be appropriately rewarded for my work on their behalf, even when the result falls short of what the patient and I would like to see achieved.

Lawyers, accountants, car repairmen, dentists should have, and the best of them, do have, similar ethics, but probably have fewer conflicts or concerns about profiting from their interactions with me.  In that sense, medicine is something special, and to the extent that I can interact with those in my profession who share my values, it is extremely rewarding.

It is very frustrating to share a profession with physicians who sell vitamins for an ungodly profit, or refer their patients for tests to laboratories they own, on what might be a greater frequency than they would be ordering those tests if they didn't receive a return from them.  It isn't difficult for me to filter out self-interest at the expense of my patients.

Retailers, business men and venture capitalists.... well, buyer beware!  But do we want to bathe our egos in the salve of respect, such that we can say with a straight face, "Trust me, I'm a doctor."  

I suspect that Michael really knows the answer to the questions he asks.  And who is responsible for the ethics of other people or professions?  We must begin with ourselves?

And this fear of government that permeates our society!  WE are the government, and we can change the government, and the government is not the enemy.  If the government runs a health care system, it will not be running it to make a profit for its CEO, or its stockholders.  Is it so hard to understand that man is a social animal, a herd animal, and that we develop societies for the benefit of our species, and that Darwinian law is modified by our ongoing attempts to extend justice to all members of our group, and that we should not hoard material wealth at the expense of members of our society who are less fortunate.

In a time of material wealth, are not all members of our society entitled to medical care that preserves their life and health?  Is that not the First Question?  If the answer is "No," then medicine has lost its role as a profession, and it is a guild, its practitioners, technicians.  Then, the market is an appropriate arena for competition for material reward.  But that isn't what motivates the vast majority of physicians when they begin the long path to their professional status.

I can't be anyone but an advocate for affordable Universal Health Care, and I can't avoid learning from the experience of the industrialized world.  A for profit health care system is unjust, and when we attempt to bring justice to it, it becomes unsustainable.  Rationing is a fact of life, but rationing on the basis of a for profit health industry ignoring those who can't pay for it... well, that is very Third World!  For the Third World, it's not a choice.  For Americans, it is a choice!  An ethical choice.

Luckily, I keep posting here, otherwise the comments would be be rather homogeneous. First to the CherokeeGirl, it is becoming more and more clear that you are hostile to capitalism, an economic system that encourages profit. To Laurence, I feel a kinship with your view of medical ethics.  I too object to medical practitioners - or anyone - taking advantage of the consumer by selling products and services that are not truly needed.  Excessive medical care, for profit or for other reasons, has troubled me greatly in my 20 yr career. 

I suppose that one response to these ethical misadventures is to regulate actions and behavior.  This would be the Rep. Pete Stark approach, whose career is a series of 'Thou shalt nots' directed to the medical profession.  The more 'utopian' approach is to select and train ethical physicians whose rectitude will guide them to do what is right.  I think it's preferable to have an ethical physican than one who is forced to behave ethically by external forces.  Sure, this is an ideal view, but many other commenters on this post are proudly striving for the ideal. www.MDWhistleblower.blogspot.com

If the profession of medicine is recognized as something special within the society, with requirements that go beyond the conducting of this profession as a business, that it is a sacred trust, a responsibility to be upheld by its practitioners, even to some financial sacrifice, then a new approach is required.  The students who enter this profession must be screened not only for their intellectual ability, but for their ethical commitment.  The spirit of the Hippocratic Oath needs to be resuscitated.

The responsibility of government is to make medical education affordable to this ethically elite cadre and to expand its presence to a dominating position in the medical profession.

In my utopian view, physicians educated and supported economically (allowed to have families at an age that approaches their contemporaries, and to work hours that permit enjoyment of other aspects of life) would owe an appropriate number of years to society.  They would go, for a time, to where they were needed, to ensure that health care was available where it is not.  This would not necessarily be the military or the Public Health Service, but a civilian non-profit, integrated with the resources that these communities would need.

Removing the profit without rationalizing the educational process and the costs incurred would defeat the goal of affordable Universal Health Care.  Physicians, as valued members of society, should not have to take a vow of poverty, and society should be able to take a physician's word that the treatment he proposes is purely in the patient's best interests.  

Laurence, I read your thoughtful post.  Quite utopian!  With regard to your comment, "physicians educated and supported economically (allowed to have families at an age that approaches their contemporaries, and to work hours that permit enjoyment of other aspects of life) would owe an appropriate number of years to society.  They would go, for a time, to where they were needed, to ensure that health care was available where it is not. ", might this not apply to every college student who has rec'd financial aid?  I am in earnest about this.  Most college kids today have their education subsidized.  Should they also be required to give back to society in return?  Indeed, we could make a case that every citizen should have a service obligation, but particularly those who have enjoyed discounted education.

Michael,

When I attended UCLA from 1953 through 1958, my education was well and truly subsidized.  I seem to remember something like $75 a semester and that included the Associated Student Fees and tickets in the football rooting section.  There is still an education to be had at UCLA for less than at a private university, but the fees are considerably higher.  Parents often subsidize or partially subsidize college educations, but there is an industry built around extending loans to students.

I did not discuss the notion of national service, but I'm all for it, for a variety of reasons, for I think that citizens owe something to their fellow citizens, and service is more of a commitment than paying taxes.  I believe we all have an obligation to serve our fellow man, and this is one very constructive way.  I see it as a privilege of citizenship, or residence.  

Laurence,

We agree.

MK

I'm not hostile to capitalism. Except for the fact that I put hundreds of thousands of dollars into a startup organic coffee bar. That's how much I believe in capitalism. We would of made it too, had a 30% in only 11 months, even when a new Raleys and Starbucks opened across the street. It was when Ralph's Market closed next door that our business slid. We were a new business and couldn't take that hit. 6 months after they closed we closed and I lost everthing. So don't preach to me about capitalism. It's a slanted field towards large corporations. It took me months to even get anyone to rent a decent spot to me. I had to settle for the mall that they knew was closing, but neglected to mention it to me.

So, you go ahead, Mr. Kirsch and worship your corporate masters, You do your thing, and I'll do mine.

Michael, by "Laurence, we agree" can we take that to mean you are now converted to being a single payer advocate?

Won't you join 75% of the doctors polled and support a public option at the very least?

Aren't you tired of insurance getting between you and your patients?

Join www.madashelldoctors.com today and get on the right side of history.

I liked Dr. Lewin's post so much, I sent it to the whitehouse mailbox. Maybe they'll listen. :)