The Stupid Party strikes again

Congress passed the Affordable Care Act in 2010 by the slimmest of margins, securing the necessary votes by methods that were (at best) dubious, and without bothering to read the stupid thing. We have to pass the bill so you can find out what's in it, then-House Speaker Nancy Pelosi famously said.

The process was so partisan and (arguably) so tainted that there was a backlash and Democrats were swept out of the majority in the House of Representatives in the 2010 mid-term elections. Speaker Pelosi was reduced to Minority Leader. But, just as it takes both the House and the Senate to pass a bill, it also takes both houses to repeal a bill.

The Republicans did not recapture the Senate. So despite the House Republicans' voting to repeal it nearly every other day since taking over the majority in 2011, the Affordable Care Act, now universally dubbed Obamacare, remained on the books.

Remains on the books.

You have to start at least from there in evaluating the current debacle in Washington.

Actually, you could go back a couple of decades and note that many of the key components of Obamacare have Republican roots, including the now-hated individual mandate. There are a number of Republicans in Congress today who were for individual mandates -- who viewed them as nothing more than a tax, just as Chief Justice Roberts would do much more recently -- before they decided they were unconstitutional abominations. (Repeat after me: The Supreme Court is not final because it's right, but right because it's final.)

Mr. Potter would have loved the Affordable Care Act

And you can see why many Big Business Republicans might have been for Obamacare at one point: It looks like it was designed by a committee of the most cold-hearted, miserly MBAs ever assembled.

Let's see... health insurance for an employee's family generally costs $10,000 to $15,000 a year. And businesses have to hire people to assist with employee claims (when the insurance company inevitably messes up) and negotiate with the insurance company on annual rate increases and benefits provided. Or, under Obamacare, they can pay a tax -- ooooh, a penalty -- of $2,000 an employee and let the workers fend for themselves. Gee, that's a hard one. Hmmm. Save as much (or more) than $10,000 per employee and avoid the hassles of dealing with insurance or pay a negligible penalty? Now, of course, penalties will go up -- so give everyone $6,000 (for example) and send them into the exchanges to fend for themselves.

Obamacare was designed to fail. Do not kid yourself otherwise. Private insurers will benefit in the short term (idiot MBAs again, lured by the fool's gold of government subsidies) but when the dust clears the government will be paying most of the nation's insurance tab, whether through income-based subsidies or as the insurer of last resort.

Many Democrats want this to happen because, they believe, the nation will then demand a more "equitable" single payer system instead.

Meanwhile, many large companies -- Big, Big Business -- have applied to the Obama Administration for waivers for a year or more before assuming the burdens (and -- for them -- the benefits!) of Obamacare, and the Administration has granted most of the requests. Some unions and some states (apparently even some "Blue" states) have requested waivers of certain Obamacare provisions as these apply to them in whole or in part.

But there is one group that has definitely not been granted any sort of waiver: The Little Guy. The currently uninsured. They must plunge into the exchanges (ready or not) and fend for themselves.

Instead of shutting down the federal government, the Republicans might have highlighted the unfairness of this: Giving breaks to Big Business while throttling the Little Guys' necks.

Of course, a lot of Republicans (just like a lot of Democrats, apparently) think that sort of thing is just fine.

So... the Republicans decided to play "chicken" with the Senate and shut down the government.

Except... Obamacare implementation is not affected by the shutdown! It continues, while tourists are turned away from museums in Washington and campers are turned away from our national parks.

All the Republicans had to do was call press conferences to read constituent complaints about Obamacare. There'd be a lot of press conferences. But, no, the Republicans decided to shut down the 'gummint.'

Stupid, stupid, stupid.

Obamacare survives the Supreme Court -- now what?

People were celebrating or denouncing yesterday's decision in National Federation of Independent Business v. Sibelius according to their preconceived prejudices.

MSNBC viewers were jubilant.

Fox viewers were outraged. I got an email from one right-wing group which began, "The U.S. Constitution died today." Kentucky Sen. Rand Paul (son of Ron) said "just because a majority of the Supreme Court declares something to be 'constitutional' does not make it so."

CNN viewers were simply misinformed -- at least for awhile.

Actually, according to the linked post on Constitution Daily (from which the image was grabbed), Fox viewers were also initially told the mandate was thrown out. Presumably Fox is not getting flak for this screw-up because no one necessarily expects Fox to get the facts right in the first place.

But let's see where we are now: Congress passed a lengthy law that most of its members didn't read (remember how quick the final product was rammed through?) which the Supreme Court has now upheld on grounds different from those urged by the Administration in support of the law.

Five members of the Court did in fact reject the Administration's attempt to justify the mandate that all Americans must buy insurance or pay a 'penalty' as an impermissible distortion of the Commerce Clause. Chief Justice Roberts, however, said that -- whatever the Obama Administration might want to call it -- the mandate is a tax, and Congress does have the power to tax persons who don't buy insurance.

The American people have already gotten the goodies that Obamacare has to offer. My family is already benefiting from the requirement that kids be carried on their parents' health insurance to age 26. My unborn grandchild needs that assistance because her parents don't yet have health insurance of their own.

But... let's think a moment about this, shall we?

What incentive does any employer have now to provide insurance for employees? The mandatory obligation to provide insurance is on each individual, not on employers. Companies that have more than 50 employees will also be penalized for failure to provide insurance starting in 2014 -- but the penalty is only $2,000 for each full-time employee. I stopped paying individual Blue Cross premiums when my wife went full-time with the Chicago Catholic school system. That was about seven years ago -- and I was paying $10,000 a year then. Do you think premiums have gone down since?

Yes, the premiums paid for employees are deductible expenses, but administering health insurance plans for workers can be a real hassle. There will be paperwork either way (I'm sure) but if there's such a per capita differential between the cost of insurance premiums on one hand and fines on the other, wouldn't it be prudent to choose the fines? And smaller employers will not have these concerns. Without new and better incentives to do otherwise, lots of employers, big and small, will probably drop employee insurance as a benefit.

Hopefully, this won't happen overnight (or overnight in 2014 when most of the Obamacare provisions kick in) -- but isn't this going to happen?

Insurance stocks are up in the wake of the Supreme Court decision, too. True, under the new law, they can't turn down customers because of pre-existing conditions. Presumably they now should look forward to all sorts of new, and largely healthy, customers.

But they have a captive market. True, Insurance Company A can compete, in theory, against Insurance Company B on price and service -- but are they really going to beat each other to death knowing that everyone must buy their product, no matter what?

Is this really going to contain health care costs?

Big Business, doctors, hospitals, insurance companies, pharmaceutical companies -- all these had input into Obamacare. The elected representatives of the people -- the sad sacks we call Congress -- were presented with a fait accompli and voted for it, or against it, according to party loyalty.

Brace yourselves, ladies and gentlemen: The unexpected consequences of this one are going to be really, really severe.

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Substantively updated July 1 after reviewing John Flynn Rooney's article, "Health-care law faces deadlines," in the June 29 issue of the Chicago Daily Law Bulletin.

One more thing about this health "insurance" stuff

(Shelby asked for more on this... so don't blame me.)

When I was taking the bar review course, around a million years ago, one of the instructors (a Kent law professor, Michael Spak), said something about new laws that's stayed with me: New laws are always good for lawyers, he said. It may not be in your field, but it's more work for somebody which means more work to go around for all.

The current health care bill, or bills, or whatever, may prove the exception to this rule.

Oh, the legislation is going to provide a field day for all sorts of lawyers -- state attorneys general from a number of largely "red" states are already plotting constitutional challenges to the packages. But that will surely be only the tip of the iceberg, depending on whether the laws survive these initial court challenges.

A colleague said to me yesterday, in fact, that he's figured out the bill: Congress has required all Americans to have money, he said.

"Money?" I asked.

"Money," he said. "You have to buy health insurance under the new law. You need money. If you don't buy health insurance, you'll be fined. You need money for that, too. Either way, you need money."

"But what if you don't have money?" I asked.

"That's the part I haven't figured out," he conceded.

Sarcasm aside, the key flaw in the new health insurance laws seems to me to be the idea that Congress has the power to compel citizens to purchase anything -- insurance, corn flakes, arugula -- under our Constitution. (Read this column by Jonah Goldberg on this point -- it's from the National Review Online, though I read it this morning -- in print in the Chicago Sun-Times.)

The federal mandate to purchase health insurance is not like a state law which can compel citizens to purchase auto insurance for two reasons: First, driving is a privilege granted by the state. I sure hope the distinction between driving and living is comprehensible -- even to federal judges. Second, states have police powers that our federal government of specific, enumerated powers does not have. Or did not have.

The challenges to this health care law will bog down all sorts of lawyers in the courts, perhaps for years, and may (will probably?) work its way up to the Supreme Court of the United States itself. Who knows who will be sitting then? John Paul Stevens is nearing 90 and clearly considering retirement. Ruth Bader Ginsburg has had a couple of serious cancer bouts; rumors of her retirement also circulate from time to time. Whoever is sitting at the time, the Court might divide 5-4, along ideological fault lines, on the constitutionality of the health insurance laws... and that would be a disaster for the country as a whole and the legal profession in particular.

If the health insurance laws are thrown out, the Left will decry right-wing judicial activists and the Right will be more firmly convinced than ever that the Court is our last bulwark against a rogue Congress. The rule of law -- the idea that we are a nation of laws, not of men (the word "men" used here in the generic, non-gender-specific sense because "people" sounds wrong) -- will suffer in both camps. (Suffer? I would venture to suggest that faith in the rule of law is flickering and nearly extinguished in both camps already.) And yet, it is the rule of law that has made our nation rise above the petty ethnic and tribal differences that have doomed other civilizations.

And the funny thing is, more and more, as I think about it, "health insurance" isn't really insurance at all.

The fringe elements are in control of both of our political parties. We must either reclaim the parties or start new ones. And we need new census maps. Anti-incumbent maps -- maps drawn in compact, contiguous shapes, as near to square as population will allow, without regard to the political or other leanings of those who reside therein. We got away from that -- legally -- to protect minority voting rights under federal law. I don't know if we can go back. But that's where I think we should start.

On the morning after Obamacare passed the House

The Channel 9 news at 9:00 cut to the C-Span feed at the end of the newscast last night to show the first of the votes on Obamacare. But the station couldn't stay with the count; there was a Sunday sports show to air.

I flipped over to C-Span to keep watching.

I watched to vote carry -- with a couple of votes to spare -- then I watched the Republicans try to resurrect the anti-abortion Stupak amendment -- then I watched Rep. Hoyer rise in opposition to the motion and cede time to Rep. Stupak, who argued against the amendment that had once been his (winning great applause from fellow Democrats) because President Obama has promised to issue an Executive Order that will preserve the status quo established by the Hyde Amendment some years ago. All this happened fairly quickly and without identifying captions on the speakers but this is what I perceived and I think I perceived accurately. It was hard to follow, because the actors in this drama were following a script written in procedural gibberish. Youngest Son, who was watching also, kept asking for "English, please," but I could not translate and follow the proceedings at the same time. I do know that one of President Obama's first acts as president was to repeal an Executive Order entered by George Bush -- that revived an order first implemented by Ronald Reagan, then reversed by Bill Clinton -- the so-called "Mexico City Policy" which prohibited American funding of family planning services to groups that "offered abortion-related services overseas, even if funding for those activities came from non-government sources. It essentially barred recipients of U.S. foreign aid from promoting abortion as a method of family planning."

Given President Obama's documented opposition to pro-life causes, it is hardly surprising that some were skeptical that his promise for a pro-life Executive Order implementing Obamacare would be redeemed. But it is significant that Rep. Stupak believed: The small number of Democrats who would have supported his amendment switched sides -- and these were the margin of the Democrats' victory last night. There is reason to believe that the Republicans who raised the banner that Stupak laid down were doing so not from pro-life convictions, but to try and bury the overall bill.

The whole thing was a disgusting spectacle and I could only bear to watch for a little while. The last straw, for me, was when C-Span began taking calls from viewers, all of whom had strong opinions, pro and con, about the legislation, with no clue about what the bills actually provide.

This morning, the markets will react to the inevitability of Obamacare. Pharmaceutical and health care stocks will go up or down based on the wild speculations of committed proponents and opponents of the legislation alike. But the speculators will, for the most part, not have read, and certainly not have understood, the bill.

Neither have I. Neither have you. I would bet that most of the congressmen who voted for and against the bills last night have not read the bill either. I wonder if most even have someone on their staffs who claims to have read it all.

Part of the blame for this must rest with the administration and congressional leadership: The negotiations of the final bill were secret -- and the final provisions were not made public until the middle of last week -- and, by "public" I mean public only in the loosest sense because in the muddle of the Internet I am unable to locate what I can authoritatively link to as the exact text of the bill passed last night. It was at least claimed that the final bill was released in the middle of last week. I can find a million news stories telling me what others think is in it, good and bad, but not the bill itself. I can't even tell you how long the bill is -- I've heard 3,000 pages, but that may be an exaggeration.

It is certainly more than 1,000 pages. Various versions clocked in at more than 2,000. So, whatever the actual number, hundreds and perhaps thousands of pages of legislative sludge will be inserted into the statute books, probably this week, allegedly affecting one-sixth of the American economy. The Congressional Budget Office, which has studied the actual bill, believes it will reduce deficits even as nearly a trillion new government dollars are poured into health care.

There's only one way that can happen: The bill must raise taxes.

The Republicans who oppose the bill have done a poor job of pointing this out. The Democrats who supported the bill may not even know that they have supported a massive tax increase.

Court challenges will follow as details of the final plan emerge. Some 38 states are considering -- and one has passed -- laws refusing to participate in Obamacare. There will be challenges to these as well, perhaps even a constitutional crisis as the national government asserts new powers in areas formerly governed by state law only.

If courts strike down all or some of the Obamacare provisions as unconstitutional, will respect for our courts be increased or diminished further? (I'd make book upon the latter, assuming the Obamacrats remain in office when the court challenges are finally resolved.)

The administration and the Congressional Democrats were bound and determined to get health care "reform" at any price. A bill -- any bill -- had to be passed. The Republicans were equally insistent that the bill -- any bill -- must be defeated. In both camps, truth was the first casualty of the ideological war. But, eventually, the details of the price we will all pay will emerge as people begin to obtain and read through and study the actual new law.

Neither the Republicans nor the Democrats have performed admirably in these events. Each blames the other, but both are to blame. And we the people will reap the consequences.

Have you ever heard of a "hospitalist?"

I visit Ellee Seymour's blog on occasion; she's been kind enough to return the favor (or, since she's English, I suppose I should say 'favour') from time to time. Ms. Seymour blogs on English politics and apparently enjoys a considerable following.

Earlier this week Ms. Seymour had a post entitled "Introducing the Hospitalist." Per her post, this is "an American concept." An excerpt:

A hospitalist is a medic who cares for all the patient’s needs from the moment he enters hospital, until the moment he leaves. He is also a point of contact when the patient returns home and wants to call and check on medication or has any immediate concerns. Patients and their families often find it hard to take in important medical information and its full implication while in hospital, and it is reassuring for them to know there is one person who is aware of the full facts and, most importantly, is accessible.

As I understand it, the hospitalist is basically a case manager who will liaise with patients and hospital staff to ensure their needs and will follow through all the needs regarding his treatment. They will ensure there is no confusion or misunderstanding surrounding complications, such as when a patient has more than one medical problem and is seeing more than one consultant.

I've never heard of any such thing.

Of course, I'm a middle-aged Dad and, therefore, by definition, clueless on most things, especially if they are in any way trendy. Also, with the significant exception of having most of my colon removed three years ago (how time flies!) I have managed to avoid hospitalizations recently and may, therefore, have a reasonable excuse for not knowing about it.

So, I open up the discussion to the group: Have you ever heard of a "hospitalist?" Have you any experience of this specialty... whether good, bad or indifferent? If you have some information on the topic, leave a comment, please (and, lurkers, please consider yourselves specifically invited to leave a comment as well).

Thank you.
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And, if anyone is interested in my own hospitalization story, here are the posts, in chronological order. I thought these were pretty amusing when I wrote them... although, of course, I was heavily drugged up at the time....

• I'm ba-ack... sort of (March 5, 2007)
• The lawyer tax (March 7, 2007)
• Epidural (March 7, 2007)
• SICC -- the case of the bad neighbor (March 8, 2007)
• Nurses -- or -- There goes another fantasy (March 9, 2007)

An heretical thought about health "insurance"

I realize it's probably too late in the process to go back to first principles in the American health care debate, but I have a day job and I can't think about these things full-time.

I am an insurance lawyer by trade. I started out in insurance defense and moved into coverage work. I have limited experience, though, in life, accident or health coverages. My work has been primarily in the area of auto, homeowners, OLT (owner-landlord-tenant) or CGL (business) coverages. At one point I did a lot of fire work, both first and third-party stuff (meaning sometimes I was representing the insurer directly and sometimes I represented an insured who was accused of causing a fire loss at someone else's property).

In the course of my career I've learned that the bedrock principle of insurance is fortuity. Basically, insurance can be procured to protect against things that might happen -- not for things that must happen. For example, if the wind blows very hard and tears the roof off your house -- that's covered. However, if the roof wears out and lets the rain in -- that's inevitable and, therefore, not covered. (Entropy increases.)

And therein lies the difference between property insurance and what we call health insurance: With proper maintenance, a building can last indefinitely. (Tourism depends upon it.) The fortuitous risks to which a building may be exposed in the course of any given year can be identified and measured and rated accordingly.

On the other hand, with the best possible maintenance, and a dollop of good luck, a person can expect to last for... what? A hundred years? 90? As people age, even those who've enjoyed very good health can expect increasing problems. They may never occur -- but, when they do, they're not unexpected.

Doesn't the very idea of health insurance violate the principle of fortuity?

I think that the principle, or something very much like it, might apply if large groups of people are considered. But individual health policies take into account the health of the insured at the time of application -- they are 'rated' individually. Thus -- as the reformers keep telling us -- people with pre-existing conditions or predispositions to certain conditions or even prior conditions can't find insurance. Well, of course not -- not if we're talking about a product that only covers fortuitous losses.

The Democrats in Congress are shortly expected to pass mandatory health insurance requirements as part of the bloated, however-many-thousand-pages-this-week health care bill. Yet I'm not sure we know whether there is such a thing, really, as health insurance.

I'd like some guidance on this, please.

The absence of a plan has been noticed....

(Oliphant cartoon obtained from Yahoo! Comics. Click to enlarge.)

Neither Mr. Oliphant nor Chicago Tribune columnist Eric Zorn are likely to be reported to the White House as non-believers, but both have questioned, as I did in Monday's post, whether the President really has a health care plan.

Mr. Zorn's linked column decries the efforts of the vocal naysayers who have (so far, at least) seemingly turned the tide of public opinion against health care reform. But even Mr. Zorn is obliged to concede, "There is as yet no one plan for proponents to defend, so every idea remains an attack target."

It is said that every general prepares for the last war. This is why, presumably, no battle plan survives contact with the enemy.

These familiar military aphorisms apparently apply to politicians as well.

Mr. Obama was anxious to avoid the Tablets-From-Mt.-Sinai approach that doomed Hillarycare in the 1990s. So he made a point of convening experts from a wide range of disciplines and secured consensus that reform of our health care system was imperative.

Then he got lazy.

Instead of doing the work of leading the country toward a consensus plan, building on the White House meetings, Mr. Obama delegated the process of writing the actual bill to Democratic True Believers in the House of Representatives, many of whom had been advocating a single-payer (O Canada!) system for years. It is one thing to show some willingness to modify a plan in conformance with political necessity; it is quite another to outsource the making of the plan in the first place and promise to claim ownership of any proposal that survives.

To make matters worse, Mr. Obama insisted on a unrealistically short timetable for adoption of his plan, which wasn't his plan at all, and was -- despite the dog and pony shows at the outset -- no more inclusive than the process was which resulted in Hillarycare.

In his Tribune column this morning, John Kass writes:

Americans wanted some break in ridiculously high health-care costs. They deserved a break. They were primed for it, with Obama promising and promising and news story after story during the campaign buttressing his position, all about how somebody got laid off and contracted a disease, but they couldn't afford the insurance premiums and lost their home.

The sad fact is, that really happens. People have lost their homes. And folks wanted something done.

But Obama's people turned it into a disaster. It got so bad that the White House encouraged Americans to rat their neighbors out on that official White House rat line, which begged Obama-loving Americans to tell the president when health-care opponents put out "disinformation."

The people of this country, I believe, do want something done with health care -- but I don't believe there is as yet any true consensus on what that something should be. The True Believers on the Left do want something very specific. But they aren't leading; they are dictating. They are controlling the Administration's side of the "debate" because of the absence of leadership from the top: Mr. Obama, who signaled a willingness just last weekend to jettison the so-called 'public option,' now has retreated in response to blowback from True Believers. Mending his fences in this way may help Mr. Obama get some sort of bill through the House this year... but what doth it matter if he gains the House but loses the Senate?

Meanwhile the Republicans stagger around in increasing irrelevance, mumbling about "death panels" and "tort reform."

And we elected these people!

The truth about the President's health care plan?

The truth is, there is no plan.

There is a thriving marketplace of ideas -- many of which have evolved into tome-length statutory proposals.

For example, the plan that gets the most ink is H.R. 3200, America's Affordable Health Choices Act of 2009. At the moment, this plan contains a "public option."

But there is also H.R. 676, the United States National Health Care Act or the Expanded and Improved Medicare for All Act. This is the "single payer" bill. (O Canada!)

There is also a bill drafted by the Senate Health, Education, Labor & Pensions Committee (the HELP Committee, get it?) which consists of 615 pages of light afternoon reading. According to news reports, a key difference between the HELP Committee proposal and H.R. 3200 is that the Senate proposal has no "public option."

I could not find, in my quick search this morning, a link to the proposal touted by Sen. Kent Conrad (D-N.D.) which calls for not-for-profit health insurance cooperatives instead of a government controlled entity.

While one of these proposals may become law, it will not pass in its present form. Congress is a sausage-grinder. Even if a consensus forms around one plan or another, the details won't be made public until the House-Senate Committee works on a bill reconciling the versions eventually passed by each house.

Thus, there is no plan. There is no up-or-down, take-it-or-leave-it proposal that your Congressperson can say she's for or against.

The President has been perceived as generally in favor of a "public option" in a health care bill and the press has understood this to mean that he supports H.R. 3200 -- but the Obama administration gave clear signals this weekend that it could live without it. Whereupon Howard Dean broke ranks, calling a public option "indispensable." (Meanwhile, in the Senate, Sen. Conrad is telling all and sundry that there aren't the votes for a public option.)

Mr. Obama is correct when he says that bureaucratic interference with doctor-patient relationships, irrational delays, and uncontrolled costs are all features of our largely private health care system right now.

He is, further, correct when he says that reform is needed.

But what, sir, is the plan?

A useful role for government in health care reform

OK, we have to wrap this up: I don't think there's anyone in America that doesn't agree that the health care system is in serious need of reform. I also think most people would agree that, when it works, our health care system is the best in the world. It just doesn't work that way for many. The goal of reformers, therefore, should be to preserve the quality of care that is available in America to some... and make it more available to more people.

I don't believe that government can achieve this goal by providing health insurance or health care itself. Government provided health care sounds like eternity in line at the DMV, only with people coughing, hacking and sometimes passing out.

On the other hand, sitting back and wishing for the "market" to work all by itself is foolish, too.

First, right now, there is no real easy-to-define "market" for health insurance and health care. Some people provide their health insurance, as I did for many years. But most people don't see or feel what it really costs for health care: Either their employer provides it (O! You dwindling few!)... or the State provides it (Medicaid and Medicare)... or the Bankruptcy Court dismisses it (for those uninsured who guessed wrong about the state of their health).

There are (to borrow a recent, but still hackneyed phrase) 'green shoots' of a market in phenomena such as nurse practitioners beginning to staff 'clinics' in pharmacy chain stores.

Sound government policy, I'd submit, would be to wean Americans off the employer-provided system and introduce an individual-based one.

Now I've railed here against some of the horrible companies I've seen providing individual coverage: Thieves and liars are some of the nicest things I've called some of them. So it may seem strange for me to suggest that this can be a model for us to follow.

But this is where government can play a constructive, useful role.

Government can be a nifty referee, prescribing mandatory rules for coverage and providing a level playing field for consumers and holding insurers accountable for misconduct through -- are you ready for it? -- the court system.

Government can insist on uniform standards for all health insurance policies: All policies must cover preexisting conditions, for example, or insure over genetic tendencies. Prohibit health insurers from 'negotiating' prices for services: Make doctors and hospitals charge what they need and compete with other hospitals and doctors on cost and/or quality of care. And let's take Medicare and Medicaid out of negotiating prices, too. If a hospital wants to charge $3,000 to Blue Cross for an overnight stay, it can't charge $3,500 to Aetna -- or $10,000 to an uninsured person.

But what would keep doctors and hospitals from jacking prices through the stratosphere? Shame alone won't work. We seem to live in a post-shame world. But we can require (regulation) that non-profit hospitals must truly be non-profit, or forfeit that status. And we can permit health insurers hire their own doctors and run their own hospitals. The new Blue Cross might be able to pay (say) 75% of any insured's hospitalization at any place the insured chooses -- but 85% of the hospitalization if the surgery is done at the Blue Cross owned hospital. Here again, government could set the upper and lower percentages and thereby be helpful. That's appropriate regulation. Within this regulatory framework, people could make decisions appropriate to their own circumstances and prices would be controlled.

Even if uniform health insurance standards were prescribed at the national level, I'd like to see health insurance contracts enforceable in the state courts -- and no diversity removals, either. Let local communities decide, in jury trials, whether one of their neighbors has tried to cheat the insurer... or vice versa.

The meaningful threat of an attorney fee award can be a significant deterrent to an insurer that might be tempted to boost profits by failing to provide contracted coverage.

Encourage the formation of doctor-owned malpractice carriers... even tort lawyer-owned malpractice carriers. But prohibit malpractice insurers and health insurers from being jointly owned. That's useful regulation. Health insurers that run hospitals or hire doctors would be subject to the same malpractice risks as any other hospital or employer of physicians. Don't cap malpractice recoveries but, rather, insist that malpractice insurers have the right and duty to settle cases where settlement is indicated. Don't brand doctors with the Mark of Cain because of a malpractice settlement -- but beef up state medical boards to weed out incompetent doctors. Regulation, again.

Some people will surely be unable to provide coverage for themselves or their families, no matter what price the policy. Government will in effect be picking up the tab for these people whether it is through charity hospitals (e.g., Cook County Hospital) or by setting up its own clinics and hospitals or by paying for services obtained. I'm willing to bet, however, that -- government being as incompetent in most things as it is -- most people, if they have a meaningful, reasonably-priced alternative, will choose anything other than government health care every time.

I've been trying for three days now to think of an analogy to show what I think government can and can not do.

This is the best I've come up with. I know some lawyers, both plaintiff and defense lawyers, who know more medicine than most doctors. They can diagnose and evaluate with the best doctor you could find. That's how they can evaluate cases, taking good ones, or settling bad ones. Yet, I wouldn't let one of those lawyers near me for treatment, not even with a 10 foot thermometer. Just because a lawyer has extensive medical knowledge does not make him or her a doctor. In a way similar to my lawyer acquaintances, government can develop expertise in regulating health insurance and health care -- especially if it permits the nation's lawyers to keep the players honest -- but government can't provide health care.

As we are about, I am afraid, to find out.

Malpractice "crisis" a monster in the closet

Some in the audience at the AMA convention booed President Obama yesterday when he said he would not favor "caps" on medical malpractice cases -- contrary to my fearless prediction here yesterday morning -- but there were cheers when he indicated he was open to other reforms. I'm all for reforms that will make things better. One thing we need to do is to call a truce in the war between doctors and lawyers -- especially over medical malpractice cases. If there's a doctor in the house, swallow your bile and read on as I explain why the malpractice crisis is no more real than the monster in your kid's closet.

It is a fact that, in the universe of cases filed, there are relatively few malpractice cases. The extraordinary verdicts in some of these are usually in cases where the doctor is incredibly, embarrassingly guilty.

Oh, huge malpractice premiums are real enough. Premiums are so staggeringly high that they can, and sometimes do, drive good doctors from vital specialties -- such as obstetrics.

And, if you'll pick up any random edition of the Cook County Jury Verdict Reporter, you'll usually see a large number of medical malpractice cases represented.

But that's not because so many of these are filed -- it's because a disproportionately high number of these kinds of cases go to trial vis a vis other types of cases.

In Illinois, these kinds of cases go to trial because doctors have traditionally had veto power over any settlement.

That's not the way it works with an auto liability policy. A person sued for allegedly running a red light and smashing into another car has no say in whether his insurer settles -- even though he may insist, loud and long, that he did not run that light, that it was not his fault. The insurer makes an economic decision; sometimes it may even believe its insured -- and still settle the case, if the price is right, because it considers its costs through trial and the risks of receiving an adverse verdict.

But no matter how clear-cut the case against Dr. No may be, Dr. No may be able to insist on a trial -- and that seemingly outrageous verdict which follows may be the result of a justifiably outraged jury. Caps are the wrong way to contain these rare cases; the better way would be to allow insurers the right to settle cases when settlement is appropriate.

And even with those occasional guilty (and stubborn) as-all-get-out cases, in the plaintiff-friendly, overly generous, "judicial hellhole" of Cook County, doctors win more malpractice cases than they lose.

You could look it up.

Here, in one of America's largest cities, there are only about 10 or 12 plaintiffs' attorneys that I would entrust with a real medical malpractice case. Some I know by name, others only by reputation. I might be undercounting by a few -- but not by many. (For comparison purposes, there are something like 80,000 attorneys in this state.)

Why are there so few attorneys who I believe capable of handling a med mal case? It's not just that malpractice cases are difficult (although they are) but most attorneys simply can not handle the cost of carrying even one malpractice case to trial.

Nor is every incident of arguable medical malpractice a case that lawyer would or should take. Let me illustrate with an example in my own family, that I first wrote about in 2005. Older Daughter developed some serious foot problems while she was in college and these had to be treated with surgery. The first surgery did not go well.

[In that first surgery] a nerve was severed that should not have been. It has caused my daughter pain and discomfort since. A subsequent operation, by a different doctor, in which the nerve was 'tucked into' the muscle, has failed to resolve the problem. Now the second doctor has sent her to a third doctor, who proposes still other surgery.

My daughter was convinced that the first surgeon was a butcher who should be called to account. I tried to explain to her that, despite the severed nerve, the doctor might be found to have complied the applicable standard of care. And then I gave her the real bad news:

[I] pointed out that, although she continues to have pain, especially if she's too long on her feet, she may not have been injured badly enough to make it economically worthwhile to pursue a case for malpractice, given the costs and uncertainties of such a claim, even if a lawyer specializing in malpractice cases agrees with her unkind assessment of her first doctor.

She didn't want to hear that from me. She thought I must be a very bad lawyer to tell her these things. She wanted a second opinion.

Eventually, worn down, I referred her to a prominent, very successful attorney in Champaign (who also clerked for me many years ago before joining his brother's successful practice Downstate). Older Daughter went to meet with him; he was sympathetic.

However, he told her, he did not handle malpractice cases in Champaign because of the expense involved. He would refer her to another attorney who would evaluate her case.

Guess what? My ex-clerk sent Older Daughter to one of the 10 or 12 lawyers -- in Chicago -- that I would consider capable of handling such a case. This particular fellow was not one of the ones that I know personally.

And the punch line? This attorney reviewed all the records (I was pressed into service delivering them) and consulted with his own doctors (all the best malpractice attorneys have a stable of doctors with whom they can discuss the merits of a possible case; in fact, to even file a case in Illinois, a lawyer must have an affidavit from a doctor in the appropriate specialty attesting to the potential merit of the suit). After all this, he gave Older Daughter the news: Despite the severing of the nerve, it was at least arguable that the doctor complied with the standard of care -- and besides that, even if the case had real merit, the injury involved was insufficient to justify the expenses involved in bringing the case. Hmmmmm. Where had I heard that before?

No suit was filed.

I suppose Older Daughter could have found someone to file her suit. Some malpractice cases clearly are filed by attorneys who shouldn't be handling them. But those aren't the cases that result in boxcar verdicts.

Anyway, I firmly believe that doctors AND lawyers will have a part to play in real health care reform. Now that we've reached a truce on this malpractice business, let's move on to real reform tomorrow, OK?

Obama dangles 'caps' to AMA -- part one in a discussion of why the Left and Right are Wrong on health care reform

Mr. Obama will speak today to the meeting of the American Medical Association in Chicago. He will tell the doctors that health care "reform" is a priority and can not be delayed.

What shape those reforms might take is still... largely under wraps. The President's supporters hope, and the doctors fear, that whatever program is put forward will make the government a player in the health insurance business. The unquestioned goal among many Obama supporters is to make government the only player.

Many doctors fear anything that will jeopardize their income and status, yes, but many also fear that an increased government role in health care will deprive them of the right to choose what they believe best for their patients. Government health care may mean the loss of professional judgment and freedom.

So Mr. Obama is expected to wave a carrot at the recalcitrant doctors today: He is expected to express an openness to liability limits on medical malpractice claims. Caps.

So many doctors want caps so badly that they would give up almost anything -- including their professional freedom -- to attain them.

It is apparent that the days of employer-provided health insurance are numbered. An employer-provided option may exist, on paper, in the bill that emerges from the low-profile meetings now ongoing among usually high-profile congresspeople, academics, and lobbyists. But, if such an option does make it into the language of the bill, it will be largely a chimera.

The biggest employers in this country don't want to provide health insurance (e.g. Walmart)... or can't afford to anymore: The decline of the American auto makers has been blamed on health costs as much as anything else. So Big Business has finally been converted to the cause of government-provided health insurance; the Left has always has been in favor of it. I've said it here before... the skids are greased.

There may be an alternative.

Now, I'm not a great fan of individual health policies: I've paid for far too many over the years. When my Long Suffering Spouse began teaching full time in the Chicago Catholic schools, I got a big raise: I no longer had to shell out what was, by then, nearly $18,000 a year in health insurance payments.

As an insurance lawyer, I've seen horrible examples of private health carriers screwing individuals for having the temerity to become ill during the policy term, even suing to rescind health coverage.

And, personally, as one who's had a brush with cancer, I greatly fear my own ability to procure individual insurance -- at any price -- in a tooth, fang and claw free market system.

But... I've also seen Medicare liens that included amounts for services provided that never were provided. Out and out fraud... in $10 increments... but multiplied over a whole flock of old people... a gold mine for the unscrupulous.

Older Daughter worked in a hospital based medical practice for a year, one of six people who did nothing more than code bills for insurance payments. Why the elaborate codes? Because Medicare is already driving the health insurance market, and does so more with each passing, Baby-Boomer-aging year. Old people may not make up a majority of the population... but they consume a disproportionate share of medical services.

And hospitals and doctors charge obscene prices, at least on paper, for the uninsured, driving up costs for everyone and everything because Blue Cross or Medicare will only pay a percentage....

Mr. Obama, is right, at least to this extent: Reform is badly needed and badly overdue. But government can not even take proper care of its soldiers, sailors and marines who have been injured in our recent adventures in Afghanistan and Iraq. Think of the recent scandal at Walter Reed... the jewel of the military medical system. There are far too many other examples for our purpose this morning.

But both the Left and the Right misunderstand the proper role of government in health care reform.

For the Left, single-payer is the only way to go -- no matter its flaws and inequities elsewhere in the world. And since government will be running the show, we can even cap malpractice claims... because, after all, our barefoot doctors laboring for the President would never make mistakes.

But those on the Right, with their slavish devotion to the Market, the Market, the Market, are no better. These people are the geniuses who gave us credit default swaps.

For the Left, the government must be a Player. For the Right, the government must be a Bystander.

Does no one think the government might best serve as a referee?

That's the role of government in an individual option that I want to talk about in a future post. Perhaps -- work permitting -- as soon as tomorrow.

(Do not fret overmuch, however: Froth and levity will not be suspended indefinitely.)

Aggravated by the doctors' Praetorian Guard

I have a doctor's appointment in a little while.

It was supposed to be at 8:30 this morning, and I set it at that time so that I could go from there to the office and not miss much of my day.

But, on Friday, the doctor's office called -- the doctor with whom I had made the appointment would not be in after all. I could see his partner... at 11:00 a.m.

There goes Monday! (And I've brought work with me to do; it won't be a total waste.)

But that's not the most aggravating part of this.

The reason for this appointment is entirely, completely unnecessary.

Last year, when I had my surgery, it was explained that I would have to have a follow-up in a year's time. I haven't nearly as much plumbing to explore as heretofore, so the testing would be relatively easy. All I had to do, the doctor said, was call the office and schedule the appointment.

Key words in the preceding sentence are "the doctor said."

Because, in America today, doctors do not appear to know beans about their office procedures. They do not control their schedules. They are guided by their staffs from room to room: Heal here, heal there, counsel here, surgery!

I called the doctor's office as the one year anniversary of my diagnosis approached. I called to schedule the procedure that I was told I'd need.

And I was not permitted to schedule it.

The doctors' Praetorian Guard requires me to see the doctor first, before any scheduling of a further procedure. Why, I can not fathom. It is on my chart; it is on their computers. But some iron-clad procedure would apparently be violated were I to do what the doctor said I was supposed to do.

So I'll ask him why I am required to see him for 60 seconds in the middle of the day just so I can schedule the appointment for the procedure we both know I need to have.

And it won't make any difference what he says... because he doesn't really know.

This, by the way, is an excellent group of doctors -- the best at what they do in the area. (This is not just my personal testimony, it is the consensus of medical opinion -- I researched this). And I have the best possible health insurance -- a Blue Cross PPO.

But -- don't worry -- once we have Universal Health, we won't have any problems like this....

HA!
--------------------------------------------------------------

Update 1:16 p.m.

It took a little over two and a quarter hours to get to, from, and wait for an appointment which took a little over two and a quarter minutes. The doctor was apologetic -- but more for suggesting in the first place that I might be permitted to make an appointment on my own for a test that we both agreed I should have -- and which will be a little more than two and a quarter months overdue when the test is finally performed. It is... frustrating.

Before getting too excited about 'universal health' -- another in a series

Please read this post by Ellee Seymour. You may want to follow the link to York Press article cited in Ellee's post.

Now, remember, comes the revolution, when we have squeezed the filthy profit motive out of medicine, doctors will treat patients for what ails them, not according to which tests are the most remunerative... and everyone can then get the treatment they need, right?

Not in York, apparently, where fully 40% of patients referred by their doctors for additional treatment last year were refused, apparently to save money, because a panel there decides who will get care... and who will not.

A panel decides who will live.

And who will die.

You thought HMO's are bad? (And they are.) This sounds worse.

Before getting too excited about 'universal health' -- continued

Herewith an article from the March 1, 2008 edition of the Toronto Globe and Mail. I have no reason to believe the Globe and Mail to be in the thrall of the American insurance industry; a quick check of the newspaper's Wikipedia entry suggests that it has ambitions to be the Canadian newspaper of record.

I have included Lisa Priest's entire article, not because I am contemptuous of Canadian copyrights (I hope I always respect copyrights), but because I do not wish to be accused of selectively cherry-picking quotations from the article to make a point. I believe, in this instance, for this particular occasion, that full reproduction of this one article constitutes "fair use":

Why Ontario keeps sending patients south

LISA PRIEST
From Saturday's Globe and Mail
March 1, 2008 at 12:45 AM EST

More than 400 Canadians in the full throes of a heart attack or other cardiac emergency have been sent to the United States because no hospital can provide the lifesaving care they require here.

Most of the heart patients who have been sent south since 2003 typically show up in Ontario hospitals, where they are given clot-busting drugs. If those drugs fail to open their clogged arteries, the scramble to locate angioplasty in the United States begins.

“They rushed me over to Detroit, did the whole closing of the tunnel,” said Eric Bialkowski, 47, of the heart attack he had on March 14, 2007, in Windsor, Ont. “It was like Disneyworld customer service.”

While other provinces have sent patients out of country – British Columbia has sent 75 pregnant women or their babies to Washington State since February, 2007 – nowhere is the problem as acute as in Ontario.

At least 188 neurosurgery patients and 421 emergency cardiac patients have been sent to the United States from Ontario since the 2003-2004 fiscal year to Feb. 21 this year. Add to that 25 women with high-risk pregnancies sent south of the border in 2007.

Although Queen's Park says it is ensuring patients receive emergency care when they need it, Progressive Conservative health critic Elizabeth Witmer says it reflects poor planning.

That is particularly the case with neurosurgery, she said, noting that four reports since 2003 have predicted a looming shortage.

“This province and the number of people going outside for care – it's increasing in every area,” Ms. Witmer said.

“I definitely believe that it is very bad planning. ...We're simply unable to meet the demand, but we don't even know what the demand is.”

Tom Closson, the Ontario Hospital Association's president and chief executive officer, said 30 per cent of Ontario's hospital medical beds are currently occupied by patients awaiting more appropriate placements, such as assisted living centres, a nursing home, a rehabilitation facility or even their own homes with proper home-care supports.

That squeezes the system at both ends: Patients in intensive care units whose condition improves cannot get into step-down units, and some emergency patients can't get a bed at all, he said, adding that “everything is jam-packed at the moment.”

A method for determining the right mix of beds and health services required in Ontario needs to be developed, he said, noting that that task has not been undertaken on a provincial basis for a decade.

Laurel Ostfield, press secretary to provincial Health Minister George Smitherman, said that in emergencies, where the patient goes becomes a clinical decision.

It is preferable for someone with a heart attack in Windsor to be sent to Detroit, a few kilometres away, rather than on a long ride to London, Ont.

When demand has peaked, government has responded, she said. It struck a neurosurgery expert panel to study the problem and $4.1-million has been provided to stem the tide of U.S. neurosurgery patients.

As well, stand-alone angioplasty services were created in Windsor in May.

Canadian Medical Association president Brian Day said he couldn't speak about the Ontario problem, but noted this country is the last in the Organization for Economic Co-operation and Development to finance hospitals with global budgets.

Under that model, patients – and often doctors – are sometimes viewed as a financial drain.

“We keep coming back to the same root cause,” Dr. Day said in a telephone interview from Ottawa. “The health system is not consumer-focused.”

Patients first learn of the problem when they are critically ill.

Jennifer Walmsley went to Headwaters Health Care Centre in Orangeville in October and was diagnosed with a cerebral hemorrhage due to a ruptured aneurysm. That acute-care hospital does not have neurosurgery and no Ontario hospital that does could take her. She was then rushed to a Buffalo hospital.

Headwater's chief of staff, Jeff McKinnon, said three neurosurgery patients have been sent to Buffalo in the past year. Others have gone to Toronto, Mississauga, Hamilton and London.

Radiologist Louise Keevil said Headwaters has an arrangement with neurosurgeons at other Ontario hospitals to send electronic images for their assessment, but “the limiting factor is availability of beds in their hospital.

“The physicians are very accommodating but their hands are tied by availability of service.”

Kaukab Usman had a heart attack after a gym workout in Windsor on Dec. 9. She was rushed to hospital and given clot-bursting drugs.

When they failed, she was sent to Henry Ford Hospital in Detroit, where she had angioplasty on one clogged artery and two stents inserted.

“It was a miracle for me to be alive,” Ms. Usman said in a telephone interview from Somerset, New Jersey, where she is recuperating.

Aaron Kugelmass, director of the cardiac catheterization laboratory at Henry Ford Hospital, said a system is in place to get these patients the care they need expeditiously.

“We try to make their length of stay in the U.S. as short as possible,” said Dr. Kugelmass, associate division chief of cardiology. “If they are stable for discharge, we discharge them to home in Windsor, with clear follow-up plans.”

Cross-border emergency health care should become less frequent when Amr Morsi, an interventional cardiologist currently in Orlando, Florida, comes to work at Hotel-Dieu Grace Hospital in Windsor in April; a second interventional cardiologist is to come on board there by end of year.

When the program is fully functional, Dr. Morsi expects Hotel-Dieu Grace to be able to do 500 angioplasties a year.

“The idea of starting the program in Windsor is that we will be able to do more of the angioplasty procedures in Windsor without having to send them to Detroit or London,” said the Toronto native who did his cardiology training at the University of Toronto.

“It will take some time to decrease the numbers entirely, but that certainly is the long term plan.”

Mr. Bialkowski of Lakeshore, a town east of Windsor, had angioplasty and received four stents. The stents, typically made of self-expanding, stainless steel mesh, were placed at the site of the fully blocked artery to keep it open.

The price to treat him, including a two-day hospital stay in March, 2007, was $40,826.21 (U.S.) With a 35 per cent discount from Henry Ford Hospital, the bill to the Ontario Health Insurance Plan tallied $26,537.03(U.S.), according to a health ministry document, a copy of which was sent to Mr. Bialkowski.

The father of six, a human resources manager for a manufacturing company based in Windsor, is back at the gym and feels great. It didn't matter where he received the lifesaving care, he said, just so long as he obtained it.

“I guess the Canadian government took care of me,” he said.

It's nice that American hospitals can provide this service for our Canadian neighbors -- but how long would we be able to do under our own "universal health" system? And where will we go then?

Before getting too excited about 'universal health'

Consider that government-funded (or government 'subsidized') universal health care will have to meet budgeting necessities... and "priorities" will have to be set.

And who will set them?

Harvard researcher Dr. Susan Mitchell? This AP story, by Carla K. Johnson, that I saw yesterday morning in the Chicago Sun-Times, suggests one lovely cost-cutting measure: Just let senile old folks die. Why bother giving Alzheimer's patients antibiotics, Dr. Mitchell argues in a study cited in the AP article, when they have a fever? After all, their disease is "terminal."

The problem with this logic is that we're all terminal. Some have a better idea of when than others, that's all.

There may be reasons why someone chooses to turn their face to the wall and submit to the Inevitable. There are surely valid, moral reasons why loving families will agree not to pursue heroic measures in exchange for merely delaying death... and prolonging agony. I remember my own mother -- my mother who set something of a record for the length of her hospitalization, so rare in the age of Medicare -- I remember my mother showing off her 'DNR' bracelet. "See my new jewelry?" she said. And she wasn't complaining. She was reconciled to her situation; she maintained her good humor to the last.

I was at a wake last night for a neighbor's mother, a woman who made it to 90, though the last few years were clouded by Alzheimer's, eventually to the point where she had to enter a home to receive needed care. At the end, she wound down like a mechanical clock, whose ticking slows... and slows... before it stops. The night before she went the staff called the son in. They offered hospitalization. But she was so peaceful. She was just winding down. Hospitalization was only going to disturb her.

They decided to let her go.

They.

The family.

Not some snot-nosed bureaucrat a thousand miles away setting priorities. Or some Ivy League, ivy tower doctor who thinks antibiotics are wasted on the old.

Note to Democratic Presidential Candidates, continued -- the other side of the coin

And I do mean coin.


Here's another Prickly City comic, this one from November 17, also taken from Yahoo! Comics. (Click to enlarge.)

My blogfriend Hilda responded to the preceding post, also illustrated with a Prickly City comic strip, in which I asked why we shouldn't be afraid of national health care in America. She said, "Because many other industrialized nations have socialized medicine and manage just fine. Despite recent election results and the fact that 'The Bachelor' is still on the air we're not dumber than they are, so we should be able to do it right."

But Jean-Luc Picard (who seems very well acquainted with conditions in 21st Century Britain for one piloting a starship in the 24th Century) responded, "The NHS isn't that good here in Britain."

But that's just an opinion. My blogfriend Claire has been writing about the trials and tribulations of her mother, the cupboard monster, and her on-again, off-again surgery and attendant complications. She wasn't being political -- she wrote as a concerned -- if almost completely irreverent -- daughter. I would not want necessary surgery for someone in my family set and canceled and set and canceled again because of someone else's priorities....

But, Hilda says, "[M]ost of the Democratic plans as I understand them will give you the option to maintain a private plan if you and/or your employer choose to BUT those who don't have that option will at least get some degree of health care so they don't die in the street like animals."

Point 1 first: Wal-Mart can't wait for national health care. Do you think any major American employer is going to continue to offer private health insurance (except maybe as a perk for top executives) once we get our own national health system? One of the big excuses for the decline of the American auto industry is that too much is paid into health and pension plans and not enough into coming up with cars that best the foreign competition.

Well, private pensions are already just about history. Do you think American auto manufacturers will offer private health insurance on day one after national health comes into effect?

Then Point 2: At least in Chicago, people don't die in the street from lack of health care. They may die waiting in line....

I had the uncomfortable experience of trying to get public health service for my brother a little more than a year ago. The lines before the clinic opened were horrific and the people waiting seemed listless and sullen and there was (it seemed to me) an overwhelming feeling of hopelessness. We have great emergency care for the poor -- we have a number of public hospitals and all hospitals that accept public money -- and that's all of them -- are obliged to take a certain percentage of charity cases of lose that privilege. (There has been a modest scandal here about how few charity cases some of the Catholic hospitals really take. About all I can say for certain is that my brother had to be admitted recently -- and he was diagnosed with an "anxiety attack." The cynic in me says this is what hospitals call heart attacks when patients have no insurance; because of the minimal diagnosis, he could be, and was, released in only a day or two.)

Long lines and short staffing in clinics prompts people to overburden emergency services, even where there is no emergency. I have heard stories of expectant mothers calling 911 for rides to clinics for well-baby care. (In the stories I've heard and read the callers don't state the real reason in the call; they claim 'difficulty breathing.') Sometimes these stories come out when someone dies waiting for an ambulance in a real emergency (because, for example, someone didn't believe a real difficulty breathing call).

But I can't help but think that part of the problem with delivery of health services to our poorest people here is the fact that it is already politicized. It is already a patronage haven. There may be less than generous funding that has come into our system from Washington -- dominated as it was for several years recently by right-wing Republicans. But it isn't Republicans who allocate where the money is spent here. And it isn't Republicans who provide the local component of our public health care funding. Nor is it Republicans who are cutting nursing jobs and sparing management positions in Cook County.

So... I'm not reassured. But I'm not thrilled with our current system either. I wrote just last month about abuses I've witnessed in our current system. But I'd like another option, please.

Note to Democratic Presidential Candidates: This is what I'm afraid of

Prickly City from November 15. Obtained at Yahoo! Comics. (Click to enlarge.)

Now: Why shouldn't I be afraid?

Is there a real cost of health care? A horrible example -- and some questions about a suggested alternative

President Bush recently vetoed a proposed expansion of the State Children's Health Insurance Program (SCHIP) (the link will take you to the government site explaining the program) and the usual suspects are predictably aroused.

Here, for example, is an ABC News story about the feared consequences of the veto. Although the proposed SCHIP expansion had bipartisan support, not all Republicans favored it. Here is a link to an op-ed piece in the Kansas City Star by U.S. Representative Sam Graves (R. Mo.) defending the veto.

I'm not taking sides here on a political question, but I'd like to add a couple of observations and ask questions of anyone who comes across this.

I write as a lawyer who has some experience of the ridiculous nature of our health care pricing system. Let me give you a real-life example from a case that is settled and done.

You'll understand that I can't use actual names and must fuzz the details.

But I represented a middle-aged woman and her mother who were involved in a traffic accident downstate about two years ago.

Accident is far too polite a term for what happened to them. It was still daylight, but the driver coming in the opposite direction down the Interstate was roaring drunk. He hit something or swerved to avoid something in his own lane of traffic -- even the police were vague on the details -- and, because he was traveling at such a high speed, literally became airborne. His car flew into oncoming traffic, directly into the path of the middle-aged woman and her mother.

The mother was driving. And she could see, in that awful split second, what was about to happen. A maternal instinct kicked in and she turned the wheel of her car so that the airborne car would hit her side of the vehicle and possibly spare her daughter. The middle-aged woman saw her mother do this.

And the daughter was spared. But her mother's decision to turn the wheel was the last decision she would ever make.

Surprisingly, the drunk driver had some liability insurance. Not a lot, mind you, but some. And my client had underinsured motorist coverage. And since neither of their policies were issued in Illinois the policies were stackable (that's not true for Illinois auto policies).

Now the health insurance angle: The middle-aged woman and her mother were working poor. The middle-aged woman's husband had a job with a major retailer, one which has a justly deserved reputation for preventing its employees from ever qualifying for health benefits. My client had no health insurance.

My client was taken from the scene to a nearby hospital. She was kept overnight for observation and released the next day. There were a number of diagnostic tests performed -- all coming back negative. And because my client had no insurance, her bill was over $17,000. A health insurer would have been billed a far, far smaller amount.

And the hospital found a way to bill the mother, who was killed at the scene, another $10,000.

These bills helped me get the maximum available auto insurance benefits, yes, but then I had to deal with the liens.

The hospital had gotten med-pay benefits from my client's auto policy -- $5,000 for each accident victim. The balance of the mother's claim was submitted to Medicaid -- not Medicare, don't ask me why -- which paid only a few hundred dollars of the thousands of dollars still claimed. And the hospital took it, willingly, and closed its file on the mother. But that hospital wanted full value from the surviving daughter. And the hospital had its own lawyers seeking payment on the lien.

Well, sure, you say, but shouldn't the hospital be entitled to collect its fee?

But what should its fee be, please? What is the actual cost? What it charges Blue Cross? What it charges some other health insurer? What it would accept from Medicare or Medicaid? These are all different -- far lower -- prices.

I listen to the politicians bloviate about letting the market work, or making the market fair and I see insurance distorting any semblance of any market I can understand.

In the example I'm using today, this money -- which the hospital would never have gotten from Blue Cross -- was taken from a woman who needed this money to bury her mother. And, frankly, losing the mother's social security check -- whatever it was -- was a blow to the family's finances. These people were not retiring to the South of France on this settlement.

So I ask: Is it too late for the market?

I have to tell you that I don't have high expectations for a government run health system. Seems to me the recent scandal involving the treatment of returning war veterans at Walter Reed Hospital provides a strong starting point for any argument against "socialized medicine." We have been providing health care for soldiers, sailors and marines since we became a country... and we don't have even that down pat. Will adding hundreds of millions more people to the ranks of those who are entitled to government health care make things better?

This is why I was intrigued to read recently about SimpleCare -- doctors who have opted out of the insurance system, and coding bills, and large staffs devoted solely to tracking insurance payments and claims. From the SimpleCare website:

Better care for less money – it’s just that simple!

How does it work? We call it PIFATOS – Pay In Full At Time Of Service – and it is truly a "Cash-Based Revolution." A patient sees a doctor for a non-catastrophic reason – yearly check-up, a nagging flu, a twisted wrist, an aching stomach, etc. The doctor bills the patient after the visit. The patient pays in full before leaving. Because doctor charges are anywhere from 25 – 50% inflated due to administrative costs caused by the health insurance industry, you’ll be paying drastically reduced rates for your medical expenses. In conjunction with a regular catastrophic health insurance policy to cover extremely costly procedures, PIFATOS can save the average healthy adult and/or family up to $5000/year!*

The asterisk takes you to an example: It claims a catastrophic health policy can be had for $3,000 a year while a regular health policy must cost at least $9,000 a year. (In the last year I paid health insurance premiums -- a few years ago now before my wife got benefits from teaching full-time -- I was paying $18,000 for the family, and that was with several large deductibles that had to be satisfied before the customary 85/15 split would kick in.) If you spend $1,000 going to the doctor in that year, you've saved $5,000.

I am intrigued that there would be -- could be -- a market-based price. A real price -- and not one that depends on who's asking.

So, gentle readers, tell me: Is such a Nirvana attainable? Have you heard of this? Does it really work? Could it?