Universal Health Care -- NOW and HOW

A starting point for my rant today is an article in Salon
http://open.salon.com/blog/mishima666/2009/03/06/secrets_of_hospital_bills_revealed and an observation by a CNN reporter this morning that there are 87 million people, i.e., 1 in 3 people, in the US who are uninsured. There goes the old Republican argument that health care should be determined by a person and their personal provider -- those who have no health insurance do not have personal providers and often no care at all unless it is paid for by taxpayers.

According to this CNN reporter, another 1 in 3 people receive taxpayer paid health care through Medicare because they are old or through Medicaid because they are officially poor, or at taxpayer expense because their salaries are paid by the taxpayers -- Congressmen, Senators, federal government employees, federal contractor employees, state government officials, state agency employees, state contractor employees, teachers, policemen, etc, etc.

The rest of us, the 1 in 3 who have health insurance (primarly through private employer plans as long as we have jobs), are footing the bill for our own health insurance through payroll deductions. We're paying out of pocket the deductibles, copays, and costs for procedures or products not covered by our own insurance. We're also paying the bill for the 1 in 3 people in the US who now recieve health care at taxpayer expense. We're paying so our elected officials can have worry-free health care. We're paying when the uninsured need healthcare. The answer to the question of how do we pay for universal health care is simple -- we are already paying!

How to pay for universal care isn't the question. How do we make health care insurance affordable isn't the question? The real question is how do we make health care affordable?

The next time one of your "right" thinking friends ask how we'll pay for universal health care, answer firmily that we are already paying and move on to the next question -- why are those costs so high? My answer is that costs are so high because of our multi-payer system. Providing health care has become a "big corporate" enterprise. Profit, not quality or affordability of care, is the motive of both provider enterprises and health care insurers. Until we eliminate the profit motive, we will never get to affordable health care.

The usual Republican answer -- the same they offer up when we, the citizens, cry out for legislation that caps the compensation of Wall Street execs and punishes the swindlers-- is that in a free market you don't control compensation or fix costs. Bull Feathers! Wages and prices are controlled by somebody -- it's either the fat cats who charge whatever they think they can get away with or it's the taxpayers who say enough is enough.

I'm tired of both paying for health care coverage and worrying it won't be there when I need it. Here's why. A couple of years ago I had what has for generations been a routine and low cost surgical procedure. When I said yes to the procedure, nobody would tell me what it would costs -- I was assured that it was "covered" so not to worry. Afterwards, the surgeon was paid $1000 for the procedure by my health insurer. They paid another $2000 to unlicensed-in-the-US doctors who get to practice here under the unbrella of "assistant surgeons" -- how many unlicensed-in-the-US assistant surgeons are preforming surgery in our hospitals, I don't know. The hospital got another $3000 for my three day stay -- that's $1000 a night for an roadside motel grade single room with a bed from hell and "nurses" who didn't speak English showing up infrequently to refill my water container.

After a couple of months of resubmitting bills for reconsideration, the lot of these medical providers were reimbursed about $5000 total by my insurance company after a $1000 deductible contribution by me. Not so bad for a hospital stay these days. However, when I asked for an itemized bill, it totaled $45,000 USD. One hour of non-life-threatening surgery and 3 days of economy room and bad food -- $45,000!

No, I didn't have to pay the difference, because I had an insurance company who had negotiate a "fair and reasonable cost" for "reasonable and necessary care" that precluded the providers from coming after me for the difference. Had I not had insurance, the providers would have charged me the full $45,0000. The difference between the $6000 paid for the procedure and the $45,000 billed must have gone into that magic land where the uninsured dwell.

But let's do the math. In addition to the $1000 deductible that year, I paid over $5000 in health insurance premiums through my employer, as I had done for many years before. The health insurance company had no true out of pocket cost for me that year; for prior years they had several thousand dollars in profit because I paid in $5000 and only used up a few hundred in routine office visits. The providers who performed the surgery earned a substantial amount for the time they spent administering to my body. Let's assume that $6000 was the fair market value of that service, because that's what they agreed with the insurance company was "fair and reasonable." So, why was I billed $45,000? Greed on the part of this major hospital corporation? Deceptive trade practices? Criminal racketeering? All three. You be the judge.

Same song, different verse, different singer. A senior citizen friend who is on Medicare and an additional private Medicare-regulated insurance policy was recently in the emergency room and then hospital care for three days due to internal bleeding -- they never figured out where or what was bleeding inspite of the use of all sorts of high tech equipment for tests. Luckily the bleeding stopped on its own and she returned home. A week later she got a bill for $28,000, of which Medicare will probably pay something less than $3000 and she'll have to come up with the Medicare deductible out of her social security income.

As a tax payer with a pre-existing condition that now needs medical monitoring from time to time, I worry that my insurer will decide some test or procedure is not "reasonable and necessary" and I will have to pay the full-price billed. I worry that I will have no insurance at all and go into that magic land where the uninsured dwell if I should lose my almost affordable employer sponsored health insurance -- there is no way an unemployed person who isn't independently wealthy can afford to pay Cobra rates for insurance -- there's no way an unemployed person can afford the full-price billed for services. I can only imagine the mental anguish of millions of our fellow citizens who have lost their jobs and their health care insurance.

It makes no logical or moral sense to me to continue allowing medical providers to bill one group of patients -- the uninsured -- ten times what they bill those with insurance (private insurance, Medicare, or Medicaid) for the same exact procedures in the same exact facility. It makes no sense to continue allowing medical providers to charge 10 times the amount for pills dispensed in a hospital, pills they buy in bulk at discount, than you would pay at your local pharmacy for a 30 day supply. It makes no sense to allow medical providers and health insurance companies to continue their expectation of annual double-digit profits. It makes no sense, in this new American "greed is busted" land to allow medical providers and health insurers to control the national economy. It's time to level the playing field!

While not all medical doctors live lavish lifestyles, many do. Yes, doctors spend years of "borrowed student loan money" time and lose a lot of sleep getting a post-graduate education, but a heck of a lot of people in this country incur debt and lose sleep getting a post-graduate eduation in their fields -- teachers for instance -- and those people never earn more than $100,000 a year. Most nurses, who provide the major portion of medical care, never earn more than $60,000 a year.

I once worked in the field of bankruptcy law in the mid-1980s economic downturn and saw several doctors come into bankruptcy chapter 11 to restructure their bad real estate deals -- one heart surgeon in particular earned $10 million post-pettion (money his creditors couldn't touch even though they tried hard ) income in six months after his filing.

So, should we the taxpayers, we of more modest incomes, let medical providers continue those kinds of earnings at the expense of our own peace of mind and the financial ruin of 1/3 of our fellow citizens? I think not. Not in these greed-busting times.

My basic solution for paying for "health care for all" is the same as Obama's -- extensive costs cutting -- medical costs should receive the same hair-cut that home prices and stock prices have received. I just can't see how his plan to convert medical files to internet records will generate the savings he envisions. But I can see how lots of other things could lower costs. Here's my list, aka the Box Thinker 15-point universal health care plan:

1. Charge everybody the same -- the lowest negotiated price with any payer. I would require every medical practioner/providerer to have only one price for any procedure or service -- the same price whether the payer is the patient, state Medicaid program, federal Medicare program, XYZ private insurance -- and I would require the provider to submit charges to any payer in the exact same format as they submit it to any other payer. I would even let the IRS design them a short form so they don't have to spend any medical dollars devising their own -- maybe even let the government withold 10% of each payment for income tax purposes.

2. Disclose costs before the procedure. I would require every medical practioner/provider to post costs for all procedure in a prominent place in their places of business -- perhaps on a menu board the same way as McDonald does, where you can see all prices fully disclosed at the check-in counter. That way, everyone knows what the price is and the provider doesn't need a big back-office staff to cook the books for each category of payer.

3. Advertise medical procedure prices. I would allow, even encourage, medical providers to widely advertise -- television, newspapers, internet, other -- their charges for the procedures they provide. A patient with an small hand cut may want to choose a novicane injection and office suture that costs a couple of hundred dollars rather than a day knocked out in a hospital surgical suite for $10,000; a patient with an ankle sprain may elected to have a $200 x-ray and not a $2000 CT-scan or $3000 MRI. Some patients may elect to go to lower costs providers. Not all facilities will be able to afford the latest high-tech equipment -- they may have to send patients to other providers. But isn't that what a "fair market" is all about -- informed consumers making informed choices. Full disclosure of health care costs, before the buyer signs on the dotted line, will do a lot to bring down costs.

4. Fair fee agreement contracts. I would require that any leally enforceable agreement between a medical practioner/provider and patient fully disclose of all anticipated costs -- those of the provider and all associated providers -- of the procedure as part of the agreement. Give patients equal rights to recover payments for any procedures that are wrongly charged along with attorneys fees and court costs in any lawsuit over fees in which they previal.

5. RICO and DTPA. I would, by a specific federal law, make medical practioners/providers subject to both federal RICO and state deceptive trade practices laws.

6. Disclosure of financial interest. I would, by specific federal law, require any medical provider to disclose in writing to the patient any financial interest they have in any treatment facility or treatment option they are recommending. I would extend this to a disclosure of anything of value the doctor has received from the drug or medical devise company whose product they are recommending.

7. Medical fee jury. I would require each state to create a board of 12 ordinary people not in anyway associated with the health care industry or the health care insurance industry -- aka the medical fee jury -- to determine the "maximum" costs providers are allowed to charge on a procedure by procedure basis. To keep them honest and not corrupted by the medical industry, no person could be on this "medical jury board" any longer than 12 consecutive months and must provide a full accounting of all income during this time period. Medical providers, who now recieve a substantial portion of this nation's disposable income, should have the same amount of scrunity as public utilities and the auto and home-owner insurance companies when it comes to rates.

8. Citizens first. To solve the problem that the "border-control-NOW" people envision, I would require anyone presenting for medical care at any facility -- doctor office, clinic, hospital, other -- to proide a valid social security number through E-verify, and I would require those over 16 to produce a valid state or federal issue photo ID. Those who don't present valid indentification at the time of service would still be treated for life-threatening conditions, but released only to Immigration or other designated law enforcement agency where they would be held until such reasonable time as they could establish valid citizenship or green card or be deported, with or without their anchor children. We provide foster care for children whose parents are incarcerated for violating other laws; we can provide foster care for children whose parents violate immigration laws if the parents don't want to take their children back home with them.

9. Pre-existing conditions. The word "pre-existing" should be outlawed. A medical care provider or third-party payer takes a patient where they find them in whatever condition they find them. Treat whatever needs treating when it needs treating; don't treat what doesn't need to be treated.

10. Senior care facilities. I would mandate that all senior care facilities (nursing homes, assisted living, whatever) be allowed a maximum fee per month from any patient/inmate no greater than the total montly benefits that patient/inmate receives from Social Security regardless of any other assets held by that senior. After all, providing for living expenses in old age was the intent of paying into Social Security as a worker and living expenses is what we're talking about when we speak of assited living facilities - a clean room and three meals a day provided by minimum wage workers. None of us ever anticipated that the health care industry would decide that providing an elderly person (or two elderly people sharing) an 8x10 room would costs $2500 - $10,000 per month if anyone in the immedate family has the income to pay and ony $800 - $1500/month if Medicaid pays. An 8x10 room is the same room whether the patient is "private pay" or "Medicaid." Senior care facilities should not be allowed to charge more per month than luxury cruise ships. Senior care facilities should not be allowed to bankrupt seniors or their fifty-sixty something children.

11. In-home care. I would, as part of the new jobs enhancement program, mandate that both Medicare and Medicaid pay for up to 20 hours a week for in-home senior care (at $7 to $10/hour for at least 2 hours per day to help the senior with cooking, cleaning, and personal grooming instead of the currently paid-for twice-a-week $200/10-minute drop-in visit to check blood pressure by a "skilled home health care provider"). In home medical monitoring does little to prolong an elderly person's life, but basic home care services -- preparing meals, light cleaning, help with personal grooming -- will allow an elderly person to remain in their home for a much longer period of time before they need nursing home care. A patient's family should be allowed to select the home care giver and the home health provider, hire and fire either, and elect facility care instead of home care if they believe that is the best solution for their elder family member. Having affordability and flexibility in choice of senior care would solve both the lack of adequate facilities for seniors and some of the current unemployement problem of low-skill workers. The vast majority of elderly just need someone who can drop by a couple of hours a day -- to make sure they have at least one hot meal, that they have clean clothes and a clutter-free room, that they have a safe bath -- to be able to remain in their home indefinitely. A few hours work each day by a low skill individual who provides home care at several homes during a week will provide full employment for that low skilled individual for about the same current costs as twice-a-week home health care monitoring and the weekly costs of unemployment compensation, and it will allow elderly people to remain in their own home rather than be forced into higher costs custodial senior care facilities as their only option.

12. Medications for Seniors. I would closely monitor all medications given to people in senior care facilities for "medical necessity" and "standard of reasonable care." I would disallow recovery from any payer -- patient, insurer, government -- for any treatment that is not "medically necessary" and doesn't meet "standard of reasonable care." I would impose criminal penalities for providers who prescribe or administer medications that cause harm to an elderly person in a senior care facility, whether due to negligence or intentional act. This would substantially reduce the costs of the Medicare Drug program. This is one issue of which I speak from personal experience. My mother-in-law, still living alone at the age of 90 (her choice, not ours), fell and suffered a dislocated shoulder so that she could not provide her own basic care. She wanted to stay "at home" near her friends and church rather than relocate to the state where we live. Our only solution was private-pay assisted living at the newest senior care assisted living facilities in her community -- not an inexpensive solution. Within a few months she had recovered from the shoulder problem but soon had other health problems -- breathing problems, attention problems, memory problems. We questioned her medications and learned that multiple doctors (first they took her to one and then to another) had prescribed and they were now dispensing three high-cost blood pressure medicines and four other high-cost drugs to counteract the problems caused by the blood-pressure medications. No doctor had asked to see the complete medication list from the facility before prescribing more drugs. The facility nurse had never questioned the multiple medications. When we pointed out the problem, the facility refused to stop the multiple medications because "they had to dispense what the doctors prescribe" and the assisted living facility wanted to move her to higher cost nursing care instead. We removed her from the facility to protect her from her "providers," who were, of course, billing Medicare for the high price drugs. Back at home with in-home care, she was soon weaned off most medications and back to her normal alert state, living another five years in reasonble health. My mother-in-law is not an isolated case. You be the judge -- $3000/month for assisted living, $5000/month for nursing care, no additional revenue if no drugs, higher revenue with multiple high-priced drugs -- do you see greed or medical necessity at play here?

14. Outlaw drug company advertisements. On the subject of legal drugs, I would immediately outlaw any advertising on television or anywhere else for any pill (big Pharma or supplement), medical devise, or medical procedure. As we've all learned with Viox and it's sisters and brothers, any pill that has not made it to generic status, i.e., been around long enough to have been tested on enough people to prove it safe and effective, is just as likely to kill you as cure you. Behind all the pretty pictures of people strolling through flower gardens and pretty words in those television ads urging you to take pills you never before knew you needed are the "warnings." It is the duty of goverment to protect people who can't protect themselves; if there's a warning of a serious complication, the drug should not be advertised to the general public. Let's face it, a lot of people just aren't smart enough to figure out from those carefully crafted advertisments that they'd be better off with whatever condition they have than taking a drug that can kill them. And we certainly don't need any of those people with newly discovered errection or twitching leg problems cluttering up waiting rooms asking their "medical provider" if they're a candidate for this or that new drug.

15. Competitive pricing on drugs. I would require that any legal drug paid for out of taxpayer dollars be competively priced (through a competetive bid basis). If Mexico and Canada are our trading partners, we should be allowed to buy drugs at Mexican and Candian prices.

Why do I proposed my Box Thinker 15-point universal health care plan? Well, I like specifics and I don't believe those guys in Congress and the Senate can get off their talking points to figure it out. Universal care for all citizens should not be subject to the whilms of politicians, the bottom-line of employers, or the greed of the health care industry. Medical care should be universal, portable, affordable, and single payer for every American citizen and on an emergency care basis for illegal aliens.

There was a time in this country where doctors and hospital provided good care at reasonable costs, back when I was a kid in the 1950s, even back when I was a young adult having my family in the late 1960s -- the last child born in 1968 cost $250 in hospital bill and $50 for the doctor -- and we paid on an installment plan with the provider, same as we did with the house and car and the clothes for the kids. Then the middleman industry sprang up, substantially increasing the costs of medical care because doctors then had to hire people to try and collect from the insurance compaies, and patients separated from the true costs of their medical care became more demaning of care they really didn't need, demand fuel by advertisements by pill-makers.

While we're re-structuring, getting back to basics in every other aspect of our economy, let's restructure our health care system into something every red-white-blue American can be proud of. It's time to look back to the time when doctors were doctors and not a profit center in a maga health care corporation, a time when there were no middlemen insurance companies and not every clinic believed it should be a full-service hospital, when people who needed care paid to the best of their ability and doctors wrote the rest off to charity (and still had the best house and best car in town).

I'm not afraid of "socialized" medicine. I have traveled to other countries who have universal health care, and I have recieved very fast, very competent, very reasonable unreimbursed medical care. In a doctor visit in Beligum, which involved an EKG, blood work, and an hour of devoted time by the doctor, I paid the same amount as my US insurance co-pay for everything and everything was done in the doctor's office. I knew the results immediately. I was given a prescription that cost a fraction of the US cost for the same medication. Our own health care is not the best. It's just the most expensive and the most complicated. I has been brought to you by the same politicians who gave you the last Wall Street bubble. We can do better.

I'm not afraid of single payer. A single payer who fircely negotiates prices is what we need to control costs. Social Security delivers a check every month on time to millions of senior citizens; they pay "fair and reasonable" Medicare medical expense for those seniors on time as well. The Medicaid people are equally compentent as medical bill payers for the people too poor to afford health insurance. Both of them are much more efficient than any private health care insurance company I've ever been insured by. By combining Medicare, Medicaid, many VA funded services, and health care for everyone else under one universal health care "insurance" government agency we can make quality health care affordable for all. If we continue with the present multi-payer/multiple prices "free-enterprise" system and continue thinking of health care profits as the right of corporate America, we will never get there.

Quality medical care should be the right of all, just as quality police protection, fire protection, and other health related services are in our society. We don't have to ask how much when we call the police to come save us from someone breaking into our home; we don't have to ask how much when we call the fire department to come put out a fire in our home; we shouldn't have to ask how much when we need medical care to save our life. If medical providers and health care insuerers are reduced to earning no more than policemen and firemen to make that happen, it's a price I'm willing to pay!

Lastly, I don't believe a word of the scare tactics in paid advertisment by hospital corporations and medical insurance companies. I believe that if you cut out middlemen insurance companies and regulate provider and drug manaufacturer pricing, you can have both good and reasonably priced medical care for all, just as the other countries who have taken this approach have accomplished. If you believe the same, tell every one of those Republican congressmen and senators pontificating on the subject to either pass univeral health care or give up their own free taxpayer healtcare. And, while you're telling politicians what you want them to do with your money, tell Obama how to go about it.