“MediCare-for-All” –> No-Care-at-All.


People from Nancy Pelosi to daily bloggers are screaming “MediCare-for-All” as the answer to our healthcare crisis. Is MediCare the solution for us all? The answer is clear: no.

Unlike MediCaid, MediCare was never intended as an entitlement. MediCare was supposed to be self-sustaining: people would pay in while working and take out as needed after they retired. It was sold as a Program that would pay for itself: no additional funds required. Hah!

Inconvenient truth #1: MediCare quickly became a Ponzi scheme just like Social Security. Contributions of the presently employed are not saved for the future but are spent to pay for the expenses of the retired.

According to the GAO, Medicare will run out of funds Just like the house of cards called Social Security but sooner (2017). The addition of the President Bush’s ill-conceived Drug Program For Seniors simply accelerated the slide to bankruptcy by adding another (unpaid for by the contributors) expenditure. When MediCare runs out of money, it will be No Care for All.

MediCare tries to contain its costs in two ways: neither works and neither is what patients want. First, it rations care. Yes, I said it. Many of the things your doctor would like for you are denied as not “cost effective.” Let’s just ignore inconvenient truth #2 that there are at present virtually no scientific cost effectiveness studies on which the government denies payment. Denying payment means denying care and thus again, MediCare-for-All is No Care for All.

Inconvenient truth #2A: Beware of what President Obama is touting as cost effectiveness studies in the proposed Healthcare Reform Bill. Just like in Great Britain and Australia, what the government defines as effective is often not what patients and doctors want as positive effects.

The second “cost saving” method used by MediCare is to reduce reimbursements. Put aside for a moment that this actually increases costs. Current payments to physicians are now below their marginal costs. The more MediCare patients a doctor sees, the quicker she goes broke. That is why fewer and fewer physicians accept MediCare patients: they cannot afford to. Those who still do so make up their losses on the ever-shrinking pool of privately insured patients – the infamous cost- or more correctly revenue-shift.

I guarantee that your local hospital engages in money shifting. How do I know? If it is still in business, that is the only way to survive.

Low payment schedules make it fiscal suicide for doctors to see MediCare patients. So what will Healthcare Reform (HR 3200) do to increase access to doctors for MediCare patients? Answer: it cuts physician reimbursements even further. Perfect!

In a recent Letter to the Editor, a local resident complained that at age 65 he thought he had to choose between Medicare and carrying additional, supplemental insurance to cover those things that MediCare does not. The writer was wrong…for now. To add to the Perfect-Program-for-all-Americans called MediCare, Congress is now considering adding that very limitation to their “Healthcare Reform” Bill. Perfection indeed!

Final inconvenient truth: Whether it is MediCare-for-All or the infamous “public option” that kills the private insurance business, under government payment schedules doctors will be paid less than their costs to stay in business. End result: no doctors. Then for sure,

“MediCare-for-All” will be No-Care-For-All.

PS. The last paragraph is intended to defend NEITHER the status quo nor the private insurance industry. Both need to change drastically. Okay, both need to…go. We need a totally new system, not tinkering with what we have. We could begin with a discussion of personal responsibility. Oops, I’m sorry. That phrase (I’m whispering) is political cyanide and will never come up for serious national debate.

System MD

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#1 deanewaldman on 10.05.09 at 7:35 pm

The blog “MediCare-for-all = No Care for all” appeared as an Op-Ed pice in our local newspaper. A citizen emailed me at the University with Comments that I believe should be shared. I have taken the liberty of copying his remarks below and then will respond in a separate Comment (above).

“While we know that Medicare pays only a portion, often as much as 80%, of medical costs: (1) Have you or your colleagues done anything to reduce the cost of medical education, which leaves the younger entering physicians with huge debts? That causes many to enter a specialty rather than become family physicians. (2) Even though physicians are underpaid by Medicare, do you know a physician who has lost a home, a car, etc. because of inadequate income? (3) Toward the end of you OP-ED you have two statements (a) The more Medicare patients a doctor sees, the quicker SHE (my emphasis) goes broke; (b) There will be no doctors. What happened to your oath and that taken by much of the medical personnel? What about the physicians who are for some sort of public option?

While I have two of the best local specialists in the Albuquerque area in cardiology and dermatology, both of them women, and a recent excellent experience at the Mayo Clinic with another female physician, my Medicare has been accepted for years. Even the Mayo Clinic in Arizona files for Medicare, but the check comes to the `patient, and there is a surcharge of about 15 %. Perhaps the Mayo system is a good example for the public option.. What do you, Dr. J.D. Waldman, propose? You are against a public option or anything like it in your entire presentation, but what are you for to clean up the “dysfunctional health care system?.

Your doomsday prediction, appearing as “Then Medicare-for-all will truly be No-care-for-all” was picked up in the heading, thus providing a scare which you seem to intend.. But, again, what do you propose? There are hundreds of thousands of New Mexican waiting for an answer. And the H1N1 flu is ready to pounce.”

#2 deanewaldman on 10.05.09 at 7:38 pm

Excessive costs of medical education
The debt burden carried by some graduating doctors can and often does force them to choose higher paying (procedural) specialties in preference to lower paying primary care fields. Primary care is where the greatest patient need exists. Unfortunately, the possibilities for lowering medical educational costs are quite limited, especially in comparison to the cost-lowering possibilities in the clinical practice of medicine. To address this on the ‘cost’ side would require subsidization of the students’ education.

On the revenue side, we need to pay doctors differently than we do at present. Payment of money (profit) for anything is a reward for an activity that society wants to encourage. Car companies make profit when they produce cars we want. Pharmaceutical companies make profit because they create drugs that make our lives better and longer. Professional athletes make huge sums of money because… For doctors, society should pay for (reward) the outcomes that patients want: health and longevity, rather than encouraging (paying for) procedures that patients must have to deal with illness.

Finally, the Commenter takes me to task for not lowering the costs of medical education. Medical school Professors (like this author) are the group with the least power over finances.

Overpaying the doctors
The Commenter seems to suggest that doctors are overpaid. Reality check: the truck driver delivering Enfamil makes more money than the pediatrician to whom he delivers the milk. The truck driver starting earning a real living when he was around 20 years old while the pediatrician started around 30. When I took my first real job (age 32) and moved from Boston to San Diego, the 46 year-old driver of the moving van had an enviable retirement portfolio and I had $300 to my name plus $10,000 in debt.

Yes, I do know doctors without jobs; who cannot afford school for their children; and even some who have lost their homes (to medical bills!) Candidly, doctors are the second most undervalued group of altruistic individuals in our society. The one group more undervalued and even more critical to our nation’s future are the school teachers.

The Commenter asks me whether I took my oath seriously. I did and I do. The Hippocratic oath does not include a vow of poverty. Doctors and nurses want to make a good living, expect to make a good living, and they should. What they do requires extensive education and training, is emotionally stressful and even personally dangerous. Society says that it wants health care but then blames the doctors for high costs: watch Peter Orzag (representing President Obama) on Charlie Rose; treats the doctor like a perpetrator, guilty until [never] proven innocent; and undervalues their work, at least judging by government payment (euphemistically called reimbursement) schedules.

The undervaluing of health care providers – nurses, doctors and allied personnel – is being driven the government. What do you think I get paid for doing a complex, dangerous, technically demanding heart cath procedure in a newborn baby? The charge can read as much as $5-7,000. My maximum reimbursement (regardless of what it reads on the bill) from the government is $387. I guess saving the life of a critically ill baby isn’t worth much.

Increasingly, MediCare or MediCaid are paying doctors less than their fixed costs. Doctors have only two choices: stop seeing MediCare patients or leave the practice of medicine. Both are happening, equally.

I put down the “public option” but not the motives of many who support it. They simply do not understand that it will fix nothing. You cannot fix a sick person or a sick system unless you treat the reasons for their sickness. The public option is a political sham that will make things worse for both patients and doctors. The applicable phrase from systems thinking is a “fix-that-fails-or-backfires.”

The Mayo Clinic is an excellent model in many ways (too many to list here). However, fixing healthcare nationally will require a change of much greater magnitude than trying to expand their model. Taming the cost spiral and making the system work can only be done from Washington. Take a look at the One-eyed King and ask how anything being discussed in Washington will cure even one of the root causes of healthcare overspending. Also please note who spends the most money for the least value, what I call the”waste of the middle.”

What do I propose?
Since I do not like MediCare or the public option, what do I propose? In one sense, the answer is easy. We need to treat the reasons for healthcare dysfunction and not do what politicians have been doing for 45 years: confusing symptoms with root causes and ‘partially treating’ the former. In medicine, this is called malpractice. Is there such a word as malmanagement?

We need first to agree as a populace on what principles should guide healthcare. Our nation was founded on principles. Every country with so-called universal health care has a set of principles on which it is based. U.S. healthcare has none. Until we have a consensus on those principles, healthcare will remain broken (dysfunctional).

My book called “Uproot Healthcare” explains this in detail while still being easy reading. It comes out in January 2010. I urge the Commenter (and everyone else) to read it so we can begin the national dialogue, which is the mandatory first step to healing healthcare.

I guarantee someone will complain that what I propose will take too long. There are no quick, easy, painless or cheap answers, at least none that work. The sooner we start a curative process, the sooner we will have a cure. If in 1964, we had started the necessary national dialogue instead of passing soon-to-be-bankrupt MediCare, we would now have a system that would be the envy of the rest of the world instead of what we are.

#3 Steve on 10.08.09 at 4:39 pm

Reading your blog and the comment section headed ‘What do I propose”, I couldn’t wait to hear what bright ideas you would have for solving this country’s healthcare problems.

Instead I get a ‘read my upcoming book’ comment.

Good grief.

#4 deanewaldman on 10.09.09 at 4:18 pm

Many of the principles underlying the ‘fix’ for healthcare are in the blogs in “What to do.” As I write over and over, a true fix (defined by MDs as a “cure:” pt no longer has the problem, disease, or condition) will not be simple, easy or stated in one sentence, even in one blog. Wait. In one sense, that is false.

I CAN offer the cure for health: create a functional system rather than the mess we have now that calls itself a “system.” That IS the cure but how to do that takes a whole book (Uproot Healthcare; coming out in January 2010).

#5 Nerdse on 11.01.09 at 10:53 am

Well, I have to hope the local library will have a copy. But I’m betting you’ll just blame everything on fat people, as usual. That’s the way you keep them subservient & dependent on the Great Doctor for help. I’m sure you’ll glom onto smokers, too; but you’ll have to go easy on addicts & alcoholics; they’ve been declared “victims” of a “chronic disease” & thus immune from blame.

No help ro end obesity is forthcoming from most doctors. Under current practices of insurers, you can make a really hefty (I know, bad pun) profit from keeping them dependent on things that just really don’t work.

Obesity is a worldwide pandemic. A disease. Pandemic implies contagion of some sort.

Since there are obvious exceptions to the rule that “the more you eat, the fatter you get” AND “the less you exercise, the fatter you get,” you could start there. Those exceptions could help unravel why 3rd world poor people are getting fat after roving the streets hunting for work, for some cash, for anything, & showing up as obese diabetics on 500 cal of garbage a day. And they could help fat people who really ARE telling the truth about compliance with your prescribed regime of the max 1200 cal. you’ll allow (after all, if their metabolism doesn’t shut down, you can’t talk them into the REAL moneymaker of obesity surgery), You might even look up that researcher who found a virus that appeared in most fat people but in few if any thin ones, & see where that leads. You know, instead of ridiculing him a la Semmelweiss.

What you’re doing isn’t fixing obesity. You claim you want to fix healthcare, but you’re not willing, any of you, to do the basic research that might lead to answers to the “why” questions in something as basic & in such desperate need of a cure as obesity. One lousy disease, & you all fold. How do you propose to fix the much greater problem of healthcare if you can’t tackle this one problem?

Yes, I know overesting leads to obesity – SOMETIMES. Couch potatoes become obese – SOMETIMES. Some fat people eat more for breakfast than a family of 4 eats in a week for 3 meals. It’s disgusting.

But it’s also disgusting when a thin person does it to train for an eating contest. Glduttony is gluttony, even if the person doesn’t wear the evidence on their body. So, let’s figure out WHY.

Unfortunately, the only incentive you’d have for that is if the insurers really checked the so called “savings” obesity surgery’s purported to give. Not really, because after 5 years, most WLS victims start to age rapidly – ending up with high blood pressure, osteoarthritis, osteoporosis, malnutrition, anemia, slow multisystem organ failure, diabetes, the only thing they miss is the gall blader removal – because they remove the gall bladder when they do the weight loss surgery, as keeping it in there causes a lot of complications. I don’t believe WLS saves lives, or lowers costs. It just shifts costs to different things.

Plus, weight loss surgery, like your very first strict diet, stops your weight loss when you’ve gotten rid of 60 – 80% of the EXCESS fat – which, no matter what numbers you punch into the equation, leaves the fat person less fat, but still obese or overweight, & thus to blame for all the health problems that WLS or extreme dieting actually cause.

The point of current obesity “care” is to milk the patient & his/her insurer for as long as you can. It’s NOT aimed at fixing the problem; it’s aimed at getting repeat business. The only way to stop obesity is to fund only research that does NOT rehash the failed “diet & exercise” model one more time, but has a chance of real results.

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