Posts Tagged ‘Health Care’

The Thinker

Aging gratefully

Another birthday rolled around yesterday. For once the first of February felt like it should: bitterly cold and snowing. I am not much on celebrating birthdays, which is probably why I scheduled an outpatient procedure on my birthday. Specifically, I had a colonoscopy, a distasteful but necessary procedure for us insured humans age fifty plus. This being my second time, I knew what to expect. When I had my last one at age fifty, I could get it done in a local surgical center. This time, because I was subsequently diagnosed with sleep apnea, it meant going to the hospital instead. It also meant arising at three a.m. to down a second dose of medicine guaranteed to empty your digestive track, not to mention spending the day before at home on a liquid only diet, trying to make a bottle of white grape juice substitute for solid food.

Happily the procedure went well. One reason I was repeating it after only five years instead of the normal ten years is because polyps run on my mother’s side of the family. She never had a colonoscopy and as a result due to a huge polyp had to have part of her large intestine removed. Sure enough, yesterday my gastroenterologist found a polyp, but it was easily sliced off and removed. By ten a.m. I was home eating solid food none the worse for the experience but with lovely color photos of my large intestine showing the emerging polyp.

That’s kind of how it should go at age 56. You have given up chasing immortality and have made peace with conforming to the practices of modern medical science instead. Few men or women my age can credibly claim they have the strength and stamina they had when they were in their 20s. Perhaps I could get the illusion of it if, like some foolish and better moneyed people my age, I ingested steroids and got shots of HGH (human growth hormone). Along with the HGH, regular injections of testosterone probably would make me feel manlier. Marketers think they know what I need and lately it’s been testosterone supplements. I can rarely go to a web site without seeing ads telling me about the benefits of testosterone therapy. I remain skeptical. Estrogen replacement therapy for women has proven to have more minuses than pluses for most women. I doubt testosterone supplements and shots are without serious risks as well. Perhaps it will keep my hairline from receding, or suddenly make me attractive to women half my age, but I doubt that is worth any of the potential complications.

Or perhaps I should do what has worked so well for my father, age 86, still reasonably healthy and walking around. Perhaps I should simply give up on the silly pseudo science, ignore the multitudes of marketers of immortality and pragmatically get regular exercise and regular checkups instead. My father has been battling precancerous melanomas for decades, but he is still alive. This is thanks to regular trips to the dermatologist, which often results in skin removal or replacement. It doesn’t appear that I have inherited that particular condition, but it does look like I have my mother’s tendency toward polyps in the large intestine, so I best better bear the indignity of these colonoscopies every five years.

I also inherited her family’s tendency toward tallness, narrow throats and a large uvula, all of which contribute toward a tendency to snore and which eventually lead to a diagnosis of sleep apnea. For a whole year now I have been sleeping with the aid of a BPAP machine. It regularly fills my lungs with air, even when my body would prefer to stop breathing for a while. For a month or two using the machine was more torture than restful until I figured out how to put the mask on properly so it did not hiss at me during the night. Now the BPAP allows me to get genuinely restful sleep, and many nights I sleep like a baby. Waking rested gives me more energy than any shot of testosterone is likely to provide.

Maybe there is something unmanly about depending on regular checkups and medical science. Real men in their fifties, if you believe the ads, are supposed to be climbing mountains, roping steer, running marathons and bedding women in their twenties. What most real men my age are doing appears to be quite the opposite, at least according to my observations: eating too much crap and limiting their exercise to changing cable channels with their remote controls. I confess to eating too much crap myself, but I also eat plenty of healthy food, and since 1981 I have been getting regular aerobic exercise. My health is obviously not perfect, but it is better than most men my age. I can’t seem to go see any physician without getting blood drawn, so I have constant opportunities to tweak Vitamin D deficiencies, check my cholesterol or measure my triglycerides.

So at age 56 I remain a work in progress. I am realistic enough to know I won’t live forever but stubborn enough to insist that as much as feasible I will enjoy those years that remain. If that means sleeping with a BPAP machine for the rest of my life or having to endure the indignity of having my colon probed every five years, so be it. At least I am still here, in reasonably good health, and with (I hope, no guarantees) much more good life ahead of me. My testosterone levels may be receding like my hairline, but with luck the next thirty years of my life will be happier years with less heartache and struggle.

I’ll keep my physician on speed dial to make it so.

 
The Thinker

Solving the medical forms hassle

Seven years ago, I suggested that the ubiquitous thumb drive should become our electronic wallet. You would simply plug it into the point of sale device, authorize the transaction (a PIN is acceptable, but a thumb scan would be better), and an electronic receipt would get stored on the device. The receipt could later be imported into your personal money management software, such as Quicken, for automatic categorization, giving you better insight into your spending.

Some years of experience using thumb drives regularly shows that it is not the ideal device for an electronic wallet, in part because the USB terminal can wear or tear, rendering the device useless. Today, a smart card might make more sense because it would fit in our wallet right where the credit and debit cards go. My point was that to be useful the device would show you your balance at a glance, and it could receive as well as send data. Today, the device could also be network aware, making secure connections to your bank periodically to get the latest balance. You might call it a smart cash card.

A few weeks back I had an annual physical. As is typical of someone fifty plus, I left with a stack of prescriptions and referrals. As a consequence, I have since been making my way to various specialists. Yesterday I visited an endocrinologist, who was examining some minor cysts in my thyroid. Naturally before I could see him I had to go through a daunting process of filling out four pages of forms, listing for the umpteenth time my long and tedious medical history. I am sure you have had the same experience many times. List all your medications and dosages. List all your surgeries. List current and past conditions that you have had, including hospitalizations. List your family’s medical history, parents and siblings. Provide an emergency contact. Oh, and don’t forget your name, address, phone numbers (home, cell and work), email address, date of birth, social security number, current employer, current employer’s address and phone number not to mention, of course, your almighty health care insurer, their phone number, your policy number and your group number.

As someone who works in information technology, filling out these forms repeatedly is an obvious problem that should just be solved. Yes, as part of the Affordable Care Act, health care providers are being nudged into electronic medical records. I can understand the reluctance of doctors’ offices to go there, given the voluminous information they collect and the chance of clerical errors. Still, much of the information is route and common. It could be provided by the patient in an electronic fashion very easily. All it needs is a law to make it happen.

This is a job for government, not to make such devices, but to set standards for them and to require health care providers to accept them. Such a government standards entity already exists:  the National Institute of Standards and Technology. Other agencies, probably the Department of Health and Human Services, through regulation could require health care providers to accept electronic data provided by the patient in lieu of filling out those awful and painful new patient forms.

Here is how it might work. Next time I visit a new doctor, I would take out my medical smart card. It would be more than an electronic wallet, but also have my medical history. I would wave the smart card over the card reader at the receptionist’s desk and it would ask for permission to transmit certain types of data. Ideally, it would show me on a screen all the information requested. I would be able to change it (in the process changing the data on the card, since it would be inaccurate) or blank out fields I don’t want to share. I would then give my permission to share the data using some sort of authorization mechanism. Ideally I would do this by pressing my thumb on a spot on the card. However, a PIN or retinal scan might be okay as well.

There are devices out there that get part of the way there. For example, MedicTag is one of a number of devices that puts your medical history on a USB drive that you wear at all times. The problem with devices like this is that there is no guarantee that your health care provider will even think to check for the device. Even if they can, there is no standard for encoding the information so that it can be easily read into a provider’s health care database yet stay secure. To make sure that the data can be read in an emergency, it is likely unencrypted. Worst of all, since most health care visits are not for emergencies, then routine trips would likely require you to fill out paper forms anyhow. Certain providers, principally emergency rooms and ambulance companies, would have permission to read your card without your authorization.

I would bet that most health care providers would be glad to install devices that could read structured medical information from these devices. They would quickly pay for themselves in productivity savings and accuracy of these data. Most health care providers already have a records management system, generally Medics Elite. These companies would find plenty of incentive to build software for point of presence terminals to collect the data.

I am sure that a smartphone could be configured to do this. It can already be your electronic wallet. That seems to be the thinking behind Google Wallet, but so far vendors have been lukewarm embracing the technology. Doubtless apps could be created that would comply with any NIST standards for sharing medical information. With cloud services now becoming standard, most of us would be glad to pay a reasonable fee to have our medical and other private information backed up in the cloud, in case we lose the smartphone. The real problem is that there is little in the way of standards for transferring frequent medical information, at least from patient to provider. This is why we need the benevolent hand of government. Once standards are in place and providers create interfaces, any number of vendors could compete to provide devices and apps to make this a reality. Just as many of us now have electronic boarding passes that are scanned off our cell phone, there is no reason why the same data could not be transmitted using an infrared or wireless connection, once authorization is granted.

As an aging human being who doubtless has many hundreds or thousands of doctors’ appointments ahead of him before I die, a device like this cannot come soon enough. After all, as you age you realize time is short, and you can save heaps of it not filling out redundant medical forms.

 
The Thinker

Some ways to cut medical costs

Are we paying too much for medical treatment? Ask a physician and they would probably tell you that you are not paying enough. Ask the rest of us and we would say, “Hell yeah!” One clue that physicians may be myopic on this is to compare how much Americans pay for health care vs. other countries. In general, Americans pay much more money for inferior outcomes.

It’s well known that a lot of the money we spend on health care is wasted on unnecessary procedures and treatments. Other spending is fraudulent. Medicare is a fee for service insurance program. All sorts of fraudulent and fly by night outfits bill Uncle Sam for bogus, superficial or overpriced treatments. These costs amount to billions, if not tens of billions a year. The problem is hardly limited to Medicare. The same is true in the private insurance market. I have a Blue Cross/Blue Shield standard option plan. My insurance company blithely went along with all sorts of medical treatment for me that turned out to be a waste of money. I had veins removed on my leg a couple of years back. Remove extra veins and the theory went the remaining veins would better take up the slack, relieving pressure on my foot and thus the numbness I was experiencing. My legs look great but the surgery had no effect on solving my problem. Indeed, it might have exacerbated it because I had to wear compression stockings for weeks after surgery. If you have a nerve impingement issue, this makes symptoms worse.

All sorts of parts of our medical system are ineffectual. We depend on physicians, but it is clear that many of them are ethically compromised. No doubt you have witnessed what I have seen many times in doctors’ offices. It’s amazing physicians can get any work done with all the drug representatives coming in and out of their office. Like Santa Claus they come loaded with Christmas presents, often including catered lunches for the doctors, but also plenty of drug samples for their pricey proprietary drugs. (I know this because I get reports from my wife, who works in a neurology practice and sees this happening regularly.) More than one physician I have encountered are on a first name basis with these drug company salesmen and women. This is not surprising since they see a whole lot more of the physician than I do.

A little legislation is in order. My physician suggested a statin for my high cholesterol. He wrote a prescription for Lipitor, which came with a $75 copay for me and costs Blue Cross hundreds of dollars for each bottle. He has done this for other drugs he has prescribed for me, even though I have repeatedly told him I prefer to start with a generic drug, and use a branded drug only if necessary. I am currently trying to get my Lipitor prescription changed to a generic. It may be that I need Lipitor, but I doubt it. I seem to have garden-variety cholesterol issues. I suspect that he prescribed Lipitor by default because of the Lipitor brochures in the examining rooms and likely on his desk. (I sometimes wonder if he is on the take, and gets a percent of any prescription he makes.) It rarely occurs to my physician to give me a generic drug. I’ll bet that your physician is the same way.

Only one physician I associate with has the presence of mind to start with a generic drug (my cardiologist). As a result my heart medicines cost about ten dollars a month instead of hundreds. No one seems empowered to tell physicians what they can and cannot prescribe. It is clear that many are in the pocket of drug companies. There needs to be a law: physicians must treat with a generic drug if available and escalate to a branded drug only for a compelling and urgent need, to be enforced by local medical boards. Moreover, the AMA should change their code of medical ethics. It should be unethical for physicians to meet with drug company representatives unless it is at neutral forums where counterpoint is possible. It should be unlawful to accept any of the bountiful gifts they receive from these drug companies either.

If we cannot enact common sense laws like these, then physicians offices should at least have a prominent policy statement in their lobbies saying how they interact with drug and similar medical companies, so patients like me can know in advance and maybe shop elsewhere. They should record and annually publish statistics on the companies that came to call, who they saw and what freebies they received from these companies. As consumers, we have a right to know if our physicians are being influenced. Right now we have to trust that the physician is looking out for our best interest.

Our primary care physicians must remain our speed dial, but it is clear to me that the primary care system is breaking down. PCPs are generalists by training. As medical knowledge has increased, it is clear that they can no longer sort it all out. What we need now are centers of expertise that can assist PCPs. A PCP would still be the one we would go to for physicals, urgent cares, cold, flus and the like. When an issue reaches a certain degree of complexity, the physician would elevate it to a center of expertise. I can use myself as an example. Both my vein surgery and tarsal tunnel surgeries were clearly a waste of time and money because they did not solve my problem. However, if it had been presented to a team of specialists (who should not be on the payroll of any health insurer), they might have had me follow a more logical course. They might have researched foot numbness like I had, figured out the tests I need, diagnosed sciatica as a likely condition and treated for that first, starting with physical therapy, then chiropractic therapy. My PCP suspected neuropathies and sent me to a neurologist. What I needed were teams of experts: a neurologist, a podiatrist, an orthopedist and likely others to put their heads together and present a step by step treatment plan, probably moving from most likely to least likely, based on my symptoms. My problem was beyond what my PCP could handle, beyond writing me referrals. Besides he had boatloads of other patients he also had to juggle.

The Affordable Care Act is moving toward elements of what I have in mind, which proposes outcome-based reimbursements rather than for a fee for service model. It all starts with a proper and intelligent assessment. The patient is the ultimate person that should approve final payment. Did the treatment solve his problem? Did the treatment persist?

A new payment model might look something like this. Unless the problem is simple enough that a PCP can handle it, the first payment would be to an outcome center for a treatment plan. It would be based on as complete a medical record as exists for the patient. The second would increase payment to 75% when the treatment plan is completed, with perhaps staggered payments if the treatment plan will require months or years. The outcome center would reimburse specialists as needed. The balance would be paid three months later when the patient certifies that the outcome was satisfactory. This would give everyone incentive to get the treatment right the first time. Moreover, physicians would begin to align themselves to meet the market for what are medical needs actually are.

There is no socialized medicine here. Those who want to see a specialist on their own would still have complete freedom to do so. The government would not dictate treatment plans or what are reasonable patient outcomes, although existing institutions like the National Institutes of Health can shepherd the creation and certification of outcome centers and best practices. Patients would get better, faster and more effective treatments. Physicians could take pride that they are doing what is best for their patient as part of a holistic approach. PCPs would find their jobs more manageable. Moreover, health care resources would align toward the efficient needs of consumers. Of course change is always scary, but changes like these are long overdue.

 
The Thinker

State of the Union

President Obama gave a pretty good state of the union speech on Tuesday. He ended it with the usual rhetorical flourish that speaks more to our aspirations than to reality. He closed with:

We do big things. The idea of America endures. Our destiny remains our choice. And tonight, more than two centuries later, it’s because of our people that our future is hopeful, our journey goes forward, and the state of our union is strong.

I won’t be running for president so there is no chance that I will be giving a state of the union speech. However, if I were to give one it would read in part a lot like this:

Thank you very much. As you know it is my duty as president to annually report on the state of the union. Unfortunately, I have to report that the state of our union is fractious. At no time since the Civil War have we been so divided as a nation. Extremes on both sides of the aisle are pulling us apart as a country. This extreme polarity as well as refusal on both sides to move toward meaningful compromise are undermining our national security, economic growth and put our nationhood at jeopardy.

Barry Goldwater once famously said, “Extremism in the defense of liberty is no vice.” Goldwater was dead wrong. Our liberty is only sustained through finding and expanding our common ground. It happens by moving toward consensus rather than confrontation. At this critical time, true patriotism will be measured in our ability to come to consensus and make painful but necessary choices that one Congress and White House after another has punted.

We cannot undo these past damages, but we can move toward a sustainable and prosperous future for our country. Finger pointing no longer serves any national purpose. None of us here are blameless. We all contributed to our national problems. It includes me, Harry Reid, Mitch McConnell, Nancy Pelosi and new Speaker John Boehner. Many of us followed what we believed was the right and sustainable path. Sometimes an individual policy we advocated may have been right for the nation. However, if it is not congruent with our national needs it is still wrong. What can be said is that, in the aggregate, we were all wrong and have been mostly going in the wrong direction for decades.

For example, taking care of our senior citizens in retirement is a worthy national endeavor, but only if programs for them like Social Security and Medicare are put on a sound footing and are soberly and competently administered. It is scandalous that both Democrats and Republicans allowed Medicare costs to expand without addressing its inefficiencies and creating a plan to keep it solvent. Similarly, it is scandalous that both Democrats and Republicans allowed the last Administration to lead us into a war based on false pretenses. It was scandalous to offer tax cuts without offsetting these tax cuts with reductions in government services. My administration, previous administrations and previous Congresses failed to competently manage and govern our own country. Time and time again we put short-term thinking and ideology ahead of the national interest.

These are facts beyond any reasonable dispute. The evidence is overwhelming and can be found in record numbers of mortgage defaults, our bloated budget deficits, the high unemployment, the growing ranks of our homeless, our obesity epidemic and a fouled environment. By virtually any metric that you can use, our government has failed our job as national stewards. We, its leaders, have failed America.

The state of our union is fractious at best and alarming at worse. Now we must right-size our government so that it meets the needs of our nation. We need a new national strategy and we need sound tactics that align with our national strategy. Our strategy requires clear national goals, and both parties must agree on these national goals.

I offer six goals. Our most immediate challenge is not the budget deficit, as wrenching as it is in scope and size. It is to break the back of unemployment in this country, which has been dangerously high. In breaking the back of unemployment, we must do it in a way that creates good jobs that will restore our fading middle class. We don’t want to restore it by putting talented people to work flipping burgers or sweeping floors. Prosperity drives everything and makes anything possible. We can do this today by continuing to invest in common sense infrastructure projects, all of which will aid our current and future prosperity. To facilitate that our infrastructure investments are made wisely, we need an independent commission that places our money in investments that will create an improved infrastructure in the most productive ways possible.

That is our short-term goal and it should be easy for us all to agree on. However, infrastructure does not just happen. It will take money, and if we cannot agree on something simple like raising taxes on the rich to levels that were in effect in the Clinton administration, then we must keep borrowing the money. Projects that promote short-term employment and are most needed to improve our infrastructure should get the highest priority.

Our long-term goals should also not be controversial. I propose five long-term goals, in priority:

  1. Ending the extreme partisanship in this country
  2. Fix the federal government’s deficit spending
  3. Living in a sustainable way
  4. Making the United States the 21st century leader for new technologies and services
  5. Ensuring that all Americans receive quality health care

First, partisanship. Partisanship is not necessarily bad. However, our partisanship has reached extreme and dangerous levels. This did not happen by accident. It happened because we permit gerrymandering of our legislative districts where partisan interests are unduly represented and the interests of moderates were squeezed out. To solve this problem, Congress must pass and the states must ratify a constitutional amendment requiring all states to draw federal congressional districts in a politically impartial manner to be overseen by our federal judiciary.

Our government’s deficit spending has reached dangerous levels. We do not want America’s future to be like Greece’s present. To achieve fiscal solvency, a number of unpopular things must be done. Entitlements like Medicare must either have self-funding mechanisms in place or be limited to a percent of GDP or the federal budget by law. Both must be governed by independent and impartial commissions empowered to make changes to the system to ensure their viability. Medicare spending, for example, could be limited to twenty percent of federal expenditures or require premium increases annually to ensure that it remains solvent. Do these things and most of our other federal financial problems will take care of themselves.

America’s failure to live in a sustainable way increases the likelihood of war and suffering at levels so extreme they are hard to imagine, but are frighteningly real. Climate change and population growth are already causing wars, unrest and mass migration. It contributed to unrest in Tunisia. We must find a way to cap our population growth and live sustainably with nature. Our failure to get our environmental act together inside our country and with the rest of the world ultimately dooms not just our country but also our species. It will change life irretrievably here in our sacred home, the Earth. However, if we succeed we will do so by developing many of the products the world needs so that it too can live sustainably. Being green is not just good for the planet, it is good for our prosperity and it helps mitigate future wars and immense suffering.

To prosper, we must out innovate the rest of the world. Our prosperity rests in nurturing our human capital. Not only do we want to create business environments to allow companies like Google and Apple to flourish, we want to make sure that our children receive a first class education so when it is their time they can out innovate the rest of the world in the future. This cannot happen when we won’t pay teachers salaries that correspond to their importance to our nation, or when school districts in states like Oregon cannot afford to put their children in public schools five days a week.

Lastly, but certainly not least, we must make health care available and affordable to all, not just to those who can afford it. America cannot flourish unless we are healthy. There are plenty of examples in other countries of national health care systems that work. Some align very well with the American way. Japan’s health care system, for example, offers enormous competition at very reasonable prices. Let’s let an independent commission tell us which of these many plans will work best here in the United States, then let’s move aggressively forward to make it happen in our nation.

I am offering six steps toward a prosperous and sustainable future for our country. I need each of you to work in the common national interest. If you do so, you and this Congress will be forever revered in our national history.

Thank you and good night.

 
The Thinker

Why Republicans are duty bound to cancel their insurance

Over the last couple of years, my family has been at fault for two automobile accidents. I got in a minor fender bender when a car clipped the side of my bumper as I was trying to pull into traffic. My daughter, being a relatively inexperienced driver, also had an accident. She learned it’s not a good idea to change a CD if your car is creeping forward.

No one was hurt in either accident, thank goodness. My daughter was in shock for a while, but after paying a $250 deductible for each accident and about a week of hassle, our cars were better than new. Our auto insurance rates did go up modestly. Clearly, we were not out of pocket the $5000 to $10,000 it would have cost to pay the full cost of these accidents.

Of course, the whole purpose of insurance is to protect you from major financial liabilities. Most of us would agree that insurance is perfectly reasonable, as most of us are not sitting on a pile of money to pay out a judgment against us if we were found at fault.

Still, isn’t there something more than a little socialistic about insurance? That’s what I am wondering after listening to conservatives, Tea Party and Republican activists talk about repealing “Obamacare”, assuming they get a majority in one or more houses of Congress. As best I can tell, they consider the legislation socialism, even though no public option survived in the legislation. A couple of things seem to be sticking in their claw. First, they really don’t want to pay for those who cannot afford insurance. Second, is their incessant mantra of “personal responsibility”. People should pay for their health insurance. If they cannot afford it, well, things are tough all over, Mac. Trust to luck, vitamins, five-dollar prescriptions from Wal-Mart and, most importantly, don’t get seriously ill. And if you do end up with some chronic condition, rather than send the bill to the government or those who are insured, host a fundraiser, get relatives to pay your bills, or just accept the fact that you must suffer more and die prematurely. After all, the dictate of personal responsibility is more important than anything, even if this means because of your inability to pay that you are subject to immense suffering and an early death. Your suffering simply makes us a stronger country!

Curiously, few conservatives, Republicans or Tea Partiers seem to object to uninsured motorists insurance that they pay as part of their auto insurance. Whether auto insurance is required or not, some drivers won’t buy it. Also, some people have such miserable driving records that no insurance company will sell them a policy. For you, the driver, the result is the same. If you are hit by an uninsured motorist, then unless the motorist is independently wealthy, you will pay the cost of someone else’s mistake. In other words, someone will have escaped personal responsibility!

Fortunately, the number of uninsured motorists is relatively small. The same cannot be said for the number of Americans without health insurance. At last count, some fifty one million Americans did not have or could not afford health insurance. That’s roughly one in six Americans. Many more have some insurance, but it is insufficient. Certainly some of the uninsured pay their medical expenses out of pocket, but more typically, uninsured Americans allow chronic conditions to develop because they cannot afford to treat them earlier. When driven by necessity, they run to our emergency rooms and receive essentially free care. As most of us know, the insured bear the cost of this care. It is added in indirectly to the cost of a health insurance premium. So if you have health insurance, you are paying for the uninsured whether you like it or not, albeit indirectly.

At least with auto insurance the cost of uninsured motorist coverage is usually itemized. This rarely happens with your health insurance premiums. The last statistic I read estimated that about eight hundred dollars of each annual health insurance premium went to reimburse hospitals for the uninsured. These costs contribute substantially to the cost of health insurance. Moreover, as the ranks of the uninsured grow, these costs escalate. In addition, both state and the federal government, principally through Medicaid, pay other health care costs for those too poor to afford health insurance.

A good Republican, Conservative or Tea Partier though should not have any insurance policies. Why? Because they believe that personal responsibility is a black and white issues; no shades of gray allowed. So you should not even drive a car, or see a doctor unless you know you can pay these costs out of pocket. Co-pays are socialistic in nature because they encourage you to take risks at someone else’s expense. So you need to first either inherit a pile of money or have to earn enough money on hand so that you can pay for all your costs out of pocket. (This also allows you to negotiate good deals with your doctors, who are inclined to give cash discounts.)

Republicans, think carefully because insurance defeats the whole notion of individual responsibility. It encourages you to get into auto accidents, to neglect your house maintenance and to hit the Country Buffet every day. If you knew you would have to pay a million dollar judgment or hospital bill out of pocket, of course you would be far more prudent. If you knew because of hitting the Jack in the Box twice a week you would not be able to afford your Lipitor, you would be eating salads instead.

So that’s my suggestions for everyone into personal responsibility. No more weaseling. Time to put your philosophy where your mouth is. Cancel all your insurance immediately and pay for everything out of pocket. Because surely if everyone did the same America would be a utopia, right?

 
The Thinker

Hospitalized

It was more than ironic that less than twelve hours after writing my last post on violence related to recently enacted health care legislation, I would be putting our health care system to the test. After posting Wednesday night I readied myself for bed. On my way to the bathroom, my right toe grazed the side of the door frame. It hurt but I have broken this toe before. I hoped it wasn’t broken and shuffled off to bed.

The alarm woke me at 6:30 AM. I optimistically assumed I was good enough to go to work, so I shuffled to the bathroom to shave. It sure hurt walking. I realized I had injured my toe more than I thought. I figured a couple of Ibuprofens would take care of the pain. Since I injured the smallest toe, I knew there was nothing a health care provider could really do. Sometimes they are wrapped to the adjacent toe for support, but aside from elevating, icing and trying not to use the foot while it is painful nothing else is done.

What I did not expect was the incident of vasovagal syncope I was about to experience. Since it hurt to put pressure on the right foot, I put it on the left foot instead but the right foot still throbbed painfully. I tried to shave but started sweating and felt dizzy. Feeling I might fall, I sat myself on the toilet then blacked out. My forehead and my nose made a sharp contact with the side of our bathtub. Blood poured out of my nose, into the tub and over the floor. When I regained some semblance of consciousness, I whimpered to my wife, still asleep in bed.

Both the bathroom and I were a bloody mess. She wanted to call an ambulance but a few minutes later I was capable of staggering outside to our car on crutches. I was sweating and shaking on and off. I often felt short of breath. Kleenexes were stuffed up my nostrils. She made the short drive to Inova Fair Oaks Hospital’s Emergency Room which fortunately at 7 AM had a completely empty waiting room. I staggered in on crutches, collapsed into a wheelchair and within a few minutes I was wheeled into a triage room. Ten minutes later we were in Emergency Room 7. An emergency room physician was shining lights in my eyes while I stumbled through the various procedures in a shivering and cold haze.

I was still short of breath and still feeling somewhat nauseous. A saline drip with anti-nausea medication soon went into me through my arm. X-rays of my foot and abdomen were ordered, and were followed by a CT scan of my head, which fortunately did not show a concussion. However, it did show a broken nose to complement my broken toe. My face and forehead were swollen. No amount of tissues seemed to stop the blood from trickling out of my nose.

It took a few hours to feel better and to understand what had happened. If I had ever fainted before, it was as a child because I have no memories of previous episodes. Vasovagal syncopes though are fairly frequent occurrences. They are often a result of combining dehydration and acute pain, and I had both of them. They result in a sudden loss of blood pressure, which naturally caused the fainting. Some particularly squeamish people can get them from watching other people in pain. For example, some husbands have episodes while watching their wives giving birth.

After spending the usual restless night in the hospital, this morning I am expecting to be discharged. I am in the hospital out of what is probably an abundance of caution. Since Marfan’s syndrome runs in the family, and I already have an enlarged aortic artery, there is some concern that there may be a relationship. Some twenty years ago I had a brother pass out from Marfan’s symptoms right in the middle of taking a bath. It may be that as I age my Marfanoid symptoms are expressing themselves. To find out, I am tethered to an mess of sensors on my chest which are wirelessly transmitting signals to some nearby collection machine. Except for when I walk on the foot, I now feel fine. I would prefer to be home.

So what is the state of hospital care today? For those of us who are insured, and even many of those who are not, it’s pretty darn good, at least here at Inova Fair Oaks Hospital. My emergency room physician was on the mark. His diagnosis was confirmed by a visiting primary care physician later in the day. I got lucky in that I did not have to wait long for emergency care or tests. I fell around 6:45 AM and by noon I was wheeled into room in the Telemetry section in the north wing.

I may feel less charitable toward the hospital when I get the hospital bills. My insurance company will pick up the bulk of them, but of course pretty much every physician who sees me will bill me, and I will probably pay 25% or so of their bills as deductibles. They will dribble in over the next few months. I hope I have enough in savings to cover them. It is likely they will amount to a couple of thousand dollars out of pocket.

My roommate is both less lucky and luckier. He is lucky because his girlfriend telephoned him on Wednesday and realized he wasn’t making sense. She called the paramedics, who had to get the super to let them into his apartment. They found him tethered to an empty oxygen canister. His oxygen levels were dangerously low. He would be resting in a morgue tonight instead of in a hospital bed had it not been for his girlfriend. I don’t know all of what is going on with him but for a guy my age he is a mess. From over the thin hospital curtains I hear details of his life: his daily trips to the methadone clinic and his constant companion: the oxygen tank. While here at Inova, he is constantly being probed and wheeled out of his room for more tests. From his disheveled look, I doubt he has a steady job. He is likely among the uninsured or marginally insured. A good portion of my hospital care is probably subsidizing his care.

He spends most of the day and night asleep or groggily repeating his name when they come to measure his blood pressure or draw blood. He will awake to find the movie that he has had on is mostly over which he then restarts it again. I am already sick of the movie Duplicity and have even memorized some of the lines. As for me, they periodically come by to take my blood pressure and temperature, which are always in the normal range.

Despite the frequent nighttime annoyances, this hospital stay could have been much more unpleasant. For the chronically ill, at some point these constant interruptions in sleep patterns must feel like torture, because they are never allowed to sleep for a sustained period. For me one night in a hospital is just an annoyance. Inova Fair Oaks Hospital is all high tech these days. I can have movies on demand but more importantly they offer free wireless. By mid afternoon yesterday I was united with my laptop and spreading my news electronically. This episode will mean that I will miss spending a week in Denver next week on business travel.

The staff has been as caring and considerate as possible considering they have to periodically abuse your body. The hospital food has been surprisingly good but the portions have been small. You place your order over the phone from a menu that is provided. The food arrives about forty-five minutes later, usually lukewarm. The rooms are clean, the beds reasonably comfortable and my devoted wife is a frequent companion at my side. No spouse could have been more helpful in my time of need.

While all these creature comforts are nice, some part of me wonders if they are all worth paying for. It seems to me if we are going to get serious about controlling medical costs, movies on demand are easily expendable. My major concern is whether I will pick up an infection. I have been wary of hospitals all these years because of the high level of infections. A few hospitals are good at managing infections. Most are not. I have no idea how this hospital compares with others. Fortunately, I have no gaping wounds.

I look forward to reuniting with my house and my feline later today. I hope that unlike after my last surgery I will be back to normal within a few days. I count myself fortunate to be among America’s well insured. As a federal employee (as well as members of Congress), I cannot be dropped for any preexisting conditions, so I do not have that albatross around my neck. Within a few years, all Americans will have this privilege as well. Thirty million more will also be insured. It’s about time.

 
The Thinker

Tea Partiers: Armed and Dangerous

I guess it is too much to expect Tea Partiers to just go home and be pissed off but lawful citizens. No one expected any of them (or for that matter, most Republicans) to be happy with the health care reform legislation signed into law yesterday. It’s okay for them to vent their spleens, call the law unconstitutional (which it is not), organize peaceful but boisterous protests, petition the government to repeal the law and work actively to regain a majority in Congress. It is not okay to harass members of Congress, spit on them, call African American members of Congress niggers or homosexual members faggots. It is not okay to throw bricks through the windows of their Congressional offices, send them intimidating faxes showing their heads in a noose, or make threats to kill them, or their family, or in one case, a congressman’s brother and his family. In fact, most of these actions are illegal.

Doubtless, we will hear that those crossing the line are a tiny few, but the video evidence of protests by Tea Partiers at the Capitol over the weekend suggests otherwise. Moreover, certain members of Congress were cheering the Tea Partiers on, both outside of the Capitol over the weekend and in one case from the floor of the House of Representatives while it was in session. The instigators, i.e. the Glenn Becks, Rush Limbaughs, Sean Hannities and Bill O’Reillies of the media, not to mention dozens of other rabid conservatives inhabiting talk radio, will of course disclaim any responsibility for their part in this mess. So will Fox News, although they covered Tea Party rallies last summer like it was the most important story in the news. (Curiously, these rallies were far smaller than antiwar rallies years earlier that they ignored, dismissed or underreported.)

This is the ugly fruit of their extreme vitriol and hatred when they lose. They now control a party of people so extreme that the bipartisanship they claim to care about is virtually impossible. Almost exclusively, angry white people are now directing the Republican Party. They have cast their lot with these angry extremists in the attempt to regain political power. The reality is their party is now a party full of loose cannons beyond their control.

Tea Partiers may think that me, a liberal Democrat, cannot understand them because I don’t share their values. I do, however, know what it feels like. We had it for eight years under George W. Bush. We held rallies against the Afghanistan and Iraq wars that regularly drew ten times as many people as participated in Tea Party rallies. We too vented our spleens in protest marches. Every nasty thing that Tea Partiers are saying about President Obama we (or at least some of us) echoed about President Bush. We called him a war criminal that should be brought up on charges of authorizing torture. We railed against his illegal wiretaps and electronic surveillance policies. One thing we did not do was throw bricks into the offices of Congressional Republicans, or spit on any member of the Bush Administration, or insult them to their face with ethnic slurs. We did not target their relatives with death threats. We played inside the rules of the democratic system in our country.

Anger is perhaps expected when your side loses. It turns out that this legislation was not Obama’s Waterloo after all. Tea Partiers though need to be very careful, because through their actions they are quickly distancing themselves from mainstream America, who see their violence as crazy, extremist, unlawful and undemocratic. Instead of coming across as passionate people of conviction, they are coming across as the crazy aunt kept hidden in the attic. By their actions, they are telling America that when they think a law was passed using unconstitutional means, even if it was not, and they are willing to go to unlawful means to undo it. Essentially, they have placed a little asterisk next to the rule of law. At least some of them feel they can circumvent the rule of law and use vigilante justice when their dander is raised high enough.

I know it may feel to these people that this law was rammed down throats. Lord knows they told us often enough. Yet, nothing about how this law was enacted was unlawful or unconstitutional. Budget reconciliation has been used repeatedly by both parties, and during the Bush Administration was used to pass tax cuts for the wealthy. These tax cuts quickly ballooned our deficit, which previously had produced a surplus. Now Tea Baggers are complaining we can’t afford the health care overhaul, but not one of them is willing to raise taxes to address the revenue shortfall. Apparently, deficits only matter when your party is out of power and you see it as a way to gain political advantage, and can never be solved through additional taxes.

Really, Tea Baggers, grow up. What a terrible example you are setting for your children! There are few things more embarrassing than watching adults behave like children, but I suspect your children are actually better behaved than you are. In case you missed the presidential campaign, Obama won the presidency promising change, including health care reform. A majority of Americans (53 percent) voted for him. Americans also lawfully elected a supermajority of Democratic senators and a majority of members of the House of Representatives, in part in reaction to the extreme ways your party managed the country. The same parliamentary rules were used in this Congress to pass legislation as were used in the last few Congresses.

You may not like the health care reform legislation, but it’s the law of the land. It is highly unlikely to ever be repealed. At the earliest, it won’t happen before 2013 because it will take a new president to not veto a repeal of the law. Moreover, even if you somehow managed to replace every Democratic senator running for reelection in 2010, you would still not have the votes to overturn a presidential veto. The law will never be repealed outright. A clear majority of Americans now support the law. In particular, any attempt to remove provisions of the law that ban discrimination for preexisting conditions would ensure a legislator’s defeat. Attempts by attorneys generals from the various states to try to convince courts it is unconstitutional are dubious at best, for this law is no more an infringement of states rights than the draft is. You would be much better served by simply accepting you lost a big one, and channel your anger on the next battle.

Frankly, I find Tea Partiers not just weird, but dangerously weird in a Timothy McVeigh sort of way. I hope I am wrong, but my sense is that they are not going to peacefully accept what is now the law of the land. I think we are likely to see more extreme acts of violence from Tea Partiers in the days and weeks ahead. There are too many loose cannons on their ship and there is not one grown up in charge that can muzzle them. Should they be unwise enough to resort to more violence, they will also kill whatever chance they have of regaining political power. Americans instinctively back away from fanatics of any political stripe. Doing so will quickly prove counterproductive. The average American is greatly alarmed by their behavior.

 
The Thinker

Not exactly Waterloo

What a curious analogy by South Carolina Senator Jim DeMint: if Republicans and others opposed to “socialism” can stop President Obama and Democrats in Congress from passing health care reform, it will be Obama’s Waterloo. He will be doomed to finish out an ineffectual term, kind of like Jimmy Carter.

Most of us Americans have a hazy idea at best about The Battle of Waterloo. A quick recap for those of you who might have been asleep during the lecture on European history: in the Battle of Waterloo, Napoleon had managed to return to power in France after being exiled to the island of Elba off Tuscany. (It would be like Obama losing a second term, and then later winning another term.) Napoleon had already held power for a decade. Having been bitten many times by Napoleon, allied powers quickly organized to defeat him again. English and Prussian powers were able to defeat his armies rather handily in June of 1815 at Waterloo in Belgium. After all, they knew what they were up against and brought forty thousand more soldiers than Napoleon to the battle. After the battle, Napoleon went to live on another island, this time St. Helena in the South Atlantic Ocean, where he died rather ingloriously of stomach cancer in 1821.

In short, Waterloo was the concluding battle of Napoleon’s resurgent short second reign. In contrast, President Obama has been in office a little over a year. The closest analogy one can make between Napoleon and health care reform legislation was Napoleon’s administrative reforms, which included a tax code, a public road and sewer system, establishing a central bank, and a set of civil laws known as the Napoleonic Code which were, at least in theory, quite progressive. Many of these laws and institutions survive today and may be Napoleon’s true legacy in France.

In this health care battle, if any side has superior forces, it is the establishment. It is true that Democrats have the political advantage in Congress. However, the watered down legislation making its way toward the reconciliation process represents significant concessions to the health care and health insurance industries. Single payer health care? Gone. A public option health care plan to compete with private health insurance plans? It has virtually no chance of being added during the reconciliation process, based on press reports. If brought up, it stands little likelihood of making it through reconciliation.

In many ways, if the current legislation were enacted, it would be a great victory for the health insurance industry. These companies understand that in the end they cannot sell health insurance if no one can afford to buy it. The legislation requires most uninsured Americans to buy health insurance from the private health care insurance industry. The government is basically requiring Americans to dole out more of their hard earned money to give to private corporations, not the government. That sounds like the government is assisting the corporatocracy, not socialism. If Americans cannot afford to buy the product, in many cases the government will offer subsidies and tax credits to make it possible.

To label these reforms as socialism is ridiculous. If regulating the health care industry is socialism, then one has to ask the obvious questions of what else the government is doing is socialism, because most of the federal government could be construed as socialist. Regulating drugs for safety and efficacy must be socialism because it interferes with the free market for drugs. Federal highway transportation standards and interstate commerce regulations must be socialism. Most significantly, Medicare and Medicaid must be socialism. Yet, few of those railing against socialized health care are talking (at least openly) about getting rid of Medicare and Medicaid. Many of them loathe Medicaid (health insurance for the poor) but to vote against Medicare would estrange them from virtually every senior citizen in the country. Republicans, of course, thrive on cognitive dissonance. So sure, of course they can be for socialized medicine for senior citizens yet bitterly oppose it for the rest of the working class whose taxes, by the way, are funding the Medicare system that seniors are using.

The only health care legislation that would truly be socialist would be a certain forms of a single payer health care system. This would have the government pay all Americans health care bills. In return, you would have to get health care from a government approved health care provider. Even so, as envisioned, the single payer health care approach is probably not socialistic, because the government would not directly provide the care. Most single payer health care systems follow this model. Great Britain’s Public Health Service is a major exception. Curiously, in Great Britain the Conservative Party is aligning itself as the savior of the PHS.

Is a public option socialistic? A public option provides a government administered (not owned) health care plan open to all legal U.S. residents. It would probably look a lot like Medicare; in fact, it might be Medicare extended. However, practices currently do not have to accept Medicare patients, and many do not (or do so only with grumbling) because they do not feel they are adequately reimbursed. A public option would probably not be wildly successful. A public option would probably be like buying a “good” or “better” model refrigerator. Most Americans would lust for the “best” models available from companies like Blue Cross. However, having a public option, even if it is not as great as Blue Cross, beats having no health care at all. Ask forty seven million uninsured Americans. What a public option does is help make health care more affordable because health insurers would have genuine competition. However, as I noted, the public option has little chance of passing with health care reform.

The argument really amounts to whether the federal government should mess further in the health insurance marketplace. It’s about making sure the government does not grow any further, except in ways that matter to Republicans, like having large defense contracts to privileged contractors like Halliburton. It is apparently okay for the government to ensure that securities are traded in a fair and open manner. However, it is not okay for the government to require a level playing field for health insurers. State corporation commissions ensure level playing fields all the time with electric, sewer and water rates and we don’t fret about it. Some states even regulate health insurance providers. We recognize that industries that are monopolies, or near monopolies like the health care industry in many states, need regulation to ensure that a vital service is available at all. It is hard to think of any service more vital than health care. Moreover, it’s hard to think of an area more in need of regulation, given astronomical premium increases and no constraints about whom a company can insure.

It is clear what the cost of inaction would be: eventually there will be no health insurance industry at all. Maybe that is what Republicans are secretly hoping for, although the way they take major contributions from the health care industry it is hard to believe. After all, if no one but the very wealthy can afford to pay out of pocket for health care, perhaps with all these surplus doctors costs would finally drop to an affordable level. I personally think it’s more likely I will get a visit from the tooth fairy than this ever happening.

So I would not hold my breath there. I can guarantee you one thing: if health care reform does not pass, eventually the health care industry will be petitioning Congress for regulation. The last thing they want is not be the broker between you and receiving health care. So take your health insurance reform now or later. The reality is the current legislation is a great gift to the health insurance industry, which will likely ensure its survival with, at best, only a light touch from government.

Waterloo? In this case, Napoleon is not President Obama, but the health insurance industry. Perhaps the rock group Abba got it right:

Waterloo – knowing my fate is to be with you.

 
The Thinker

Laid Up

I wonder what the criteria are these days for an overnight stay in the hospital. They must be high. Many years back my wife had a hysterectomy and to save money the HMO sent her home the same day. She gritted her teeth and wailed all the way home from her many jostling sutures. It seems just about everything is being done outpatient these days, but if it is helping to control health care costs, it is hard for me to tell.

My relatively minor surgery yesterday certainly did not qualify for a hospital stay, which is just as well. I am more comfortable at home anyhow and Georgetown University Hospital is so far away from where I live. It took close to two hours just to drive there from our house near Dulles Airport. Much of that time was wasted creeping onto the ramps for the Dulles Toll Road and then trying to merge onto the traffic. It’s insane but just to make it more annoying they upped the tolls with the start of the new year. The Silver Line is going in, Metro’s latest controversial extension that will go through Tyson’s Corner and eventually to Dulles Airport and beyond. Money has to come from somewhere, so it comes from commuters on the toll road that have no other alternative. I am grateful I have to navigate the traffic on it so infrequently.

Parking at Georgetown University Hospital is always a hassle, but fortunately, my surgery was not. They must have finished patients ahead of me early. I had barely walked in the door and they were moving me back. I had doctors and nurses competing for my attention. They even skipped the traditional gurney ride into the operating room. My surgeon, anxious to get the procedure done with, had me walk into the operating room where the anesthesiologist hurried with my IV. One moment I was looking at the bright lights on the ceiling and suddenly it was ninety minutes later and I was in recovery. Huge bandages now cover my right foot and leg. Somewhere under all that dressing is a three-inch scar near my ankle where the tarsal nerve repair was done. Somewhere on my leg are three other incisions that helped release the pressure on those nerves. By 2 p.m. I was in crutches and on my way home.

Given a choice in the future, I would definitely consider Georgetown University Hospital again. The whole experience felt much faster and more professional than other hospitals we have used. The staff was excellent from the moment I arrived until the moment I left. I could not have asked for more professionalism and courtesy. Some years back after some back surgery, Reston Hospital wanted to give my wife some crutches, for which they wanted to bill her $200. What an outrage! Reston Hospital is a for profit hospital partially owned by Senator Bill Frist, one of the major stockholder of HCA. Georgetown, as a non-profit Catholic hospital (as well as a teaching hospital) charged me $44 for the crutches with no markup. It will take a while to see what my net bill will be but I suspect it will be lower than if I had the procedure performed locally.

Anyhow, I am home, and home is where I will stay for three weeks or so. My leg is bandaged in such a way that driving is impossible. Fortunately, I am reasonably mobile. I use crutches but due to all the gauze covering it, I can put some weight on the right leg. Nor really is there any pain. Yesterday I felt only numbness. It is clear that the surgeon wants the sutures to stay in place because the foot is wrapped so tightly that the whole foot feels numb, and it was the numbness (and pain) that I was trying to get rid of. At least one is down.

Home is where you heart is supposed to be but in truth, I am not much of a homebody. This means that three weeks at home will be something of a minor trial for me. I dread retirement because I feel like I need a place to go to during the day. For as long as I can remember it was always work or school. Even if I was having a stay-cation, should I feel the need to escape there was always the car. As I heal, I may be able to hobble around in my crutches up and down the block. This will be the extent that I will be leaving home.

To fill up the time I will first keep the foot propped up most of the day. Long naps do not seem necessary. I have a stack of DVDs I can work my way through, and there are books to read. There is also the web to surf, but for me surfing the web is always more fun after I have dodged and parried with the real world the rest of the day. Thanks to 21st century technology, I can effectively do 90% of my work at home, at least for a few weeks. So I plan to resume working next week, although my kitchen table is a poor substitute for the office. It has no becalming view of the Shenandoah Mountains, nor the convenience of the cafeteria and snack bars, nor the social life one can find in the office.

Somewhat begrudgingly, I think what I will miss most of all these three weeks at home is my office social life. I am no social butterfly. There have been consecutive days when the only one I spoke to was the guy who removes my trash. Still, it is nice to interact with people other than my immediate family. Here I have my wife who for a while will have to cater to me and who is always nice to have around, but she is a well-known commodity. There is also my daughter who sleeps during the day and who generally ignores me anyhow. There is also one friendly cat. To the extent I have a social life these next few weeks, it will be with my cat.

There are still bills to pay and work for clients on the side to do. That will help. I best double my dosage of Vitamin D because it will be awhile before I will feel the sun shining on my skin again. Being laid up is a part of life, and one I should get used to. It is perhaps something to be welcomed rather than feared. As for being one of life’s trials, it will be a minor one. Come early February, I expect I will be sick of it and will look forward to returning to the office. Until then, I must be a homebody.

 
The Thinker

Half a loaf is still better than none

Polls indicate that most Americans are not happy with the health insurance reform plan emerging from Congress. Of course, most Americans are also not fully informed about the health care reform plan either. With the Senate bill alone consisting of thousands of pages, who has time to read it? We depend on the press and policy wonks to give us the bottom line. To say the least, there is disenchantment. It’s kind of like hoping for a Lexus and instead getting a Yugo. Who would not be disappointed?

I know I am. I am in line with the majority of Americans who wanted a public government administered health plan on the assumption that it would at least be fair, provide real competition and be always available when other private plans left the market. It doesn’t look like that will happen. While anything is possible in the upcoming conference committee, it is likely the House will kowtow and it will be the Senate’s version of the bill that will become law. There is no public option in there, in large measure thanks to Senator Joe Lieberman.

Many Americans are also disappointed in President Obama’s performance to date. After all, he promised change. Where is the delivery? Our disappointment is reflected in his sagging pole numbers. In reality, given polarized politics as they currently exist in Washington, Obama is doing remarkably well. Particularly when it comes to health care reform, our disappointment is because our hopes are colliding with this messy thing called reality.

We might have actually seen the massive change that we were hoping for had we had solved a few other major problems before electing Barack Obama. Specifically, we needed meaningful campaign finance reform and limits on the influence of lobbyists in Congress. The Supreme Court in its infinite wisdom says our current corruption-laden political system is entirely constitutional. This meant, as usual, that those with the money, such as the health insurance lobbies, had a massively disproportional influence on our legislators. To me it is remarkable that in spite of the hundreds of millions of dollars spent to defeat reform we got as much reform as we did.

What we are getting is largely health insurance reform and not quite health care reform. Still, getting even health insurance reform is a remarkable achievement, given the money spent to defeat any kind of reform. Every single Republican senator lined up against reform, which meant that 58 Democratic senators and 2 independent senators had to pull together. Only of course, they did not so much pull together as kept watering down the bill until health care reform became health insurance reform. Naturally, billions of dollars in tax breaks went to appease the more recalcitrant senators. The resulting bill is a lowest common denominator bill, which is what you get when the Senate chooses to allow 41 senators to block almost any legislation.

One can complain about Senate Majority Leader Harry Reid’s tactical approach. He could have placated people like me by using a budgetary rule called reconciliation that required only a simple majority to pass. This could well have delivered a more liberal bill with more actual health care reform in it. He chose not to go that route. While I think it was a mistake, perhaps he had sound reasons for it. For example, he might have decided that disenfranchising conservative Democrats on this issue would eventually prove counterproductive with a whole host of other matters on which Democrats need to remain united.

Any major changes by Congress are excruciatingly difficult because there are so many well moneyed interests aligned for the status quo. This leaves the rest of us who are much less moneyed largely disenfranchised. Yet despite these odds, meaningful health insurance reform looks likely to become law. In that sense, President Obama is right that this package is a big deal. History suggests that even this much was a long shot. Once we get used to it, we will take it for granted and wonder why Republicans were so foolish as to block it in the first place.

Half a loaf is not as good as a full loaf, but it is still half a loaf. I do not agree with Howard Dean that we are better off without this bill. While it does little to address exploding health care costs, at least thanks to generous subsidies 30 million Americans will be able to acquire health insurance, and no one can be denied coverage for preexisting conditions. This should make our premiums less than they would be without reform. Every hospital or emergency room visit by an uninsured or indigent person means that their costs are passed on to the rest of us in the form of higher premiums. Reduce the uninsured and more of our health insurance premiums will actually go to treat us.

Count me among those who are disgruntled but still grateful for the half a loaf we are getting. It was not foolish of me to hope for more than what we got. It would have been foolish of me to actually think we would get it this time around. I never did.

 

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