Sunday, February 10, 2008

National Health Care part II (for Hannah)

This was supposed to be a thread within the National Health Care post....but I guess it was too long and it wouldn't post. So I had to make a separate post.

Hannah: This initially short response turned into a 4 hour tome because of my passion for the issues raised here. I'd appreciate your attention to consider my points and examples. This isn't theory for me. I live it every day. It's doubtful any of the politicians promising "Universal Healthcare" (Democrat or Republican) have spent more than 5 minutes in an ER for anything more than a photo-op.

Thank you for defining yourself as a non-conservative and thus giving me an opportunity to discuss this with you (hopefully in a rational way)!

I (and most if not all of the other bloggers here) want medicine fixed too, we just have different methods in mind to achieve a solution. Read our posts....we're all very unhappy right now (except for Etotheipi who blissfully dissects stuff and avoids the ED)
Most Libertarians and Conservatives aren't mean or nasty. Unlike what you'll hear Hillary or Obama say, we don't want to let people die in the streets....unless maybe it's Hillary, but I digress.

Like 911 has repeatedly said...we believe there must be some level of personal responsibility to health care. If not, it's a waste of time to even treat! Even well insured patients who won't take personal responsibility don't keep their doctor appointments, don't check their blood sugar, etc are a source of ire for docs, and a drain on our system.

We DO see tons of lazy, stupid, entitled, and irresponsible people in the ED. Those folks make up the majority of our problem. But by NO means do I or any of the other bloggers here think EVERY uninsured person is lazy. I'd be willing to bet that you fit NONE of my above adjectives. You read about us bitching about the lazy ones because they drive us so crazy.

Don't feel like we're piling on you here, we're frustrated because people outside of our industry see rising health care costs and insist that the Government fix it. No, No, No...the Government is largely responsible for breaking it! Remove some of the regulations, narrowly define EMTALA, control illegal immigration, give us some tort reform, and the private sector will take care of the problem. Competition drives costs down and improves services. In my town of less than 100K people, we have 9 CT scanners (including 2 of the latest generation models), 5 MRI machines, and a PET scanner...all because of competition between 3 hospitals and several clinics.

Most of the bloggers here work in the health care industry and we see what the tremendous level of Government involvement has done thus far....everything is worse now than it was 15 years ago. "Universal Health Care" doesn't scare me because of the financial perspective (hell, I might even make least at first).

It scares me because we have one of the finest health care systems in the world. Why? Because it's based on free market capitalism. We don't want socialized medicine as providers, and I assure you that you don't want it as a health care consumer.

I could pull out lots of examples, but let's use a common one: Not a day goes by that I don't see a patient with rotten teeth in the ER for a toothache. I have NOTHING against helping the fact I don't think we help them enough.

We should work harder and spend more to get them back on their feet and back as productive members of society. With a definite END in site to their benefits. NOT the current lifetime of Medicaid as long as they don't work over 25 to 30 hours a week or make above the poverty level. (I'm not talking about folks with mental retardation or other true please don't go there with an attempted rebuttal).

I can give you HUNDREDS of examples for every condition you can think of from "fibromyalgia" (whatever the fuck that is) to chronic pelvic pain, to migrane headaches, to real diseases like congestive heart failure and diabetes.

But back to my toothache example, in almost every single one of these cases (and the other ER docs on here will back me up), the person is wearing very nice clothes, has a late model cell phone, fancy tennis shoes, manicured nails and expensive hair styles - (if female), and he or she usually reeks of tobacco. In other words they have plenty of cash for what they WANT and think is worthy of spending their cash on.

"When did your tooth start hurting?" I ask. The responses are usually weeks to years. "Have you called a dentist to schedule an appointment?" I ask. "No, they're too expensive" or "I didn't have the money to see one" are the usual replies.

It's a matter of priorities and taking responsibility for your own healthcare needs. This is where Libs and Conservative/Libertarian folks part company.

Hannah, I'd be willing to bet that you worry about paying your bills whether to the dentist, PCP, or, ER. Thank you. I'll bet you even AVOID going when you need to because of the cost, and I'll bet you chose the least expensive alternatives available(like a direct care instead of an ED). You're almost certainly NOT the problem or the source of our griping! It's the people who expect all care for free, choose when they're gonna come in (usually at 3am "don't you have a dentist here?", and want it fixed NOW, for free. These people are the problem whether we're talking toothaches, snotty noses, coughs, vomiting for weeks (always with normal lab studies...amazing), severe chronic back pain, exacerbation of "fibromyalgia", twice weekly migrane headaches only relieved with IV Demerol, knee/arm/shoulder/ pain for months etc, etc, etc.

Go sit in you local county ER as a volunteer on a couple of Friday or Saturday nights and see WHO we're talking about. It'll rock your world and change your perspective!

Usually, I'm dealing with a heart attack, a car crash patient, a stroke, and all other kinds of actual emergencies...but these non-emergent freebie people are almost always the most rude, threatening, unappreciative and demanding. ("I'm gonna call my lawyer if you don't hurry up and see me".....funny how once I hear that, their chart always leapfrogs to the bottom of the pile or occasionally gets "lost" behind the desk or into the paper shredder).

Again, the other ER docs will likely back me up on my perception.

As I said in another post when a guy complained that his ER doctor bill was almost $1,000...You've gotta understand that your charges are so expensive because you're paying the bill for all of these other people. Why?...Must be greedy doctors, right? Wrong. It's largely because of a law passed by liberals. (It started here in Texas I'm sad to say by liberals and spread nationwide to become EMTALA). It says they get evaluations regardless of their ability to pay. Of the $1,000 the poor got charged, I'd see about $65 to $70 (out of which I get to spend about $20K a year for malpractice coverage though I've never been sued).
I make no more now than I did 8 years ago and I DEFINITELY work a lot harder. I probably won't make any more 10 years from now. (But my hospital admistrator will, and your political representatives will) .

While in any other business or profession, you'd expect to make more the longer and harder you work, it ain't workin' out that way for most of us in ER Medicine. No other job in the world requires over a decade of training and then expects people to perform a significant part of their work for free. AND risk a lawsuit if the patient is unhappy.

Even the lady I buy donuts from for my nurses spent a single day learning to make the donuts...but she doesn't give them away (and no one expects her to). Health care costs have gone up in the past 10 years, but I make the same....why is that? Your answers are mostly above.

The intent of the EMTALA law wasn't to turn the ER into the cesspool that it has become, but that's what happened. It was a well intentioned attempt to keep hospitals from refusing to treat truly emergent patients. But due to typical liberal "feel-good" one ever considered the unintended consensequences of such a law. Now that we see the mess it's created (not to mention the entire culture and mindset it's spawned), it's failures are seen by the Left as a result of the medical establishment and the "Rich Doctors"...BULLSHIT!

You and I don't disagree. I believe every U.S. Citizen should have access to basic healthcare. And I believe non-Citizens can pay for it. But NEWSFLASH...ER Docs aren't trained to be primary care doctors! (I tell patients..."yes, I am a doctor, but I don't specialize in your problem. I take care of EMERGENCIES for a living. It's like taking your broken car to a refigerator mechanic. You'd never do that even though both are mechanics, you know that they're trained for different things. You must see a PCP for your xxxxxx".

I see a number of ways to help the problems without taxing the crap out of everyone or breaking down our current system into a socialist nightmare.Since fewer than 20% of the US population has no health coverage, (based on the latest numbers from 2005) why oh why do we want to screw up health care for the other 80%? I know, it's politically sexy to promise this. It makes the various Presidential candidates seem like they care....NO ONE should be this gullible, yet sadly many Americans are.

First, we definitely need more patient education! Any solution has to be accompanied by an intensive patient education campaign. It's not unusual (saw it just last night) for a parent to bring a baby to the ER because of ONE episode of spitting up!?! Baby was FINE when I saw him. Why you ask would they pack up and come in for ONE episode of spitting up in a 9 month old? BECAUSE IT'S FREE TO THEM.

Here are three quick suggestions:

1) Let docs DEDUCT the bad debt from their taxes encountered by non-paying patients. Then there's some incentive and no less penalty for seeing these folks. This would have to be associated with malpractice or tort reform nationwide (see next issue). But when you get a doc's bill, understand that it's mostly for their knowledge. We spend 11 to 16 years training to be doctors. There are plenty of bright young people (my daughter among them) that are planning to avoid medicine all-together if this socialized crap passes. Unless there's some reasonable financial reward for their many years of study and effort. College, Med School, and Residency are TOUGH! Very few people are gonna do it to be rewarded with socialistic medicine hassles and shitty incomes.

2) TORT REFORM! You'll NEVER get this passed by Democrats who are largely funded by trial lawyers and ambulance chasers. But in Texas, since it's passage in 2002, we've seen frivolous malpractice cases decline and insurance rates decrease. We went from 2 companies willing to write ER Docs policies to 11 companies! This is the result of competition in the marketplace. Despite the spin the left tries to put on the law, a victim of malpractice is still rewarded ACTUAL matter the costs. The cap was placed at $250K PER OCCURANCE for punative damages only.

3) You can already get student loans forgiven if you go to work in "underserved" areas for a certain number of years. The average med student graduates owing over $125,000 in loans. Set up county run public health care clinics for primary medical issues (the same for dentistry). Work a deal where you pay these docs a reasonable income and forgive their loans if they remain for 3 to 5 years.

Those are easy and fairly immediate solutions to the lack of access problem. The ER just can't continue to absorb these people (plus, I SUCK at primary care...that's not what I do for a living). I'm not managing your "fibromyalgia" since I don't believe in it, and I'm not managing your chronic back pain, either. I'm not an expert in chronic hypertension control or diabetic sugar control.

I'm a "safety net" with some big holes in it.

Thank you for reading.




  1. Great post. If a person can find fault in what you said they are either really dumb, a far left wackjob, or have no idea what working in a REAL ED is like. I would like the Cliffs notes next time. Just kidding.


  2. to confirm what erdoc85 is saying see this comment from one of your fellow liberals which was posted a few days ago regarding her experience in the ER...

    Elizabeth said...
    You know, I consider myself to be a fairly bleeding-heart liberal, and I almost lost my shit in the ER a few weeks ago, and Amy, I think I get why the ER docs get so frustrated. I'll explain. (and this is going to be a book. I'm sorry.)

    I had a C-section in early December. When my baby was not yet six weeks old, I stepped on one of my other kids' toys and wiped out, twisting really violently on the way down. My barely-healed incision opened back up and really, really hurt, and it was about 11 at night. I called my OB, who wanted me to go to the ER. I went.

    The ER was filled to the rafters with parents and kids. Kids who WERE NOT CRYING. AT ALL. They didn't even look sick (okay, I'm not a doctor or a psychic, but I'm pretty sure they were there for colds) Instead, they were running around screaming, throwing trash on the floor, eating cookies, drinking get the picture. They were, however, all snotty.

    I sign in. I ask how long the wait is going to be (just a ballpark range, nothing precise) (oh, and I said please and thank you) and she said she didn't know. While I waited about an hour, I saw some guy ask for pain meds while he was waiting. I saw parents just talking on their cell phones and going out to smoke while their kids ran amok in the waiting room. Then I heard the triage guy tell another person that the estimated wait time was NINE HOURS. This was not a county hospital. NINE HOURS.

    I was in a LOT of pain (and I had already taken my last hoarded vicodin from the C-section earlier that night.) but I told the triage nurse to take me off of the list, because there was no way I was waiting nine hours when I could just go see my OB in eight.

    Okay, I know for a fact that my neighbor with Medicaid uses this ER all of the time for things like ear infections, so I'm going to assume that a lot of the other parents in that ER were doing the same that why on earth do I pay 300 dollars a month for my insurance just to go to the ER and NOT GET SEEN because it's too clogged with people that could have gone to a minor med? It really pisses me off. It's not fair that I'm going to have to pay out the ass for my C-section at that same hospital while I actually qualify for Medicaid, but I'm trying to do the right thing and carry my own weight, and I can't even get seen in less than 9 hours.

    You know, it sucks when you get it up the butt for trying to do the right thing, and as a patient, I'm pissed, so I can only imagine what the docs feel at having to see this kind of stuff day after day.

    12:29 AM, February 08, 2008

  3. erdoc85,

    thunderous applause. i edited to take the spaces out and broke your linke to the statistics you quote. you make want to add it back. couldn't find it when i clicked on it... went to an 'error' page.

    and to echo what you have said, i bear no ill will to sick folks regardless of their ability to pay. in fact, i just assume they can't. it is, as erdoc85 says, the 'unintended consequences of EMTALA' that is killing our ability to do what we trained to do. people are dying as a consequence in the following ways...

    1. those who wish to have a primary care doctor often can not find one because the local docs actually lose money with certain forms of 'insurance', especially the government provided ones.
    2. these folks now have the ER as the only option.
    3. the uninsured and uncaring come here all the time for everything under the sun and usually ride the ambulance in. this takes ambulances out of service and other call responses are delayed or missed.
    4. some folks who are actually quite ill, take meningitis for example, may walk into the ER and be told it's 8 hours to be seen, go home and die.

    erdoc85 is also correct that the impending crisis is simply going to be that we don't have people choosing to go into medicine anymore. i can not think of a job that is so demanding of huge blocks of time to get trained, so draining mentally and physically, so expensive to get into, and yet so uncertain in terms of reimbursement. let me ask you, if you knew you would have to ace your college courses to get to med school, work hard for four years there where your sleep deprivation begins (and lets say you want to be a surgeon) spend up to eight years making less than minumum wage and working 80-120 hours weeks while managing your 150-300k of debt to emerge with a rare skill in your early to mid thirties only to figure out at that point that your sleep deprivation has not ended, and that it will take you ten years to get out of debt?

    the answer for more and more people is 'no'. the solution right now is to employ mid-level providers such as nurse practitioners and physician's assistants. no problem there but they can't do the complicated stuff and they can't do surgery by themselves. next, foreign medical graduates are being employed in greater and greater number. some are great, some are terrible.

    so, the reality is that we doctors are just human and we do have a 'no mas' point. legislate away! you can replace an air traffic controller in six months, it takes 8 years to replace a doctor unless it looks attractive to the young folks they won't do it.

    a prior post details (not exhaustively) the unintended consequences of EMTALA (also linked above).

    i hope you have the feeling now that we are not mad at you, we are merely trying to give you a window into the physician's lot. we are not politicians and we usually aren't good at business but we are the only people who can do what we do. we should be paid accordingly and treated as a valuable resource. right now we are demonized, almost exclusively by the left side of the aisle, as being rich, money-grubbing complainers. i am only the latter.

  4. I just have a quick question. It's my understanding that hospitals contract with groups of EM physicians. Do the physicians/group get paid a flat rate or do they bill on a procedure by procedure basis?

    Also, when people don't pay their bills, who eats the cost? Is it the hospital, the group, or both?

  5. I think using the British NHS as the absolute example of socialized medicine is not the best we can do. I have used it, it is pathetic. How someone whould want to become a physician in this mess is beyond me, but the system has been around for decades and that's all the British know.

    I have also used the French system and it is much better.

    Before you become all huffy and puffy, let me explain that I am neither liberal nor conservative. Actually, I don't vote. My personal opinion (and no, you cannot change my mind): all politicians are lying scoundrels who will tell people what they think they want to hear and once elected will switch to a one-track mind about lining their own pockets.

    Back to the French system.
    It is not free and works like all health insurances, except it is administered by the government. Your premiums are your health care taxes.Then come the co-pays.
    PCPs are the lowest, then the specialists, then ER and surgery.
    PCPs usually reserve one day a week to appointments, the other days are on a first come, first serve basis. You can wait one or 2 hours but you see the Dr. that same day.
    If you live in a large city and are too sick to go to a PCP's waiting room, for the co-opay of a specialist visit, you can call one of those Physicians on Wheels or whatever they call themselves :-)and they will come to your house.
    If you live in a rural area, chances are your PCP still makes house calls.

    What that achieves is that it is much cheaper and quicker to see a PCP than going to Emergency.
    Are there people who abuse the system? Of course, they are everywhere, but to be seen you have to have a governement-issued health card. You don't have it, you don't get treated or they'll be happy to charge you full price.
    The unemployed and indigent are given a card, so why would they want to go the Emergency when they have access to a PCP for a much shorter wait.

    I am sure there are holes in this system, nothing is perfect but the French have used it for a long time and it is still holding...
    Drs probably earn less than here, but their expenses are also less. I don't think medical school is as expensive and they do not get sued as much. For now.


  6. Wonderful post! I worked as the controller/account and budget manager for a "classified" healthcare clinic. A "free" clinic funded by the DOH. Except, only people below the federal poverty guidelines were "free." For everyone else, a sliding fee scale was available. Very sick people could end up with significant bills. Although $400 may not seem alot, to many struggling, it can be alot.

    However, as we said "NO MONEY, NO MISSION." We had to aggressively collect fees from people who were assessed to be able to pay. Even with sensitive payment plans, SOME people were resistant to paying.
    However, most were grateful to be able to get the much needed healthcare, and were grateful to pay, plus donate money to our clinic.

    So what do people unwilling to pay? Go to their local ER. Our county/ Trauma hospital had it's own clinic and during day and evening hours would refuse to see non-urgent patients and send them to the clinic (oops, where they would need to pay a little bit). How mnay people waited until the clinic closed for the night to go to the ER?

    On the other prospective and equally disgusting were what happened in a peds clinic. In NYS our "child health plus" Gov paid insurance for children was generous. No ecuse for kids to not be covered. Our Peds clinic had parents who brought their kids in because the school nurse forced them, CPS was called...etc...
    Basically, a very small minority of parents did not seem to give a shit that their kids were suffering from things like Asthma.
    This is an example were medical care is free, and people are too lazy to use it.

    It is a minority of people, the very few, who are scums of the earth. And most of them end up in your local er.

    Okay my only little liberal thing....Many impoverished people, even if homeless, would attend to their personal hygiene (hair, clothes, and nails, and cell phones) before any other expense. It is so annoying, but please keep that in mind. But still! geesh.

    I could talk about living a mile from Canada and how many canadians come over for MRI's but I've already typeed enough!

  7. Wonderful post.
    I'm currently in my 3rd year of medical school. I love medicine and I love helping pts more than anything.


    I must say that the assurance of a nice income is a huge part of the equation. Not because I'm greedy, but because I want to know that at the end of all this work I will finally be able to relax and not worry about my future. Medicine is a gamble, not so much financial (although that is changing), but of happiness. Imagine spending your 20s in a library, your 30s in a hospital and your 40s climbing out of debt. (I will owe roughly 250k after next year.) While most people are spending spring evenings hanging with friends, nurturing their relationships with their significant others, I am sitting at a desk reading or at the bedside; not with my wife/ friends.

    I dont think people understand the sacrifice that doctors make. They give their time, their youth, and many times their families to better helping their patients.

    I just hope that someone appreciates it.

  8. ryan,
    you and i are clones. i think the general public still thinks that all doctors are, or will be rich. those days are gone with rare exception (neurosurg maybe? derm? mohs surgery?). brace yourself, doctors have not done a good job of protecting our territory. funny, the only doctors who are still fee for service are veterinarians, dentists, and quakopractors.

  9. Thank you for this post. Being a person from the far left (but a lovable open minded one), it helps a lot to have such an inside look to the thinking from people actually performing. I have nothing to say to it, no rebuttal.

    The only thing I will throw into the mix is that in the last year, my household of 2 has seen two ER visits, two surgeries, and a heart cath....

    ....and it still cost me less than it would cost to insure us both for a year. I wasn't paying on a sliding scale or anything, my income doesn't require it. For many, being insured is not the most cost-effective way to go, especially if you are one of those who lived poor for a very long time and were unable to afford insurance OR care of any kind, but are now considered uninsurable even though our income is now more than enough to pay something reasonable (and by that I mean something under $1000 a month). That "uninsurable" tag means our insurance far outstrips our med bills, and we neglect nothing now regarding wellness care on any level, not to mention the costs I outlined above.

    HSAs (I'm a performing artist and my union stipulates that every company I perform for must contribute a bit to my adds up) and just flat out paying the bill is how we do it now. I know we are taking a risk as regards cancer and other truly catastrophic diagnoses, but all we can really do regarding that is try to live the highest quality life we can vis-a-vis our health.

    But we still carry the stigma of UNINSURED/UNINSURABLE, and there were plenty of docs in my town who wouldn't even consider us as patients when we were searching for a PCP upon moving here. Turned down flat, even with written proof in our hands of an excellent track record of paying our med bills.


    I don't even know what to think now about the situation. I'm glad I make enough to pay our med bills, and even for a bit of plastic surgery to correct some problems following a huge weight loss....but if I didn't have that income, I don't know which way I'd jump, or to whom I'd turn. I guess I'd just be screwed.


  10. 911 and 85,
    So how do you get the (your) word(s) out of the blogosphere and into the political and public arena?
    Do you think it is already there? I realize that blogs are public, but do think they are dismissed as ER rantings?
    I'm sure the gv't/CMS turns a deaf ear. For the 80% of us who are insured, what can we do to start a movement towards change? What can health care providers do as a whole to be the voice?
    The only good thing may be that like any gvt program, if UHC passes, it will probably take a decade to become reality. Good for those of us who are older anyway and may be able to find a way out by then. Bad news for the up and coming.

  11. dear saengerin,

    you bring up some great points. thanks for your post. you are correct that for many folks with jobs and money it makes more sense to go uninsured with an HSA. the numbers floated re the 'millions of uninsured' never has an asterisk explaining this and contributes to the hysteria.

    obtw, went to your site, hope to see you perform someday. i take it you are in theatre. are you a singer too? perhaps i will have the pleasure of seeing you someday.

    finally, here's your solution to your problem getting in to docs. call ahead and tell them you will pay up front. they will make space for you!

    MMT: this blog is the best i can do. let's face it, no one will get elected preaching personal responsibility or saying that health care is a team effort and part of the team is the patient. just won't happen. nanny state arriving soon.

  12. got this from a new blog, American Doctor Rant, thought it might be good in this thread. The whole post is worth reading but this quote is right on...

    "Democracy is a system in which people get what they want, and they get it good and hard."
    - H.L. Mencken

  13. So why don't doctors form some type of network, group, union, I don't know, but something along those lines to express their opionis? Perahpas a political group. Something to get heard. I find that those pushing for nationalized healt care are somewhat in a minority. The rest of remain a silent majority and take the pushiment for fear of retaliation. I think that doctors could have more of a voice if they could show a united front.

  14. let's face it, no one will get elected preaching personal responsibility

    They won't get elected preaching common sense and the dissolution of our socialistic mentality either. God help us all.

    Great post, 85

  15. MMT: The only way I know of to try and RIGHT the health care ship (no political pun intended) is to keep talking and blogging about it.

    I hope enough rational people read it, understand it, and refer others to our discussions. Then I have to hope when the time comes...(and man do I fear it's coming) those same people will call their Congressman and say: "if you vote for Clinton-Care, or Barak-o-surance I won't vote for you again". That's the only way a politician will ever "get the message".

    Politicians NEVER stop trying to simplify things into soundbites. Few people bother to become educated enough to support or oppose an idea on the merits rather than on the feelings.

    I don't have any ill will toward Sen. Obama (I DO hate Hillary's guts), but from what I am allowed to know, he seems likable and inspirational enough. But I find it a stunning statement about the American Political Process that a man with 2 years of State, then 2 years of National Senate experience might just be our Democrat Presidental Nominee.

    He has lots of policy statements...but NO SPECIFIC PLANS! Why would ANYONE support a candidate who won't tell you HOW he's going to accomplish something? Merely the fact that he "wants to" seems to be enough for some voters...or maybe it's just anti-Hillary votes (that I could understand).

    The most specific thing I've heard Obama say about how he's going to FUND his massive health care give away is "we can do it". No shit? Yeah, I'm a Libertarian-Republican, but I MIGHT consider voting for the guy if he had a good plan.....what is it?

    Right now, we need some tweaks to our system and a better safety net. I tried to offer 3 simple tweaks in my very prolonged and long winded post (sorry about that...I had been working nights and I couldn't sleep) that I thought would help.

    But in the ER, we need total cultural change! We need to be able to refuse non-urgent patients without fear of a colon cleansing by some John Edwards-type douche bag. We need to be able to fight back. "I was happy to see you for your 6 month old toothache Ms. Crankgrinder...the bill is $1,200. If you leave without paying for it, I'll have you arrested for shoplifting my intellectual property, then I'll get the deed to your El Camino and your trailer" (OK, maybe something not quite that harsh....but I'm just thinking here).

    Sadly, as CAT has pointed out...our side of this debate is long and boring...there's no Cliff's notes!

    I appreciate the self identified liberals for reading and considering our side of the issue. As I said before: We want essentially the SAME things, we just disagree on how to achieve them.

    IMHO, Libs have one thing much easier than Conservatives. Soundbites. I can't distill all of the reasons why Universal Health Care is a threat, and a sham into a one or two word bumper sticker. But nothing makes a lib FEEL better than believing in some simplistic slogan or notion like "CARE" or "CHANGE" or "PEACE" or "LOVE". These are complex issues damnit, not emotions and soundbites.

    Americans are so gullible, or so tired of G.W. Bush or both that they're willing to drink the Liberal Guyana Punch.

    The damage done to our current system by Universal Health Care might not be permanent, but its doubtful it could ever be un-f&&ked in my lifeteime.

    LadyK: how in the world did New York circumvent the Federal EMTALA laws passed in the late 1980's? If I could kick every obviously non-urgent patient to the street 'til their appropriate health care access point opens, I'd be much happier!

    I've written about the Arkansas system before, but as I said then, people just find the ways AROUND it.

    I see a lot of little Cindy's, Johnny's, Tae'Raesheka's, and Jesuses (Jesi?) who were seen in their Medicaid clinic yesterday for "a cold". They didn't get antibiotics, so they're in the ER essentially knowing that I'll do just about anything to get them the fuck out of my way so that I can actually concentrate on the cases I am THERE FOR!!! I know, it's my fault for giving in here, (at least I refuse to give into the drug seekers).

    Don't take this the wrong way, please appreciate my analogy and understand that I am drawing upon both my sense of humor and the history of my beloved Texas....but sometimes I tell the nurses to call me Colonel Travis (or Dr. Colonel Travis)....since I feel trapped in the Alamo totally outnumbered by the onslaught of people trying to over-run me.

    As of now, they're flying the "flag of no quarter" (taking no prisoners) and they're winning.

    Thanks to all who indulged my post night shift insomniac rant...and to 911 for cleaning it up for me!


  16. How to relate to that rant? Too long, too glib, but yes, I can see his points. Trouble is, I don't see a way out short of government intervention, and as long as docs think they have to make in excess of $200,000 and up per year, well, there ya' go.

    I'm a medical transcriptionist who until 2 years ago was still plugging away. But then I got an infection called commonly "man-eating flesh bacteria" and wound up at age 68 having to go in hospital on a Sunday evening via ambulance and indirect admission. Took hours to get seen via the ER and to finally be admitted. I'd told them right from the start that I'd just joined this Part D Medicare HMO called SelectCare of Texas, or the so-called Texan Plan. So the hospitalist at that major Houston hospital admitted me and had labs, rads, pulmonary, infectious disease docs taking care of me who I later learned were not part of the Texan Plan, and therefore, were never paid by said HMO. What could I do about it? Very little. I am still being dunned months later by the Pulmonary group, and tho' I called and explained what had happened, and that my Medicare funds had been denied to their group due to this error on the part of the hospitalist, they keep billing me. Look folks, I only received $983/mo. for all of 2007, and as of January of $2008, whoopee, it went up to $1005/mo. Big increase, eh wot?

    I didn't have insurance thru' most of the 80s and 90s, only had it for 9 months while working for one big transcription service and during that time, never had the time to go to a doc, and had I needed surgery then, would have lost the coverage in about 2 weeks time, because their health ins. coverage was dependent upon the transcriptionist's always attaining full-time production in terms of 2200 words per day for each bimonthly pay period. Yep, and when my production went down after 9 months due to changes in the software, etc., I lost my ins. Tried paying it for a couple of weeks; couldn't afford $125 per pay check. Just didn't make that much to begin with!

    Now I have great adversity from having had 6 debridements of my left leg from the area of the ankle up to the mid shin. I have not been able to regain enough strength to walk alone. I have osteoarthritis in both knees, bone-on-bone, and having already had one infectious disease no one ever heard of until about 1996, I don't wish to find out if I could pick up MRSA by having a knee replacement, so I've learned to walk with a walker, and get around with a wheelchair. I also have terrible carpel-tunnel at this point, having used these computer keyboards now for many years.

    The docs are usually very good ones. I was very fortunate in receiving excellent care save for one younger doc who tho' he was born here, hails from a Middle-Eastern background, and from a different cultural mind-set altogether. He drove me nuts. I got out of the so-called Texan Plan, went back to plain Medicare, and now can CHOOSE my own doctors, and assembled a team of guys in my age group, or a few years at most younger than myself. Find that men in their 60s look at medicine same way I do; if it ain't broke, don't fix it!

    Yes, the whole blessed system needs an overhaul, and yes, Hillary, IMO, is gonna' take it on, and y'all better make up your minds to work WITH her, and not AGIN her. I still recall my internist up home who in the 60s hated the very idea of Medicare and faunched at the bit about it; years later in the 80s, I discovered that he'd retired and was now doing medical records reviews for yep, DHEW and Medicare; he said "If ya' can't lick 'em, join 'em".

  17. the AMA and ACEP are all for nationalizing health care. the political types in the doctor's ranks seem to be rank and file libs. also, to be honest, doctors are not the types of people who picket or march or strike. the legislators are almost all attorneys. i think most docs are like me, and to this extent it's our own fault, we have no stomach for politics and beaurocracy. we just want to do what we trained to do. but if it needs to start here then sure, i hereby declare the formation of a new union, suggested acronyms?

  18. win. go away or we will bite your head off. to make the comments you made you haven't read anything here, or, if you did, you didn't process it. medicare and medicaid are a tremendous failure. if you think big government solves anything, ever, then please vote with your feet and go to some socialist utopia somehwere.

  19. obtw win, how much should doctors make?

  20. money is always touchy; Pa Shroom always grumbled that when a patient came to him privately for hemicolectomy for ca colon, the surgeon's fee, including aftercare was about £400 - 500. Whereas his solicitor charged £2000-3000 for 2 days conveyancing...

  21. "i hereby declare the formation of a new union, suggested acronyms?"

    Physicians In Search of Selective Emergency Departments.

  22. Change this to:

    Physicians In Support of Selective Emergency Departments.

    It sounds better.

  23. Great post, and great acronym.

    But 85, Hannah worked the front desk in an ER already, and her dad is an ER doc. So she pretty much knows what we see there.

  24. Guys, I agree that medicine is broken thanks to the government. But for once, can we please, please, please not make us taxpayers foot the bill to these changes? I work hideously long hours and can't afford to pay for everyone else's medical bills. Maybe we need a union as well:
    TaxpayersRapedAnd PillageD

  25. win: please don't give me the options of "licking 'em or joining 'em" when it comes to Hillary! I know that I wrote a lot, but it would have been appreciated if you'd read the discussions and arguments before you posted. If it's too much for ya, go up and read about OldFart's dick friend.

    911 is right the organizations or "unions" set forth to watch our back are nests of liberals. Few of those folks are actually in "the pits" doing the work. So they live in the theory world.

  26. Clarification....the er doctors at the county hospital don't really force people to go to the clinic. It is just 100 ft away, and it only has a two hour wait instead of eight...

    The clinic is right next door.

  27. I totall agree that the healthcare system is screwed up for physicians. It's screwed up because of Medicare and Medicaid reimbursements that then dictate all other insurance reimbursements and nickel-and-dime the doctors down to almost certainly less than half of the originally billed amount.

    This, in turn, means that the healthcare system is screwed up for the consumer as well. The problem being that the uninsured patient who is not indigent pays 100% of their bill. This of course is assuming that they actually pay it, which more often than not the don't. That means they were essentially charged twice the amount of the patient in the room next to them in the long run. HMOs and PPOs are the demonic minions of the Medicare/Medicaid devil.

    Until there is some type of insurance reform, all other efforts are for naught in my opinion.

    I work in the healthcare field as well. The salary in my field has gone down an average of 40% since 1988 when you account for inflation. That is absolutely inexcusable, but definitely not the fault of the physicians who are responsible for my is due to the broken healthcare system that we are involved in. Costs, thus quality and accuracy, must be cut somewhere and unfortunately it was at the expense of my particular profession, among others I'm sure. This in turn most definitely affects patient care in the long run, but not so glaringly as "front line" mistakes do.

    All this being said, I can assure you that I would not want to be in a physician's shoes in this day and age. The sue-happy society in which we live, on top of the JCAHO scrutiny, Medicare scrutiny, and every other bit of bureaucratic red tape that doctors have to deal with daily is absolutely ridiculous. Would I spend 4 years in college, 4 years in medical school, then however many more years in residency/internship to make 200,000 (someone else's figure) and have astronomical student loans if I could in this day and age???? HECK NO!!! I would go to 2 years of nursing school, work as an RN in a critical care setting (a requirement for the following program) while I was getting my bachelors (still making the same as I would with a 4-year degree - why that is I don't know the answer), then continue working through my extra 1 to 2-year masters in order to become a nurse anesthetist and come out making nearly 150,000 off the bat. No residency, no liability, no overhead, and nowhere near the student loans, PLUS I would have been able to make 50,000 yearly through my schooling except for the first 2 years.

    I truly admire doctors who stick it out and finish medical school, but I do not know one physician who recommends medical school to anyone else. All of the ones I know discourage students from attending in favor of becoming a midlevel practitioner. THAT is what Medicare, Medicaid, and the gimme-gimme democrats are going to do to our medical system.....we eventually will have such a shortage of physicians that even if you have great insurance, THERE WILL NOT BE ANYONE LEFT TO TAKE CARE OF YOU!!

    At some point we need to have this whole country go back to having the courage and the gumption that it was founded on when we were responsible for ourselves and our own crappy decisions. If we, as a society, quit excusing and accepting horrible decisions that the rest of us pay for, then we might make some sort of headway in the correct direction. As long as the whole country is too chicken to call a spade a spade, though, we are doomed to fail in way more aspects that just healthcare.

    Unfortunately, it will take someone much smarter than me too figure the whole mess out....I just don't think that person would have the stupidity to run for office for fear of being called bigoted or prejudiced or some other such nonsense. What does personal accountability have to do with any race, ethnicity, social standing, etc.???

  28. So how much does a CT scan at one of those nine scanners cost? You're implying that there's real price competition between the providers, so it should be pretty cheap to get a scan in your area as opposed to somewhere else?

  29. Anon: I can't disagree with any of your logic. Good grasp of the situation...much better than the moron that wanted us to lick Hillary (a little ouf of context, but funnier that way).

    The CT Scan cost (depends on your insurance and the body part being studied). Because of all of the "side deals" with various providers, the scan cost varies with non-insured paying the most!

    Agreed, the insurance industry has us all over a barrel, and patients are normally not savvy enough to know what their costs and coverages will be, and don't care if they are really sick.

  30. 911-

    Congratulations on your newly acquired skill of embedding links in your comments. Very efficient.

    Perhaps now you could work on that pinky rehab some more. Your capitalization skills are definitely getting spotty again.


  31. I do not understand how what a doctor's income has become such a major focus of resentment. There doesn't seem to be this concern over what Congress critters get paid (they provide much less benefit to us), and they've been voting themselves hefty increases EVERY YEAR for ages even though the Constitution expressly forbids them doing so (only supposed to be allowed to vote increases the year before elections, I believe).

    Or, why is there not similar outrage over the salaries of insurance executives or supermarket corporation execs? Who drummed up this rage that a doctor might make $200,000 a year? It's so phony. The liberals are experts at distracting from the real issues, creating straw men to deflect our anger, confusion and resentment, fear, and entitlement.

    Thomas Sowell once observed that Rome fell when most of its citizens began to feel 'entitled' without commensurate cost of effort. They became a civilization of whiners and complainers, lazy and greedy, and increasingly ignorant in the process. Corrupt Senators ignorantly speeded along the process. Rome disintegrated, it wasn't destroyed by the primitive rampaging hordes.

  32. love thomas sowell, but then again, i'm white, he's black, and he's an uncle tom sellout to his peeps. his arguments are bullet-proof and hard to argue so he's an oreo to the left. the left who despise, so they say, racism, the politics or personal destruction etc... and hillary is never one to play the gender card, sniff, whine, tear, poor little girl.

  33. A few years ago I learned how to replace the clutch in my camaro after the dealer told me what he wanted for the job. Once you've done it, its not that hard, and I can make $500-$1000 depending on make of car and gullibility of customer. I haven't given up medicine, but its a fun part time job. You can charge more if you say you're an "expert". I've done 3 BMW's so I consider myself one.

  34. 85 great post--thank you! Please permit me a wide eyed moment here:

    The big issue here: is WHO has the balls to take on this "health care reform" challenge. It's not just hospitals and doctors--it's insurance (both health and malpractice), it's lawyers, it's financial institutions, it's the public, it's the government, it's educational institutions. It's to the point where we need an huge eraser and a big white board marker to re-draw the system (right now the current white board looks like my 6 year-old's bedroom wall when he and his sister found our stash of Sharpies). There is no band-aid for this.

    In this land of drugged sheep, how do the few un-addled folks stop the sheep from carrying us over the cliff?

    The internet has a great untapped grass roots potential. We may be too late this year for a decent presidential candidate, but we still state and congressional elections coming up...we have the access to money, information, and communication to invoke change. Working now on promoting people that are not mired in the power politics--maybe soon we can actually turn things around with out a bloody, nasty de-evolution (i.e the fall of Rome) or revolution.

    Anyhoo--it's just some thoughts that popped out of my head--feel free to blast my naivety.

  35. I think that everyone makes great, valid points.

    The worst thing I see in the ED is the PCP's who are too lazy to do the workup themselves.

    Just send em to the ED.

    I worked a mainline ED shift last PM and a fast track ED shift today. We had a girl in her 30's who came in who was admitted in Jan for SBO, and then 2 other times for a lysis of adhesions, and for constipation.

    She called her PCP last night, who told her to come to the ED for evaluation of CONSTIPATION...PCP was worried it was another SBO instead of the OXYCONTIN that she put her on for the chronic pain. Well, so I worked her up, and admitted her, and she didn't like the floor resident, so she signed out AMA at midnight. Today, she showed up in my fast track for re-admission after she got chewed out by her PCP for leaving AMA. So, instead of doing a direct admission for a known problem, for which she was admitted and left AMA, she sent her back to the ED because "we'd handle the admission".

    A huge part of the ED and medical crunch we deal with is stupid shit like this. If I had a day go by where I didn't get a "well, my PCP told me to come in for the abnormal lab value" or "I called my PCP and she said if I was concerned about the rash or the burning when I urinate or the sniffles, to come to the ED and get checked out", we'd all be in a happier place because we aren't dealing with the BS we see on a daily basis, allowing us to be more efficient and not dealing with the people who expect too much for their little crap complaints that can be worked up as an outpatient. you need to drag your 5 year old out of bed at 3am because he's had wet farts for 6 hours? or can that seriously wait till AM to be seen by your pediatrician?

    C'mon folks. Leave the ER's to the lady who stroked out because her 3 inch long myxoma threw a clot, or the kid with CREST syndrome who blew a lung and needed a chest tube. Your runny nose and "I can't sleep" can wait. It's not an EMERGENCY.

  36. Anon: I can only guess that it's that age old belief that doctors are "rich". (if only). People can't separate the bill they get from me (which is outrageous) from the <10% of that money that I actually get. Most people are in horror to learn that our hospital CEO and CFO make 10 times what I make! (If your hospital is a not-for-profit hospital, you can view their and any organizations tax returns on

    Birdwell: Thank you. I wish I knew. You are probably right that the internet is the tool to use. 911 is trying to get the same type of organization started. People just need to be educated about what we DO make as a percentage of their bill. They need to know the drain on our current system, and they need more info than the soundbites they get from the politicos.

    B&J: That's one of my biggest pet peeves! I stopped playing the game and I come right out and tell the patient that their doc could have done a direct admit saving the patient a couple of thousand bucks! I am sick to death of the "go to the ER docs" since we're so convenient.

    My med director says "at least it's job security", but when we have a full waiting room, a full ER, we're holding 15's just plain irresponsible not to direct admit someone you want in the hospital.

    In our system where hospitalists admit almost everyone, the outside PCP's send the BS admits to the ER so I can argue with the hospitalist! "Yeah, I know it's BS, but Dr. X sent the patient from BFE to be admitted".



  37. You know, it's funny. My old PCP had been my doctor for 14 years and he never once sent me to the ER for anything. I think it's because he was an older, cranky, snarky guy and he'd rather just deal with whatever it was himself. I think because he knew I have enough sense to know what was important enough for the ER, and what wasn't. Do you think that maybe that's what's missing? The fact that PCPs almost have to have a Minute Clinic mentality to make any money at all, so they don't know you well enough to know which patients have sense and which ones are a dumb as a bag of hammers?

  38. Dear Elizabeth,
    I think the 'minute clinic mentality' is certainly partly to blame. Declining reimbursements add to the problem as well. These two factors contribute to the following problems detailed in a prior post.

  39. In addition, I'd have to say laziness, lawyers, and dumping are factors too.

    Rather than taking 15 minutes to drain your abscess, talk to the consultant, complete the admit papers, order a study, whatever...the PCP can see two more patients, so just dump the patient on the ER.

    Today, we had TWO patients sent to the ER because Medicare wouldn't approve them to have an MRI of their Head and entire PCPs sent the patients over for us to do it "emergently".

    On the patient I saw, I refused, called the PCP and explained that our ER was full with 11 people in the waiting room and I wasn't doing elective studies. I sent the patient home and suggested that the PCP re-submit the paperwork for MRI approval if he really felt it was necessary on this 16 year old chronic tingler. (I did offer to admit the kid for him so he could come over and do an H&P, then order the study...but it wasn't THAT important).

    The other patient from a different PCP saw one of my partners who bitched, but did the study anyway.

  40. Nationalized health care will not succeed in reducing costs or improving outcomes on the whole because people will still smoke and be fat. They will continue to ignore their health problems because people will be in just as much denial about their health as they are now. They will wait until the only treatment options available are the expensive interventions socialized medicine is supposed to decrease through prevention.

    I hate to say it, but the only candidate I've heard acknowledge this fact is John Edwards. He wanted to make it mandatory that every citizen go to the dr once a year.
    Land of the free -
    (Funny that tapping international calls to suspected terrorists is an invasion of your privacy but establishing enforcement and penalties for not seeing your doctor isn't.)

    On a lighter note, anyone who's been in the OR will appreciate this

  41. ryan,
    with all due respect, mandating anything sounds bad to begin with but mandating a physician visit a year is pie-in-the-sky wishfull thinking. what exactly will be accomplished by this once a year vistit? you yourself say that people are going to keep on eating and smoking and drinking etc... multiple studies have shown the veritalbe worthlessness of the 'annual physical'. now, there are things that are cost effective screens, hellllooooo colonoscope, but edwards idea was full of sound and wussy, signifying nothing.

  42. I enjoy medicine, at least most of it. I still get a warm fuzzy when I shock someone, or see that satisfying gush of venous blood from an IJ stick. I sort of envy my sister though. As smart as me, but with a worthless undergraduate degree, she somehow became an air traffic controller. Makes 90% of what I do for 1/2 the time, and because their job is so stressful, 1/4 of their paid work time is spent in breaks. Its my own fault, I could have taken the ATC test when I was 21. She doesn't get to shock anyone though. They do get to retire at 50 though.

  43. To be fair to my sister, the failure rate at Air Traffic Controller school is very high, and getting the higher paid positions is hard. Also, dealing with Pilots seems to be at least as unpleasant as dealing with difficult patients. Theres no malpractice, but controllers have a greater chance of losing their careers over a single minor mistake. You also have to sound cool on the radio, which I have never been able to master.

  44. I understand your points and sympathize, but I don't see the idea of universal health care directed just at the deadbeats you're dealing with.

    My husband and I make decent money working for a Fortune 500 company. The health insurance is not great. Hasn't been great for several years. The company has had to cut back so we are offered lower quality networks at a higher price.

    We spent $6600 last year out of pocket for medical expenses. On top of premiums. We weren't even that sick! That is insane and a significant amount of our take home pay. Those of us with insurance are helping to offset the cost of the deadbeats in the system and in the process our medical care options are limited.

    I see universal health care as a way to handle the problem of how the uninsured driveup costs.

    I think you have some good ideas, but I don't agree that universal health care is the enemy. Why should I work if I'm going to be continually penalized by the system simply because I'm employed? Something has to give.

    The issue isn't just about the poor, it's the working middle class limping from pay check to pay check to cover their co-pays, deductibles, and prescriptions too--I wish the debate wouldn't forget this. Health care is just too damn expensive anymore and I'm angry that I work and pay my bills for crap networks with high premiums.


  45. dear demente dm,
    i agree completely, i'm at work and can't type a complete response but what i will say is that you are exactly correct in that the WORST place to be in our current system is to be middle class, and employed. whether you have insurance or not you are bearing the brunt of paying for the uninsured/illegal/abusers of the ER.

    where we disagree is how to fix it. i don't mind creating a system to catch all these people, in fact we have one right now, the dirty little secret is that folks like you and me are funding it through increased insurance premiums, taxes, and, in my case, mandated charity.

    the government is the least efficient way to fix problems like this. if i had more time i would get you this info but i believe statistics show that for every dollar collected in taxes something like 30 cents gets spent for public services/projects/programs. also, while on the private side, through competition, efficiency and quality are maximized, the government, without competition, only has incentive to grow and continue it's specific beaurocracies.


  46. I am an FP. I love your idea of public clinics with loan forgiveness. Back when I was young, poor and idealistic I would definitely have signed on for a few years in exchange for being debt free with decent earnings. And think of the experience I would have gained! Now I am middle-aged, cranky, and expect to be debt free next year after 12 years of practice.

    Dumping is definitely a problem and if I personally have ever dumped on you, my dear EM friends-I apologize, I kiss your feet. Here is what really happened:
    Parent: Can you refill my baby's albuterol? She's out and she's coughing a lot.
    Me: How is her breathing?
    Parent: Well, she was a little blue earlier. But her inhaler helped.
    Me: Can you come in right now?
    Parent: No, it would take me an hour to get there.
    Me: (#$%E)the staff have already gone home. You'd better take her to the ER.
    Parent in ER with smiling pink baby: "I'm here to get a refill on my baby's albuterol."

  47. 911doc -

    What are your thoughts on private insurance with so many limitations on preexisting conditions? For example, my son has microcephaly, hemiplegia, and cortical blindness, and we essentially got laughed at the one time we tried to get insurance through someplace other than my or my husband's job (I find that employer policies never exclude for preexisting conditions, which is why my husband and I always keep jobs with benefits -- unfortunate, because he recently got offered a job that would give him about a 40% pay raise, but didn't have bennies.)

    I tried to explain that my son is the exception, not the rule when it comes to his disability, and is really never, ever sick, and I gave them med records and la, la, la, they still turned us down cold.

    I just think that more upper lower/lower middle class people like me, who bust their asses and can't quite make it would have private insurance if they didn't reject for things like PCOS, or a bum back.


  48. dear dr. bean. no worries mate! glad you are out there.

    elizabeth. bottome line, if an insurance company doesn't make money it fails. spreading risk through group plans USED to work but the cost of medical care has increased as more and more expensive and cutting edge therapies have become available. no matter, i believe without having to carry the burden of the uninsured and non payers through EMTALA insurance premiums would still be reasonable enough for companies to offer group coverage. since, however, hospital billing has been spuriously inflated due to EMTALA and the requirement to give stuff away to tens of thousands.

    i am in a similar position to your son as i have a problem which is excluded from my current coverage. since i'm a veteran i managed to get care through the VA for this but if not i would be in your exact position. as it stands our insurance sucks and we have a high deductible and 80% coverage for my family.

    i do not have an answer for you but i do know that if the government takes this over that the result will be rationed care. you might get your bypass surgery, but instead of getting it within days of your diagnosis you will wait six months. hopefully you will not die in that six months. that is what Canada has right now.

    again, it's part of my nature and part of the way i have been trained in the ER. most people don't need much of what we do for them here. tort reform would immediately drop costs for everyone. i could send the 25 year old with chest pain home after a chest xray and an ekg and not admit him/her or draw 18 labs three hours apart to rule out the 1% chance that the chest pain is dangerous.

    it's become so complicated that there is a real temptation to trash it and start over which i think is the real draw of the 'universal care' solution. the thing that would suffer with that solution is the best part of our current system which is excellent, immediate, and definitive care.


  49. The gradual removal of the consumer is the single greatest factor in our health care crisis. Free markets work when allowed to. Our problems have grown in conjunction with the increase in the percentage third party payors pay out of every dollar spent on health care.
    Until the general public is empowered as consumers of health care and take accountability in paying for the basics out of pocket, health care costs will continue to rise out of control.

  50. I'm a social worker, I've worked both in Hospital (and very often in the ER of course), and in the community which involved a lot of health service interactions. I am Canadian, and have worked and accessed health care in the US, UK, and France. Indeed these days, I am mostly in an administrative position, and have rather more unwelcome contact than I want with medical bureaucracies.

    All of the systems have massive problems, particularly in the ER, and you talk to the medical folks in any of the systems, their list of complaints isn't much different that what you find here. I don't think that socialized medicine has all that much to do with it; the systems, whether private, public, or mixed, all have insane, pettifogging, and very perverse bureacracies and incentives (and as good socialized medicine believer, even I think that EMTALA is obviously insane).

    All systems end up rationing care, one way or another, and all systems end up abusing emergency services. ALL. Socialized or not.

    I think that whatever system, the basic issue is that we hold two contradictory believes simultaneously: 1) it is wrong that one person should suffer and die because they are poor and another not because they are rich, and 2) it is wrong to prevent someone with money spending it on whatever levels of cadillac care they want. So you end up with enormous pressure to provide unaffordable levels of care to everybody. Sometimes the pressure is from lawyers, sometimes from government, sometimes from insurance.

    Your rant on what is going on in ERs is absolutely bang on, and it is pretty much the same everywhere I think (three months ago I got to spend a joyous 12 hours the ER with my wife and her excruciating gallbladder pain, I was livid at what I saw there). But the question of socialized medicine seems to me to be another matter.

    Personally, on the whole, having had both professional and personal experience with a variety of systems, I think I would plump for the French or Canadian systems myself, though not without my eyes fully opened to boths' shortcomings. I think the doctors are better treated in both (while there is discontent and some very vocal dissent, the support in principle for Canada's "single-payer" system is pretty overwhelming amongst Canadian docs), and both have better outcomes for the population as a whole. But I would never ever hold up either as any kind of panacea.

    What is clear is that the US system is such a horrible mess that something has to be done, and I think yea or nay, by this point you are going to get some kind of more direct government involvement. And if you are going to get any, you're probably better off going whole hog and root and branch than Hillary style insanely complex blended systems from the last go-around.

    Finally, I guess my objection to the free-market medicine thing is this: in this day and age, you can't really be an informed and rational consumer. I've sat holding my wife as she wept and moaned with gallbladder pain, and I've sat holding my child as she went into her third clonic-tonic seizure of the afternoon, and I would have signed anything, agreed to pay anything, and accepted any course of treatment at all that promised some hope. Economics and costs just didn't figure, in that situation.

  51. rob,
    great points. there's only one thing i can say in response and it is this, i have yet to see a functioning government bureaucracy that...
    1. is under any pressure, normally coming from competition in the free market, to keep costs low and to provide choice, or...
    2. after having done it's job well, downsizes and cuts its own budget

    your point about the intricacies of medical care is well taken. much of this is our fault as many doctors don't do good at translating into simple english. it would be possible to be an informed consumer in the following scenario... if you had a good primary physician that could spend, as they used to, 30-34 minutes in the room answering all questions and presenting all options.

  52. Ever met an insurance company that did 1) or 2)?

  53. four years late Rob, but, yes, every single insurance companey to 1, and to 2 not a single one as they are BUSINESSES and when they grow it is good for everyone, the converse of burgeoning government bureacracies.