Started to Build My Workshop

I have already got a place for most of my tools and such. A few years ago I found this scrap yard that had a bunch of shipping containers for sale. They were selling them for a really reasonable price and I bought two of them and got them moved out on the back part of the property. Then my brother in law and I started to work on them. We got a cutting torch and cut out some windows. One of them is just for my garden tractor and things like that. I have a huge garden and Jane has a greenhouse, so we need a tractor. It is a really old Ford tractor, just like the one that my grandfather had when I was a kid. It is great for what I need to do. It is really probably worth a good bit of money, because I have had a few collectors ask me if I want to sell it.

At any rate I figure that the two buildings are going to be the basis for the new work shop. It is a really simple concept. Continue reading

Health Care Vs Health Insurance

I’ll be blunt and get right to the three points of this article.
Point 1. Health care and health insurance should be separated.
Point 2. If it weren’t for the fact that health insurance has come to mean health care for most Americans there would be no health care reform.
Point 3. The only way to fix America’s health care once and for all is to bifurcate health care and health insurance as they should be.

I’ll also give you three reasons why I say this so if you choose you can go to other articles and not bother with reading this further.
Reason 1. Because health care is now paid for by a third party health insurance premiums have increased over 100% since 2004.
Reason 2. On average over 60% of every health care dollar is wasted in the health insurance claims process.
Reason 3. Because of the health insurance/health care connection Americans are being robbed of their most precious birthright – their health.

By means of government and health insurance company propaganda health care has been synonymous with health insurance since most of us can remember. At some point who among us hasn’t thought we needed a job with “benefits,” or maybe better benefits, so we could go to the doctor. We have been brainwashed by a system that profits monstrously from our lack of knowledge or apathy – whichever the individual case may be. We have been taught from our first paycheck that health insurance is the be-all-end-all when it’s time to take the kids to the doctor for a runny nose.

That is confirmed within days when we get bill from the doctor’s office that says that the cost for that visit was $225.00.

The system is rigged and it’s rigged so that each and every American thinks that someone else should pay for their health care. More on that later.

Health care should be separated from health insurance like car care is separated from car insurance. When it’s time for an oils change do you reach in your pocket for your car insurance card to pay for it? “Of course not.” you say, “That would be ridiculous.”

I ask you now to stop for a second and think why that would be a bad idea.

In case you don’t know, let me give you a little primer on insurance. Insurance premiums are based on, among other things, claims – both the number and the amount of the claims. The individual states Department of Insurance ride herd over insurance companies to see that the amount paid out in claims is in proportion to the amount collected in premiums. So an insurance company doesn’t get a rate increase unless they have the claims to substantiate the increase. (That, by the way, is the one good service that the departments of insurance serve, since as individuals we don’t have the time nor the inclination nor the resources to look all of that information up.)

So let’s now go back to the oil change scenario and look at it again. Instead of the one, two or three claims that you may file in a lifetime on your car insurance, you now find yourself filing a claim every three months or 10,000 miles. What would you expect your premiums to be like? How much would they increase? Also take this into consideration; your local mechanic or oil change service would have to wait 90 to 120 days to get paid for their money for the oil change. Plus there would be layer upon layer of paperwork to file the claim. The fact is, that if car insurance was like health insurance, your local oil jockey would have to hire an entire billing department just to file the correct forms with the correct codes – not once – but maybe as many three or four times.

Do you think the oil change would still be $35.00 at your local Spiffy Lube would still be $35.00 or with the added payers of paperwork and personnel would the cost go up?

The average face time with a medical doctor in the United States in now less than 10 minutes. The average amount of office labor involved in collecting the money for that 10 minute visit is upwards of three hours. How much is that costing you? Since there are no statistics kept on this let me do the simple math for you here. Billing and coding personnel make an average of $15.00 an hour. That could mean as much as $45.00 of your health care dollar goes toward processing your claim… and that is just at the doctor’s office. To be fair it is probably close to $30.00 on average but that is still a mighty large chunk of money.

It is even larger when you look at what the doctor gets paid. (I told you earlier we would get back to this.) Don’t look at what the doctor bills, Look instead at your EOB, Explanation of Benefits that comes in a few months down the road. Don’t get caught up in the coding and insurance gibberish but instead look good and hard at the amount that was paid to the doctor. In many cases it will be something around $50.00, up to very rarely, $100.00.

So the doctor paid out $30.00 to $45.00 to collect $50.00. Does that sound right or even smart?

Then there are the processing costs added on at claims departments at the insurance companies. Most companies have at least two tiers of bureaucracy to look at every claim. The highest cost of any division at the large health insurance companies – right after management – is the claims department.

The new health care reform law (Patient Protection and Affordable Care Act )has added no less than 159 new programs, agencies and departments in between your visits and your doctor getting paid. Anyone out there really think all of those programs will save your health care dollars for health?

The Benefits Of Home Health Care

It can be extremely overwhelming to have a family member that requires constant care. A lot of us simply don’t have the time or the facilities to be on-hand at all times even though we might want to. You may experience feelings of guilt that you can’t do all that your family member needs and can’t be with them all the time. However, you are not alone. Today, millions of adults across the word are finding themselves in a position where they are juggling taking care of older relatives or parents and their own lives and career. Many people struggle so you shouldn’t feel ashamed or guilty about your inability to do everything.

It can be hard to get the balance right between doing all you can for your elderly relative and looking after your own needs and this is why many people turn to home health care to help lighten the load. Home health care is a great way to ensure that you get the respite you need while making sure that your relative or parent is still looked after. In many cases, home health care is a necessity for families as it allows the career to get enough rest to ensure that they will be able to look after the elderly relative properly in the future.

There are many benefits involved in hiring home health care. The main advantage is that the person in question will be receiving the very best care possible. These people are trained medical staff and now how to look after your relative or parent properly. They will have years of experience and a wealth of expertise in dealing with emergency health situations so you really can trust them.

As well as providing essential medical care, home health care professionals will give the social interaction that your loved one really craves. No-one likes to be left on their own for long periods of time, and as much as they will love talking to you, they will also really enjoy interacting with other people. For some, home health care is their only connection to the world and without they feel lost.

The chances are you won’t always be available to help your loved one with their meals. If you worry that they aren’t eating nutritiously, that they aren’t eating at all or that they are skipping their medication then home health care could help. A member of staff can help your loved one with meal times and ensure that take their medication at the right times throughout the day.

Home health care workers can also help with any transport issues you may be having with your loved one. If you can’t get to them to take them to the doctors or any other appointment then they can do this for you and make sure that they get their safely.

There are so many more benefits to hiring home health care but the main one being that some of the pressure is taken off you and you can get back on track with your own life and responsibilities. Home health care really is a practical alternative to attempting to take on everything yourself. Home health care really can be a godsend for those people who don’t need continuous nursing help but who want to be cared for in the comfort of their own home. Most people feel most comfortable at home as it is the place where their family and friends can come and visit them and sometimes familiar surroundings can help aid recovery time. Home health care services vary depending on the personal needs of the person needing the care. For some, they just need some companion care whilst other suffer from more serious illnesses and require more complex medical monitoring.

Australian Health Care Benefits

Moving to Australia is an exciting prospect. However inevitably the question of health care is raised. No one wants to become ill or injured while living in Australia and then be left with an enormous bill to pay.

Does Australia have free health care?

Medicare is Australia’s publicly funded health care system however it does not provide 100% coverage. Medicare provides eligible individuals access to free or subsidised medical, optometrical (eye care) and public hospital care. Medicare does not pay towards ambulance costs, physiotherapy, spectacles, podiatry, chiropractic services, or private hospital accommodation.

Medicare also does not cover dental costs, with some exceptions for low-income earners. A nationwide Denticare Australia program may be extended in the next government budget, however the specific details are yet to be announced. Some dental organisations provide interest free payment plans, member discounted services that attract an annual fee, or discounts for regular patients to help manage costs.

Individuals can also choose to access private health services that charge for their services, and may choose to take out private health insurance to cover these types of costs.

Will I be eligible for a Reciprocal Health Care Agreement?

The Australian Government also has Reciprocal Health Care Agreements with some countries that provide ‘restricted access’ to public health care while in Australia. Restricted access usually limits care to ‘medically necessary’ treatments eg. Ill health or injury which occurs while you are in Australia and which requires treatment through a public hospital before you return home.

Individuals from New Zealand and Ireland do not get issued with a Medicare card and instead present their passport at public hospitals or pharmacies. Non-hospital care, such as attending a local GP doctor, is not covered. Other reciprocal agreements will pay Medicare benefits for out-of-pocket medical treatment provided by doctors through private surgeries and community health centres. All agreements cover subsidised medicines under the Pharmaceutical Benefits Scheme (PBS).

Note: Reciprocal agreements technically only cover individuals if they have come directly from the reciprocal country eg. If you were previously living in another foreign country prior to coming to Australia you may not be eligible, as you have not been recently been part of the health system for your country of nationality. However application of this requirement varies between Medicare staff.

Medicare Information Kits for migrants are available in 19 different languages.

What amount is subsidised by the government?

The benefit (or refund) that you receive back from Medicare is based on the Medicare Benefits Schedule (MBS) for that specific service which is set by the government. Doctors and other health service professionals can choose to charge over the schedule fee or bulk bill. Bulk billing is when doctors bill Medicare directly, accepting the Medicare benefits as full payment for the service. If doctors charge a higher amount the patient wears the extra costs.

Many doctors now offer to process Medicare claims electronically at the end of the appointment. Alternatively you can lodge most claims online, visit a Medicare office or post in your claims. Refer also to How does Medicare work?

Patients may also be required to pay for additional tests or vaccinations that their doctor requests as part of their treatment.

Some benefit examples based on the current schedule (1 Nov 2011) are below:

Standard doctor Level B consultation for less than 20 minutes with a GP (General Practitioner) in their consulting rooms: Fee = $35.60 and Benefit = 100% so you receive a $35.60 rebate. Therefore if the doctor charges $65.00 for an appointment you will be out of pocket by $29.40. If the doctor bulk bills they would charge the $35.60 fee direct to Medicare resulting in no out of pocket costs for the bulk billed patient.

Specialist doctor consultation initial appointment in a hospital or their consulting rooms: Fee = $83.95 and Benefit = 75% (hospital in-patient) or 85% (out-of-hospital) so you would receive either a $63.00 or $71.40 rebate. Therefore if the doctor charges $130.00 for an appointment you will be out of pocket by $67.00 or $58.60. You will need a referral letter from a GP to see a specialist so will need to budget for both out of pocket costs. Specialist fees can also vary considerably with some charging several hundreds of dollars if they are highly specialised and sought after. It is worth checking fees prior to making appointments so you are prepared for any out of pocket costs.

Comprehensive dental oral examination, limited to 1 per provider every 2 years: Note: Any preventive services like removal of plaque and/or stains, or any fillings etc are billed separately and can quickly add up to a sizeable bill even with the rebates: Benefit = $40.50 so if the dentist charges $95 for this item you will be out of pocket by $54.50

Medicare concession card holders will usually be charged a lesser rate or receive some services for free.

Note: If you are not eligible for Medicare you will have to pay the full appointment fees. However you are also exempt from paying the Medicare Levy and any surcharges (see below for more information on these).

The Pharmaceutical Benefits Scheme (PBS) details the medicines subsidised by the government, which must be purchased through a pharmacy. Non-PBS medications will be charged at full price.

The government also protects high users of medical services from big out-of-pocket costs through the Medicare Safety Net, and provides pension and health care concessions for pensioners and low income earners. The PBS Safety Net is available for individuals who need a lot of medicines in any year.

Individuals may also be able to claim a tax offset of 20% for net medical expenses over the threshold, currently $1,500 for the tax year for eligible expenses.

Note: The above protections may only apply to individuals on full Medicare so check further with Medicare before applying.

Are there any costs when I use an ambulance?

Ambulance cover varies between the different Australian States & Territories.

In Queensland and Tasmania, ambulance services are provided free for local residents.

In all other States & Territories, fees may be charged. The fees can vary depending on: how far individuals travel by ambulance, the type of transport eg. helicopter, the nature of the illness, whether an emergency or not, and any concession eligibilities.

Residents living outside Queensland or Tasmania can insure against ambulance costs, either through membership schemes provided by the relevant ambulance service (in the Northern Territory, South Australia, Victoria and country areas of Western Australia) or through a private health insurance fund (in the Australian Capital Territory, New South Wales and metropolitan Western Australia).

Note: Check the details of any ambulance cover provided by private health insurers carefully as it may only be limited to ’emergency’ transportation eg. not covering trips between hospitals or non-critical call outs. Membership with ambulance services may be more comprehensive.

In most cases, local holiday or business visitors to other States & Territories will be covered if they were covered in their home State or Territory due to reciprocal arrangements. However it is worth checking this before travelling to other States or Territories.

Do I have to pay anything towards Medicare?

Medicare is funded by a Medicare Levy tax deduction taken from your income with the contribution level based on how much you earn. The Medicare Levy is currently 1.5% of taxable income.

In addition, the Medicare Levy Surcharge of 1% is levied on high-income earners who do not have private hospital cover. The income threshold for 2011-12 year is $80,000 for singles and 160,000 for couples / families increasing by $1,500 for second and subsequent dependents. The surcharge is designed to encourage individuals to take out private cover and therefore reduce the demand on the public Medicare system.

If you are not eligible for Medicare then you may qualify for a Medicare Levy exemption and will not have to pay the Medicare Levy or Medicare Levy Surcharge. You must however complete a Medicare Levy Exemption Form in order to be exempt from the tax.

What are the differences between Medicare and Private Health Insurance Cover?

The Health Insurance Ombudsman has a good comparison of Medicare and Private Health Insurance.

Do I have to take out private health insurance?

You do not have to have private health insurance unless it is a requirement of your Australian visa to make arrangements for a minimum level of health insurance. A sponsor could still offer to pay the insurance, however if not the visa holder is responsible. Student visa holders are required to have Overseas Student Health Cover, although students from Sweden or Norway may have special arrangements.

However you may still want to consider taking out private health insurance to give you more health care options, to cover items which aren’t covered on Medicare such as dental costs, or if you are not eligible for full Medicare.

There are two types of private health insurance: 1) Hospital policies and 2) Ancillary or extras cover for treatments such as dental and physiotherapy. Most health funds offer combined policies.

Insurance policies may also have exclusions and restrictions, excess payments and waiting periods for certain claims. Insurance claims may also be subject to annual limits for certain types of claims. Insurers often have preferred suppliers who may offer higher benefits for members.

How much does it cost to have private health insurance?

The costs of insurance vary considerably depending on what health cover plan and insurer you choose. You should only choose a registered Australian insurer and one way of choosing is to use the many free comparison sites available. The Private Health Insurance Ombudsman website also has excellent information.

If you are currently with a recognised international health fund you may be able to obtain an insurance clearance certificate and transfer without incurring waiting periods for some claims. Continual coverage will depend on the old and new policies being similar. Many Australian insurers refer to the International Federation of Health Plans to determine whether a fund is recognised under their transfer policies.

Health insurance rates can increase on 1 April each year in line with government regulation and in 2012 this resulted in average increases of 5.06% for new and existing premiums.

In addition to the Medicare Levy Surcharge, the government also has two other key private health insurance incentives.

Private Health Insurance Rebate – 30% to $40% rebate (not applicable for overseas visitors health cover)

Lifetime Health Cover – Additional loadings that increase the later you take out health insurance during your lifetime with a maximum loading of 70%.

1 July 2012 Changes

From 1 July 2012, the Rebate and the Medicare Levy Surcharge will be means tested. This could result in substantial benefit reductions for high-income earners, particularly singles earning $130,001 or more, and couples/families earning $260,001 as their rebate will drop to zero.

What to Look for in a Home Health Care Provider

Anyone in need of home health care deserves non-medical care or in home medical care that is compassionate whether the patient is a child, adult or elder. Home health care services are provided anywhere except for in nursing homes or a hospital. These services may even be provided at an assisted living facility, a school, apartment or house.

As far as care plans go, there are a wide variety of personal care and nursing services that are not just available, they are tailored for the needs of each individual recipient. Customized care plans and follow up assessments should be provided by a registered nurse.

Nursing Supervision and Case Management

The care that is provided by personal care assistants and home health aides is typically supervised by a registered nurse. One of these registered nurses should be on call at all times in order to assist the caregivers as well as to provide medical training and oversight and to implement the plans of care.

Elder or Adult Care

Are you aware of the fact that 75% of the health care costs in the US are incurred by only 12% of Americans? These people generally have some type of chronic illness. The benefits of this type of individualized home care include much more than just being able to keep someone at home for their illness as opposed to being institutionalized or put in a long term care facility. As far as cost goes, home care visits are roughly only 10% of what a single day in the hospital will cost.

Additionally, home health care has a track record that has been proven when it comes to things such as reducing readmissions to the hospital, expensive visits to the emergency room and in managing chronic illnesses. In addition, there is scientific evidence that has proven that patients are able to heal faster when they are in their own homes. Both morbidity and mortality rates are reduced in patients who take advantage of home health care. In fact, 90% of seniors facing long term care in nursing homes prefer to stay home and get the services of a home health care provider.

Private Elder Care Coordination, Planning and Management

This involves both advising and then assisting families when it comes to determining the necessities of an aging adult. These caregivers are able to navigate many of the long term type of care resources that are available in your area. The goal here is to educate and inform the family of what the options are and them to assist them with the implementation of their decision. Typically this is done by an RN who has been certified and specially trained in the area of geriatrics who can provide:

The services of being a liaison for family members who may live a great distance away
Educating and advocating for the patient
Assisting with paperwork and forms that are related to insurance, medical assistant and Medicare
Screening, arranging for and then monitoring any in home help or options for institutional or residential care options
Care planning that is tailored to the patient

Universal Health Care

Universal Health care is a type of government created system in which every citizen of a country is given access to various forms of medical care, even if they don’t have the resources to pay out of pocket. While the citizens may be able to pay for some services out of pocket, much of the money for Universal Health care will come through taxation or insurance. One of the first countries to institute this form of medical care successfully was Germany under Otto Von Bismarck. However, the very first Universal Healthcare program was created in Great Britain.

Some of the other countries which offer Universal Health care include Australia, France, and Italy. Virtually every industrialized nation currently offers some type of Universal Health care except for the United States. While the definition of Universal Health care largely remains the same, the actual structure of this system will vary from one country to another. The system also varies in terms of how much the government is involved. For example, while some nations allow private doctors to offer their services, other countries do not. In the United Kingdon, doctors can choose to offer services which are outside the government system, but Canada has more restrictions on their medical services.

It is important for readers to realize that Universal Health care is a very wide concept. There are a number of ways in which such a system can be utilized. However, the most basic factor in implementation involves the process of allowing all the citizens within a nation to be given access to health care for an affordable rate. Because implementing such a system requires a large amount of money, many governments tax their citizens in order to fund it. The government also decides how the care must be administered, and who is allowed to receive certain types of care. While many countries use taxation to fund this health care system, the patient may still be required to pay a relatively small fee as well.

Because the Universal Health care system has worked so well in many countries, some citizens and politicians in the United States have proposed the introduction of such a system in their own country. American proponents of Universal Health care are quick to point at the rising cost of commercial insurance as evidence that Universal Healthcare would work. Indeed, the cost of health insurance in the United States has become so high that millions of Americans go without health insurance each year, and should they become sick or injured, the cost of medical care could cause them to go into bankruptcy.

Proponents of Universal Health care argue that the utilization of their system would make it more affordable for all Americans to afford healthcare, and millions would not need to go without medical insurance. While the United States does not currently have a Universal Health care system, the government does provide health care for certain segments of the population, such as veterans, the disabled, senior citizens, or those currently serving in the military.

However, it is important to note that Universal Health care is not without its opponents. Those who oppose Univeral Health care often raise questions as to who would pay the most in taxes for such a system. These people argue that depending on the rate of taxes to be charged, many of the same people who currently can’t afford medical insurance would be hard pressed to pay taxes for a Universal Healthcare system. If the taxes are too high, they argue, then the rich would suffer the largest tax burden, but this is the very same group that is the least likely to need Universal Health care in the first place, since they can afford to pay for private health care.

Many high income American citizens are opposed to Universal Healthcare because they feel they will be forced to pay for something they personally don’t need. In addition to paying for their private medical insurance, they would then have to pay taxes for Universal Health care, a service they would not likely use. Opponents of Universal Health care also argue that there are Constitutional issues that come into play. They argue that the 10th Amendment of the U.S. Constitution makes it clear that any powers not granted to the American government in the Constitution must be decided by the states.

Opponents therefore argue that the 10th Amendment demonstrates that only the U.S. states have the power to decide on the issue of Universal Health care, not the Federal government. However, proponents of Universal Health care counter this by saying that the system has worked successfully in other industrialized nations, and if it works there, it can work in the United States as well. One thing that is certain is that there are strong arguments on both sides of the fence, and only time will tell which side is correct. It should also be noted that about 15% of U.S. GDP goes toward health care payments, and this is the highest of any country on the planet.

It should also be noted that over 80% of the U.S. population already has some form of medical care, whether through their job, the government, or a private company. This has led some opponents of Universal Health care to claim that such a system isn’t needed, since only a small percentage of the U.S. population doesn’t have health insurance. However, proponents argue that while 80% of Americans may have some form of coverage, the 20% who don’t is too much. When you consider the fact that 20% of the U.S. population would be around 60 million people who don’t have coverage, it becomes hard to argue with this point.

It should also be noted that the cost of health care in the U.S. is one of the fastest growing phenomenons in recent history. In fact, the rising cost of healthcare is even rising faster than the general rate of inflation. From 2001 through 2007, the rate for family health insurance premiums rose by more than 70%, which is unprecedented. Aside from a government based program for Universal Health care, many cities and states in the U.S. are already in the process of implementing their own Universal Health care plans.

Health Care Reform is Not Healthy

HEALTH CARE REFORM IS NOT HEALTHY!

LET’S CALL IT WHAT IT Is – HEALTH INSURANCE MONEY ALLOCATION AND RE-DISTRICTING

Health insurance premiums are driven by the success or failure of actual health recovery maintenance and the costs required to deliver of service. Harris L. Coulter, Ph.D., of Washington, DC, and editor of the 8th edition of the HPUS,is an internationally renowned medical historian and author of over 30 books and essays, which include: THE DIVIDED LEGACY, a four volume epochal history of medicine, which covers its origins to present day.

“Society today is paying a heavy price in disease and death for the monopoly granted the medical profession in the 1920’s. In fact, the situation peculiarly resembles that of the 1830s when physicians relied on bloodletting, mercurial medicines, and quinine, even though knowing them to be intrinsically harmful. And precisely the same arguments were made in defense of these medicines as are employed today, namely, that the benefits outweigh the risks. In truth, the benefits accrue to the physician, while the patient runs the risks.”-Harris Coulter, Ph.D., (Divided Legacy Vol 3)

There is no question we need reform in the areas of disease elimination improvements in Health, better delivery of health care when it is needed and health insurance parity. Personally, am all for reform, but let those reforms ring with the clarity of Truth and illuminate our way through the fog obfuscation.

Overall chemo-therapy and radiation are documented to be an absolute failure in the so-called war against cancer. The long-term survival rate of cancer patients using orthodox therapies remains abysmal and the statistical reportage is obfuscated.

Refer to: New England Journal of Medicine, “Progress Against Cancer,” May 8, 1986 by John C. Bailar, III and Elaine M. Smith, and a ten-year follow-up “The War on Cancer” which appeared in Lancet, May 18th, 1996, by Michael B. Spoorn. Therein is published in leading medical journals, but they remain as the only therapies and pharmaceutical companies enjoy federal mandate.
Stated simply you cannot poison a sick person well.

HEALTH CARE REFORM is a meme used to numb the mind and sway political process but has little or nothing to do with health and certainly is neither, reform in the ways the public perceives, nor what they dearly need.

Merely by changing who and how much they profit for health services is only a small fraction of the underlying problem and ultimately it’s you who pay. Current Congressional debates will not offer true reform of our systemic disease CARE, but strengthen insurance profits and control.

The fruit of the healthcare tree, while certainly abundant, is altogether rotten, because the roots are corrupted by disease. If the Food and Drug Administration which regulates both FOOD and drugs while having far reaching powers that are beyond the Constitution of the United States of America, is powerless to effectuate the genuine change required to modify the so-called health industry.

Nor can the FDA provide the reforms by its far reaching power and control, then how can we expect it to come from mandates from an under educated over lobbied congress?

Give credit where due, the FDA has been effective in causing millions of tones of ground meat and spinach. A little too late perhaps as the FDA has done nothing to stop chemical companies from pouring oceans of deadly toxic, and known carcinogens on our crops.

“Water and air, the two essential fluids on which all life depends, have become global garbage cans” ~ Jacques Cousteau

HOW CAN YOU HAVE HEALTH IF WE DON’T HAVE CLEAN WATER AND AIR?

We must stop poisoning our earth with unnecessary toxic chemicals, which leaches out the elements and minerals building blocks of the cells of our bodies, and support and teach the farmers on bio-dynamic farming.

Why is there no respect for and replication of how the Hunzas and several other tribes on earth, wholive to be well over 120, and disease free.

These tribes drink the water which comes off of the slow grinding of the glacier across mountain terrain and gives minute quantities of every element and every mineral. Their cells have
access to all the natural building blocks of life and therefore remain impervious to invasion and disease.

Health and Old Age Places with High Longevity: Hunza Pakistan the area of Hunza in Pakistan which has a high level of longevity. A Guide to Shangri-La: The Leading Longevity Sites on Earth

For Americans and the world at large where the crop land is awash in chemicals the minerals and elements are leached out of the soil and the roots of our food crops are have no way to chelate them so that we can digest them into our bodies.

What follows is a well known symptom called pica, and we are constantly looking for something to eat to satisfy the hunger of the cells and this leads to obesity and disease on a national scale.

There are solutions, but the FOOD administration, has done nothing to listen to, study, implement, nor promote the use of Bio-Dynamic Farming, which is proven to produce greater volumes of crops far healthier and do not poison our water aquifers.

One fairly recent proactive move; the FDA and the FTC have enforced the little known Federal Law under USC Title 21 Part 56, INFORMED CONSENT. This activity is evidenced by the too frequent drug commercials and advertisements. To name one example the anti depressant drug, ABILIFY, is known to cause death and suicide.

To our detriment and demise, the FDA has a tunnel vision partisan perspective and always reactive, rarely proactive when a patient actually dies from using an FDA approved drug, they routinely avoid any blame and state “there is no conclusive evidence to prove it was because of the drug.” No drug company is ever charged with a crime and no executives, nor doctors, are criminally charged for manufacturing, nor for prescribing the drugs.

WHY? Because the drugs are FDA approved so it would mean they are culpable.

However, when a substance derived and used by another Healing Art, i.e. Homeopathy, is found to be highly effective in combating and eliminating a disease such as cancer, or reversing the side effects of AIDS, a stroke, or Cystic Fibrosis, to name a few, the FDA routinely states there is no scientific evidence to support the claims moves swiftly to prosecute to the fullest extent of the law.

We must continue to strengthen the education of the public on sound fundamentals of health maintenance.

We must allow for access and coverage to all branches of the Healing Arts. This is known as the ECLECTIC. The allopathic cartel are not the arbiters of truth, nor have they proven to be honorable stewards, nor have they provided viable solutions where other forms of healing arts have been successful, in some cases thousands of years.

THE PROBLEM

The problem is that over the past 67 years, a Federal Agency, the Food and Drug Administration, created in 1938 as an agency to ensure that Food, Drugs and Cosmetics moving in interstate commerce, were pure, unadulterated, contained what was stated on the label and safe for human consumption.

Over the years the FDA has undergone a metamorphosis and has become a threat to the civil liberties and public health of Americans, as well as added incredibly to the cost of the products it regulates.

The FDA has a long history of using the resources of the agency to conduct Gestapo type raids on medical clinics, terrorizing patients, staff and practitioners, seizing quantities of vitamins, manuals and harmless natural products, issues completely inaccurate, indeed, deliberately mendacious publicity releases slandering practitioners, nutritional products and innovative drugs and has so far departed from the purposes for which it was created as to become a menace to both the public’s health and their civil liberties.

Under 80 or more years of Allopathic domination, the standardized American health care system is unable to:

(1)Control the resurgence of Tuberculosis in the country;
(2)Control the rising rate of Cancer deaths;
(3)Control the rising rate of coronary artery deaths;
(4)Lower the infant mortality rate;
(5)Find an effective cure for AIDS.

There are available answers to all these deficiencies, but none of them are embraced in Allopathic Doctrine.

The question presented is, if there is any legal control over this vast agency and any way citizens can take legal action to cause the agency to be brought under control and be forced to comport itself in accordance with the intent of Congress in creating it, and the additional question of whether or not citizens who have been harassed by its Ultra Vires activities may sue for damages or other relief.

If such legal action is possible, is such legal action the best, or the sole means which can or should be employed to bring the agency under control.

A further question may be what or who is responsible for the agency getting out of control and what, if anything, can be done to ensure that the agency does not get out of control in the future and once again become a menace to society.

ANALYSIS

The agency in question, the Food and Drug Administration, is an out of control bureaucracy, undertaking to perform some proper regulatory functions but devoting many of its resources to illicit functions not contained in its enabling legislation and not permissible under the constitution.

The agency [which was] directed by Commissioner David Kessler, M.D, JD, who assumed the position after the enforced resignation of Joe Young, PhD, has done little to change its behavior except put on a fresh face from time to time.

An investigation revealed widespread corruption with many officials, taking large bribes, not to mention every member of Congress who are heavily lobbied by industries it was supposed to regulate, and the entire agency was demoralized and ineffective.

The agency has openly and notoriously formed “partnership” with private trade associations and special interest groups for the purpose of aiding and abetting non-price predation in the health care market.

The agency has lawful jurisdiction over some Foods, Drugs and medical devices which are in interstate commerce and has no jurisdiction over the practice of medicine or other healing professions.

Despite this rather clear distinction, the agency repeatedly attempts to interfere with health care practitioners by means of its enforcement powers and by liaison with state regulatory agencies, and by conducting Gestapo type raids on the offices and clinics of health care practitioners who practice in Schools of Practice other than the Allopathic School and by attempting to suppress the use of techniques of healing and of products for use in health care which are not within its regulatory jurisdiction.

THE BUREAUCRATIC ANTI-COMPETITIVE CAMPAIGN
WHICH POSSIBLY INADVERTENTLY or INTENTIONALLY CREATES GENOCIDE

This claim is born of deliberate suppression of health technologies which are non-toxic, effective and inexpensive; to name only a few in critical areas, these include:

I. CARDIOVASCULAR DISEASES
EDTA Chelation – Adrenal Cortical Extract

II. STROKE PREVENTION AND REHABILITATION
Oxidative Therapies / Hyperbaric Chamber / Ozone
EDTA Chelation
Human Growth Hormone

III. CANCER AND AIDS
IAT, Laetrile, L-Arginine, Black & Yellow Salves, Gerson Therapy, 714-X, Homeotherapeutics, Krebiozen, Essiac, Immunostim, anti-neoplastin, Hoxey, Glixoxide, Revicci Therapies and many others, too numerous to mention here.

THE STATE AND FEDERAL AGENCIES INVOLVED IN ANTICOMPETITIVE ACTIVITY

California (most active)

Department of Consumer Affairs
State Board of Medicine
State Board of Dental examiners
State Board of Osteopathic Examiners
State Board of Chiropractic Examiners
Acupuncture Committee
Food and Drug Branch
Attorney General’s Office
San Diego City Attorney’s Office

Other States (Generic)
State Board of Medical Examiners
State Board of Dental Examiners
Attorney General’s Office

Private Organizations Involved
Pharmaceutical Advertising Council
National Council Against Health Fraud (and affiliated organizations)
National Federation of State Boards of Medical Examiners

Administrative Agencies
NCI – National Cancer Institute
CDC – Centers for Disease Control
FDA – Food and Drug Administration
NIH – National Institutes of Health

Private Organizations
American Heart Association
American Cancer Society
Memorial Sloan Kettering Institute
Mayo Clinic
American College of Allergy
Roswell, et al

In HEALTH UNITED STATES, an annual publication by the federal government, our national death rate from cancer is approximately 2,500,000 people per year and the rate is rising. Assuming a cost of $80,000 to $160,000 per person over the last 20 years, that figure represents $200,000,000 to $370,000,000 per year and 50,000,000 lives, or $4 TRILLION to $7.5 TRILLION dollars funneled from our collective economy into the hands of the medical pharmaceutical cartel. Is it any wonder, then, why we cannot find a cure?

In addition One of the first targeted, the FDA, or “Big Medicine,” since the early 1900’s, in this country was Dr. Royal Raymond Rife. His powerful evolutionary microscope, capable of shattering cancer cells and viruses with radio frequency vibrations, was destroyed and his books burned by federal authorities and he was imprisoned.

Some other embattled pioneers include, but are certainly not limited to: The healing arts of Ethno botany, Naturopathy Chiropractic and Acupuncture and Chelation, which all met intense resistance and violent opposition by federally protected orthodoxy.

Dietmar Schildwaechter, Ph.D., MD, was invaded in his home office in a militant style by state and federal authorities in the late 1980’s for introducing a cure for squamous cell cancer, which was proven in a 20-year study in Germany.

Andrew Ivy, MD, a pillar of the A.M.A., who came back from Germany after participating as a panelist in the Nuremberg war crime trials with a cure for cancer called Krebiozen, had his career shattered.

Bruce Halstead, MD;
Warren Levin, MD;
Vincent Speckhart, MD;
Royal Raymond Rife, MD
Wilhelm Reich, MD;
Jossef Issels, MD; and Max Gerson, MD;
Joseph Gold, MD,
Emmanuel Revici, MD;
Stanislaw Burzynski, MD;
James Privitera, MD;
Ed McCabe, author of Oxygen Therapies, jailed for 547 days; a best selling author.
Hulda Clark, ND;

There too many more which are not listed here. These gifted pioneers brought relief to a suffering humanity and were ruthlessly attacked by medical authorities and scientific dogma. Each paid a high price but distinguished themselves by their courage and resolves to stand up for their convictions, even in the face of overwhelming opposition, loss of license and jail. For a closer look at the inner workings, read: THE CANCER INDUSTRY: the Classic Expose ‘on the Cancer Establishment, by Ralph W. Moss, Ph.D.

The FDA regularly approves dangerous, often lethal pharmaceuticals. The side effects of these potentially deadly, or harm causing pharmaceutical drugs can only be fully discovered by wide-spread use. This is despite the average $250-500,000,000 and 15 years to bring these drugs to market, including phase trial tests, trying to prove the elusive “efficacy” requirement of the F.D. &C. Act.

Typically, after one of their highly publicized “wonder” drugs fails, causes death or serious side effects, no FDA official nor PAC member company president, research assistant, corporate official, company doctor, nor testing lab will be subjected to raid, investigation, indictment or jail term.

To the trauma and suffering to the patients and their families and the productive work force, it comes with a hefty price tag.

Both Gaston Naessens and Dietmar Schildwaechter, Ph.D., MD, spent the last 40 years perfecting independent blood tests, which are able to pre diagnose any type of cancer and immune disorders up to two years prior to their onset, with a 1% margin of error. The industrial average false/negative ratio remains extremely high by comparison, yet these new tests are ignored or met with resistance.

THE RELEVANT SERVICE MARKET AND SUBSTITUTABLE ECONOMIC COMPETITORS

The Eclectic Practice of Medicine*

In 1906, Dr. Rolla Thomas completely revised the 1866 teaching manual by John Milton Scudder, and revised it yet again in 1907. This was the culmination of a thirty-year frenzy of published creativity at the Eclectic Medical Institute in Cincinnati, Ohio, and was the main teaching text at that school until the1930s…the college closed in 1939.

“…it were better for the doctor if he can forget that his patient has typhoid fever, pneumonia, dysentery, or whatever he may have, and study the conditions that are present. This may be wrongs of the circulation, of the nervous system, of the secretions, of digestion, of assimilation, or wrongs of the blood, but whatever the basal lesion, it must be overcome if the patient is to be benefited by medication.”

THE MONOPOLIZATION OF MEDICINE

The health care industry during the Progressive Era is well documented in academic studies and can reasonably be accepted as a given here without describing in great detail how or why it occurred. However, it was funded largely by the Rockefeller and Carnegie fortunes and was done to guarantee a dominant place in health care for the products of the petrochemical industry.

The Allopathic School of Medical Practice was picked to become the dominant survivor of the monopolization because it was:

(1) Numerically the largest,

(2) Had no well established system of doctrines which made it antagonistic to the use of a system of therapeutics based on petrochemical therapeutics,

(3) Was represented by a fairly well organized and active Trade Association which was receptive to a take over by the funders,

(4) Urgently needed a large infusion of cash and political influence to stop the growing public acceptance of its economic rivals and competitors,

(5) Had little to offer its members without such an infusion of cash and political influence,

(6) Were headed by a staff which welcomed any help – motivated by absolutely no idealism and almost entirely by avarice, the staff of the AMA was easy to enlist in the monopolization and proved extremely efficient – particularly Morris Fishbein, whose role was pivotal and whose service spanned several decades of the monopolization.

One of the chief monopolization strategies was through take over of medical education and the schools or universities which offered this. There were several hundred which offered a two year course in Allopathic Medicine and granted the M.D. degree, which was the sole credential necessary for practice at that time.

Competitive medical universities operated by Homeopathic and Eclectic interests were fewer, but at least 75 existed – some well established and endowed.

The monopolist could have selected any of these; they were all easy targets, but the Allopathic School of Practice had a void in its therapeutic system which made it ideal for the monopolist and the Homeopathic and Eclectic Schools had therapeutic systems which offered little room for the
incorporation of petrochemical technology.

Many Americans, at least those who could afford to do so, went abroad for their medical education, initially to England or Scotland but eventually to Germany where State supported Universities had better facilities and foreign students who could and would pay tuition to augment the salaries of the faculty were welcomed to the extent that lectures were offered in English as well as German to facilitate and accommodate these foreign scholars.

To a man, the initial faculty of John’s Hopkins, the first of the Medical Universities to be established and funded by the monopolists were graduates of German Universities and brought to the University both the medical and the political orientations gained as students at German universities, which they passed on to the students of John’s Hopkins, most of whom went out to become the faculties of other American medical colleges and further incorporate both the medical and the political orientations of German universities into the graduates of American Medical Universities funded by the monopolists. Those orientations remain a part of Allopathic medicine in the United States today.

This is primarily important in considering the role of the Allopathic School in genocidal activity, which the German medical profession entered into without protest between 1934 and 1945 under the National Socialist Regime in Germany.

Federal control started in earnest around 1938 with the Pure Food, Drug and Cosmetic Act and this became what it is today in 1962 with the Kefauffer Amendments to that Act, which amendments included for the first time, an efficacy requirement which gave the FDA far more power to control both drugs and information about drugs.

The Federal Act was not intended to give the agency any control over the practice of medicine or other health care professions and both its language and many decisions of Federal Courts make that clear. Nevertheless, the agency has made and continues to make increasing excursions into attempts to control the practice of medicine.

Since 1910, a combination of some practitioners and some manufacturers of goods involved in this market has attempted to attain a monopoly in the market to the exclusion of substitutable economic competitors.

Some of the goods in this market, particularly those consisting of synthetic petrochemical pharmaceuticals, are preferentially used by the practitioners involved in the monopolization to the virtual exclusion of other goods.

However, a large amount of the goods involved may be purchased and used by consumers without the recommendation or authorization of health care practitioners and the consumer is free to consult such practitioners or not as he or she sees fit, in most circumstances.

Licensure of health care practitioners is a function of State governments, all of which have a system of examination and licensure of some health care practitioners. There is some variation from state to state in which practitioners are licensed and which are not licensed.

There is universal licensure of physicians and surgeons, osteopathic physicians and surgeons, dentists, chiropractic physicians and there is considerable variation as to the licensure of naturopathic physicians and Oriental medical practitioners (acupuncturists) on a state by state basis.

Despite the state by state variation, all of these practitioners practice in a virtually uniform fashion all have trade associations and specialty societies which are national in scope and all receive fairly standardized training.

Licensure for physicians and surgeons was initially begun around 1890 on a state by state basis at the instigation of the American Medical Association, which is the trade association for the Allopathic School of Medical Practice.

When the process was begun, State Legislatures typically created three separate State Boards of Medical examiners, to examine and license medical practitioners of the Allopathic, Homeopathic and Eclectic Schools of Medical Practice; in many states the Osteopathic School was also given a Board of Examiners.

Initially, the licenses granted to these practitioners was to treat any human disease, disorder or condition by drugs, surgery or any other means and all persons not so licensed were forbidden to undertake such activities for compensation.

Shortly thereafter, other health care practitioners were also given licenses which carried out certain exceptions to the universal licensure of physicians, such as Dentists, Podiatrists, Pharmacists, Nurses, Midwives, Physiotherapists and eventually, Acupuncturists.

The campaign for licensure carried out by the AMA was for the purpose of attaining for its members an exclusive license to practice health care for compensation and to exclude all substitutable economic competitors from the market.

This was not accomplished as State Legislators usually saw fit to license their economic competitors as well in order to maintain competition in the Relevant Service Market.

The campaign to attain exclusive licensure not having succeeded, the AMA next attempted to bring about a merger between the competitive schools of medical practice; that campaign is ongoing and has succeeded in some states to a degree, although all states continue to license health care practitioners who are substitutable economic competitors to allopathic physicians and have clearly articulated policies encouraging competition between different sorts of health care providers, set forth in state legislation.

The AMA and its component state medical societies, nevertheless, continued with unrelenting efforts to monopolize health care and have been convicted of Antitrust violations repeatedly.

The Federal Trade Commission brought an enforcement action against the AMA and its component societies resulting in information concerning anticompetitive misconduct and subsequently a private enforcement action by 4 chiropractors resulted in further permanent injunctions against anticompetitive misconduct.

The later action, Wilk, et al. v. AMA was based upon a campaign conducted by the AMA through its Department of Investigation and Council Against Quackery “to first contain then eliminate Chiropractic”.

During the litigation, the Department of Investigation and the Council Against Quackery were hurriedly disbanded by the AMA and files of these organizations were handed over to a private organization which, funded by the Pharmaceutical Advertising Council, continues the anticompetitive campaigns as an ostensible private organization, which is actually an AMA front organization. Its anticompetitive activities have intensified since the injunctions against the AMA were issued and affirmed.

A large part of the plan of monopolization has been and continues to be the suppression of information about health care providers and modalities which are competitive with those of AMA members.

The AMA initially formed a sub rosa organization, the “Health Information Control Council” which had members from several bureaucratic regulatory agencies as members. This was also broken up during the Wilk litigation.

As a part of the Wilk litigation, the Court held that calling a licensed competitor a Quack would constitute an antitrust offense; since that time the AMA front organization has substituted the word “fraud” for “quack” in its anticompetitive campaigns which increasingly are undertaken with State and Federal bureaucrats into whose “hidden agendas” the achievement of monopoly by the AMA and standardization of therapeutics fit extremely well.

During the past 25 years, most of the monopoly activity of this AMA front organization has been with bureaucrats and third party payees, such as Blue Cross and Blue Shield, which are both private insurers and pay agents for governmental programs such as Medicare.

In these situations, these “insurance companies” do not function in their traditional roles as casualty insurers, but rather as cost-plus contract pay agents and, in this role, their activities neatly interface with both the AMA’s monopolization efforts and the “hidden bureaucratic agendas” of regulatory agencies.

It is this combination of the AMA, acting through a front organization, the “insurance” companies who are not insuring but acting as cost-plus contract pay agents and the regulatory agencies involved in a “hidden agenda” which in combination, are bringing about and attempting to bring about the monopoly in health care which the AMA has been engaged in creating since 1890.

This combination has already succeeded in dangerously decreasing the quality of goods and services and astronomically increasing their price in the Relevant Service and Goods Market.

This has been accomplished by bureaucratic activity which is directly violative of the clearly articulated policies of the States and has as its purpose both increasing such costs and decreasing the quality of goods and services, and although it is state action, it is not such state action as is protected from Antitrust scrutiny by the State Action Exemption to the Antitrust Laws.

RESOURCE READING

A FEW OF THE MANY AVAILABLE

Thoma Szasz, Ph.D.

Books by Harris Coulter
[1994] Empiricism vs. Rationalism in Medicine by Harris L. Coulter, Ph.D.

Childhood Vaccinations and Juvenile-Onset (Type-1) Diabetes by Harris Coulter, Ph.D

Vaccination and Social Violence by Harris Coulter, Ph.D

Vaccination and Violent Crime by Harris Coulter, Ph.D

Critique of government funded studies–Harris Coulter Ph.D.

SIDS and Seizures by Harris L. Coulter, PhD

Do Vaccines Cause Cot Deaths?—Harris L. Coulter (1996)

An Italian Study Finding Biochemical Markers of Vaccine Damage 1996, Harris L. Coulter, Ph.D.
Books

1972, Homeopathic Medicine

1975, Divided Legacy (Volume I): The Patterns Emerge: Hippocrates to Paracelsus

1977, Divided Legacy (Volume II): The Origins of Modern Western Medicine: J. B. Van Helmont to Claude Bernard

1981, Homeopathic Science and Modern Medicine

1982, Divided Legacy (Volume III): The Conflict Between Homeopathy and the American Medical Association: Science and Ethics in American Medicine 1800-1910

1986, A Shot in the Dark, ISBN 089529463x —Harris Coulter & Barbara Loe Fisher

1987, AIDS & Syphilis — The Hidden Link

1990, Vaccination, Social Violence and Criminality ISBN 1556430841—Harris Coulter
Medical historian Harris Coulter presents evidence to show that disabilities caused by vaccines are often “disguised” under different names: autism, dyslexia, learning disability, epilepsy, mental retardation, hyperactivity & minimal brain dysfunction. Up to 25% of American schoolchildren suffer from “development disabilities”. A classic.

‘…It is the thesis of this remarkable book that early vaccinations can result in mild cases of sub-clinical encephalitis which, in turn, may well be responsible — at least in part — for the increase in autism, hyperactivity, dyslexia, sociopathy, and developmental disabilities, a rise that roughly coincides with the initiation of infant vaccinations. Coulter suggests further linkages to the increase in adolescent crime and suicide, and the decline in SAT scores.’ Stanley Kripner, AHP, January 1993.

Who’s Paying For Health Care?

America spent 17.3% of its gross domestic product on health care in 2009 (1). If you break that down on an individual level, we spend $7,129 per person each year on health care…more than any other country in the world (2). With 17 cents of every dollar Americans spent keeping our country healthy, it’s no wonder the government is determined to reform the system. Despite the overwhelming attention health care is getting in the media, we know very little about where that money comes from or how it makes its way into the system (and rightfully so…the way we pay for health care is insanely complex, to say the least). This convoluted system is the unfortunate result of a series of programs that attempt to control spending layered on top of one another. What follows is a systematic attempt to peel away those layers, helping you become an informed health care consumer and an incontrovertible debater when discussing “Health Care Reform.”

Who’s paying the bill?

The “bill payers” fall into three distinct buckets: individuals paying out-of-pocket, private insurance companies, and the government. We can look at these payors in two different ways: 1) How much do they pay and 2) How many people do they pay for?

The majority of individuals in America are insured by private insurance companies via their employers, followed second by the government. These two sources of payment combined account for close to 80% of the funding for health care. The “Out-of-Pocket” payers fall into the uninsured as they have chosen to carry the risk of medical expense independently. When we look at the amount of money each of these groups spends on health care annually, the pie shifts dramatically.

The government currently pays for 46% of national health care expenditures. How is that possible? This will make much more sense when we examine each of the payors individually.

Understanding the Payors

Out-of-Pocket

A select portion of the population chooses to carry the risk of medical expenses themselves rather than buying into an insurance plan. This group tends to be younger and healthier than insured patients and, as such, accesses medical care much less frequently. Because this group has to pay for all incurred costs, they also tend to be much more discriminating in how they access the system. The result is that patients (now more appropriately termed “consumers”) comparison shop for tests and elective procedures and wait longer before seeking medical attention. The payment method for this group is simple: the doctors and hospitals charge set fees for their services and the patient pays that amount directly to the doctor/hospital.

Private Insurance

This is where the whole system gets a lot more complicated. Private insurance is purchased either individually or is provided by employers (most people get it through their employer as we mentioned). When it comes to private insurance, there are two main types: Fee-for-Service insurers and Managed Care insurers. These two groups approach paying for care very differently.

Fee-for-Service:

This group makes it relatively simple (believe it or not). The employer or individual buys a health plan from a private insurance company with a defined set of benefits. This benefit package will also have what is called a deductible (an amount the patient/individual must pay for their health care services before their insurance pays anything). Once the deductible amount is met, the health plan pays the fees for services provided throughout the health care system. Often, they will pay a maximum fee for a service (say $100 for an x-ray). The plan will require the individual to pay a copayment (a sharing of the cost between the health plan and the individual). A typical industry standard is an 80/20 split of the payment, so in the case of the $100 x-ray, the health plan would pay $80 and the patient would pay $20…remember those annoying medical bills stating your insurance did not cover all the charges? This is where they come from. Another downside of this model is that health care providers are both financially incentivized and legally bound to perform more tests and procedures as they are paid additional fees for each of these or are held legally accountable for not ordering the tests when things go wrong (called “CYA or “Cover You’re A**” medicine). If ordering more tests provided you with more legal protection and more compensation, wouldn’t you order anything justifiable? Can we say misalignment of incentives?

Managed Care:

Now it gets crazy. Managed care insurers pay for care while also “managing” the care they pay for (very clever name, right). Managed care is defined as “a set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decision making through case-by-case assessments of the appropriateness of care prior to its provision” (2). Yep, insurers make medical decisions on your behalf (sound as scary to you as it does to us?). The original idea was driven by a desire by employers, insurance companies, and the public to control soaring health care costs. Doesn’t seem to be working quite yet. Managed care groups either provide medical care directly or contract with a select group of health care providers. These insurers are further subdivided based on their own personal management styles. You may be familiar with many of these sub-types as you’ve had to choose between then when selecting your insurance.

Preferred Provider Organization (PPO) / Exclusive Provider Organization (EPO):This is the closet managed care gets to the Fee-for-Service model with many of the same characteristics as a Fee-for-Service plan like deductibles and copayments. PPO’s & EPO’s contract with a set list of providers (we’re all familiar with these lists) with whom they have negotiated set (read discounted) fees for care. Yes, individual doctors have to charge less for their services if they want to see patients with these insurance plans. An EPO has a smaller and more strictly regulated list of physicians than a PPO but are otherwise the same. PPO’s control costs by requiring preauthorization for many services and second opinions for major procedures. All of this aside, many consumers feel that they have the greatest amount of autonomy and flexibility with PPO’s.
Health Management Organization (HMO): HMO’s combine insurance with health care delivery. This model will not have deductibles but will have copayments. In an HMO, the organization hires doctors to provide care and either builds its own hospital or contracts for the services of a hospital within the community. In this model the doctor works for the insurance provider directly (aka a Staff Model HMO). Kaiser Permanente is an example of a very large HMO that we’ve heard mentioned frequently during the recent debates. Since the company paying the bill is also providing the care, HMO’s heavily emphasize preventive medicine and primary care (enter the Kaiser “Thrive” campaign). The healthier you are, the more money the HMO saves. The HMO’s emphasis on keeping patients healthy is commendable as this is the only model to do so, however, with complex, lifelong, or advanced diseases, they are incentivized to provide the minimum amount of care necessary to reduce costs. It is with these conditions that we hear the horror stories of insufficient care. This being said, physicians in HMO settings continue to practice medicine as they feel is needed to best care for their patients despite the incentives to reduce costs inherent in the system (recall that physicians are often salaried in HMO’s and have no incentive to order more or less tests).

The Government

The U.S. Government pays for health care in a variety of ways depending on whom they are paying for. The government, through a number of different programs, provides insurance to individuals over 65 years of age, people of any age with permanent kidney failure, certain disabled people under 65, the military, military veterans, federal employees, children of low-income families, and, most interestingly, prisoners. It also has the same characteristics as a Fee-for-Service plan, with deductibles and copayments. As you would imagine, the majority of these populations are very expensive to cover medically. While the government only insures 28% of the American population, they are paying for 46% of all care provided. The populations covered by the government are amongst the sickest and most medically needy in America resulting in this discrepancy between number of individuals insured and cost of care.

The largest and most well-known government programs are Medicare and Medicaid. Let’s take a look at these individually:

Medicare:

The Medicare program currently covers 42.5 million Americans. To qualify for Medicare you must meet one of the following criteria:

Over 65 years of age
Permanent kidney failure
Meet certain disability requirements

So you meet the criteria…what do you get? Medicare comes in 4 parts (Part A-D), some of which are free and some of which you have to pay for. You’ve probably heard of the various parts over the years thanks to CNN (remember the commotion about the Part D drug benefits during the Bush administration?) but we’ll give you a quick refresher just in case.

Part A (Hospital Insurance): This part of Medicare is free and covers any inpatient and outpatient hospital care the patient may need (only for a set number of days, however, with the added bonus of copayments and deductibles…apparently there really is no such thing as a free lunch).
Part B (Medical Insurance): This part, which you must purchase, covers physicians’ services, and selected other health care services and supplies that are not covered by Part A. What does it cost? The Part B premium for 2009 ranged from $96.40 to $308.30 per month depending on your household income.
Part C (Managed Care): This part, called Medicare Advantage, is a private insurance plan that provides all of the coverage provided in Parts A and B and must cover medically necessary services. Part C replaces Parts A & B. All private insurers that want to provide Part C coverage must meet certain criteria set forth by the government. Your care will also be managed much like the HMO plans previously discussed.
Part D (Prescription Drug Plans): Part D covers prescription drugs and costs $20 to $40 per month for those who chose to enroll.

Ok, now how does Medicare pay for everything? Hospitals are paid predetermined amounts of money per admission or per outpatient procedure for services provided to Medicare patients. These predetermined amounts are based upon over 470 diagnosis-related groups (DRGs) or Ambulatory Payment Classifications (APC’s) rather than the actual cost of the care rendered (interesting way to peg hospital reimbursement…especially when the Harvard economist who developed the DRG system openly disagrees with its use for this purpose). The cherry on top of the irrational reimbursement system is that the amount of money assigned to each DRG is not the same for each hospital. Totally logical (can you sense our sarcasm?). The figure is based on a formula that takes into account the type of service, the type of hospital, and the location of the hospital. This may sound logical but often times this system fails.

Medicaid:

Medicaid is a jointly funded (funded by both federal and state governments) health insurance program for low-income families. Eligibility rules vary from state to state and factors in age, pregnancy, disability, income and resources. Poverty alone does not qualify an individual for Medicaid (there is currently no government-provided insurance for the American poor…despite the fact that almost all first world countries have such a system…enter the current health care debate) but is a significant factor in Medicaid eligibility. Each state operates its own Medicaid program but must adhere to certain federal guidelines to receive matching federal funds (you may be familiar with California’s MediCal, Massachusetts’ MassHealth and Oregon’s Oregon Health Plan due to their recent media coverage). Medicaid payments currently assist nearly 60 percent of all nursing home residents and about 37 percent of all childbirths in the United States.

How are the bills paid?

We now understand who is paying the bill but we have yet to cover how those bills are paid. There are two broad divisions of arrangements for paying for and delivering health care: fee-for-service care and prepaid care.

Fee-for-Service

As we mentioned briefly while discussing PPO’s, in a fee-for-service structure, consumers select a provider, receive care (a.k.a. “service”) from the provider, and incur expenses (a.k.a. “a fee”) for the care. Deductibles and copayments are also required as previously discussed. Pretty simple. The physician is then reimbursed for their services in part by the insurer (i.e. a private insurance company or the government) and in part by the patient, who is responsible for the balance unpaid by the insurer (the return of the unanticipated medical bill despite your overpriced insurance). Again, the major downfall of the fee-for-service approach is that medical professionals are incentivized to provide services (and by this we mean any and all services they can legally request or must request to be protected legally), some of which may be nonessential, to increase their revenue and/or “C.Y.A.” (revenue that has steadily decreased as insurance companies continue to lower the amount they pay medical professionals for their services).

Fee Schedule

A fee schedule operates in the same way that Fee-for-Service does with one exception: instead of using the “usual, customary, and reasonable” amount to reimburse medical professionals, states set fees to be paid for specific procedures and services. The reimbursement is very low ($.10-.15 on the dollar) and barely covers the actual direct cost of providing the care. Physicians may chose to opt into the plan or not (starting to see why a doctor might not be so excited about this plan?). Would you sign up to be paid 10 cents for every dollar you charged for your work? Try the insurance reimbursement approach next time you go out to eat. We’ll come bail you out of the Big House if things go awry. What happens when the insurance system does this? You get the Wal-Mart approach to medicine (high volume, low quality). Not the kind of heath care we recommend.

Pre-Paid

Pre-paid health care? Like a phone card? Not exactly–but close. The pre-paid system evolved out of the insurance company’s desire to share its risk ( a.k.a “pooled risk”) with health care providers. Essentially, they wanted the doctors to have some skin in the game. In the pre-paid system, insurers make arrangements with health care providers to provide agreed-upon covered health care services to a given population of consumers for a (usually discounted) set price-the per-person premium fee-over a particular time period. What does that mean? It means that Dr. Bob gets paid, say, $30 per month to take care of Joe the Plumber including his blood work and x-rays. If Dr. Bob spends less than that caring for Joe, he makes money. If Joe is sick every month and needs lots of tests and follow-up visits, Dr. Bob could lose money caring for Joe. The set monthly fee paid to the doctor for taking care of a patient is set up on a per-member, per-month (PMPM) rate called a “capitated fee.” The provider receives the capitated fee per enrollee regardless of whether the enrollee uses health care services and regardless of the quality of services provided (not a good thing in our book). Theoretically, providers should become more prudent and subsequently provide services in a more cost effective manner because they are bearing some of the risk. Often times, however, less care is provided than is needed in hopes of saving money and increasing profits. In addition, physicians are incentivized to cherry pick the youngest and healthiest patients because these patients typically require less care (i.e. they are cheaper to keep healthy). We like that doctors are encouraged to keep patients healthy but we have to worry about the ways in which they are being encouraged to reduce costs (as little care as possible?). Again, the incentive system falls short and encourages providers to act unethically.

The Take Home Message:

Health Care in the United States today is complex and messy at best. The layers on top of layers of failed attempts to correct the system continue to encourage the wrong behavior in both patients (out of fear of medical bills) and providers (out of fear of bankruptcy). We have yet to provide every American citizen with medical care (something that goes without saying in most 1st World countries…even Cuba has it!). We spend more money on caring for our citizens than any country in the world yet we continue to lag behind in terms of national health outcomes. We think it’s safe to say that we’re not getting the best bang for our buck. The ultimate solution? We wish we knew. Only time will tell where the system goes from here. Our goal: to help you better understand the system as it stands today in hopes of developing a more effective, efficient, and comprehensive system for the future. Are you with us?

A Prescription For the Health Care Crisis

With all the shouting going on about America’s health care crisis, many are probably finding it difficult to concentrate, much less understand the cause of the problems confronting us. I find myself dismayed at the tone of the discussion (though I understand it—people are scared) as well as bemused that anyone would presume themselves sufficiently qualified to know how to best improve our health care system simply because they’ve encountered it, when people who’ve spent entire careers studying it (and I don’t mean politicians) aren’t sure what to do themselves.

Albert Einstein is reputed to have said that if he had an hour to save the world he’d spend 55 minutes defining the problem and only 5 minutes solving it. Our health care system is far more complex than most who are offering solutions admit or recognize, and unless we focus most of our efforts on defining its problems and thoroughly understanding their causes, any changes we make are just likely to make them worse as they are better.

Though I’ve worked in the American health care system as a physician since 1992 and have seven year’s worth of experience as an administrative director of primary care, I don’t consider myself qualified to thoroughly evaluate the viability of most of the suggestions I’ve heard for improving our health care system. I do think, however, I can at least contribute to the discussion by describing some of its troubles, taking reasonable guesses at their causes, and outlining some general principles that should be applied in attempting to solve them.

THE PROBLEM OF COST

No one disputes that health care spending in the U.S. has been rising dramatically. According to the Centers for Medicare and Medicaid Services (CMS), health care spending is projected to reach $8,160 per person per year by the end of 2009 compared to the $356 per person per year it was in 1970. This increase occurred roughly 2.4% faster than the increase in GDP over the same period. Though GDP varies from year-to-year and is therefore an imperfect way to assess a rise in health care costs in comparison to other expenditures from one year to the next, we can still conclude from this data that over the last 40 years the percentage of our national income (personal, business, and governmental) we’ve spent on health care has been rising.

Despite what most assume, this may or may not be bad. It all depends on two things: the reasons why spending on health care has been increasing relative to our GDP and how much value we’ve been getting for each dollar we spend.

WHY HAS HEALTH CARE BECOME SO COSTLY?

This is a harder question to answer than many would believe. The rise in the cost of health care (on average 8.1% per year from 1970 to 2009, calculated from the data above) has exceeded the rise in inflation (4.4% on average over that same period), so we can’t attribute the increased cost to inflation alone. Health care expenditures are known to be closely associated with a country’s GDP (the wealthier the nation, the more it spends on health care), yet even in this the United States remains an outlier (figure 3).

Is it because of spending on health care for people over the age of 75 (five times what we spend on people between the ages of 25 and 34)? In a word, no. Studies show this demographic trend explains only a small percentage of health expenditure growth.

Is it because of monstrous profits the health insurance companies are raking in? Probably not. It’s admittedly difficult to know for certain as not all insurance companies are publicly traded and therefore have balance sheets available for public review. But Aetna, one of the largest publicly traded health insurance companies in North America, reported a 2009 second quarter profit of $346.7 million, which, if projected out, predicts a yearly profit of around $1.3 billion from the approximately 19 million people they insure. If we assume their profit margin is average for their industry (even if untrue, it’s unlikely to be orders of magnitude different from the average), the total profit for all private health insurance companies in America, which insured 202 million people (2nd bullet point) in 2007, would come to approximately $13 billion per year. Total health care expenditures in 2007 were $2.2 trillion (see Table 1, page 3), which yields a private health care industry profit approximately 0.6% of total health care costs (though this analysis mixes data from different years, it can perhaps be permitted as the numbers aren’t likely different by any order of magnitude).

Is it because of health care fraud? Estimates of losses due to fraud range as high as 10% of all health care expenditures, but it’s hard to find hard data to back this up. Though some percentage of fraud almost certainly goes undetected, perhaps the best way to estimate how much money is lost due to fraud is by looking at how much the government actually recovers. In 2006, this was $2.2 billion, only 0.1% of $2.1 trillion (see Table 1, page 3) in total health care expenditures for that year.

Is it due to pharmaceutical costs? In 2006, total expenditures on prescription drugs was approximately $216 billion (see Table 2, page 4). Though this amounted to 10% of the $2.1 trillion (see Table 1, page 3) in total health care expenditures for that year and must therefore be considered significant, it still remains only a small percentage of total health care costs.

Is it from administrative costs? In 1999, total administrative costs were estimated to be $294 billion, a full 25% of the $1.2 trillion (Table 1) in total health care expenditures that year. This was a significant percentage in 1999 and it’s hard to imagine it’s shrunk to any significant degree since then.

In the end, though, what probably has contributed the greatest amount to the increase in health care spending in the U.S. are two things:

1. Technological innovation.

2. Overutilization of health care resources by both patients and health care providers themselves.

Technological innovation. Data that proves increasing health care costs are due mostly to technological innovation is surprisingly difficult to obtain, but estimates of the contribution to the rise in health care costs due to technological innovation range anywhere from 40% to 65% (Table 2, page 8). Though we mostly only have empirical data for this, several examples illustrate the principle. Heart attacks used to be treated with aspirin and prayer. Now they’re treated with drugs to control shock, pulmonary edema, and arrhythmias as well as thrombolytic therapy, cardiac catheterization with angioplasty or stenting, and coronary artery bypass grafting. You don’t have to be an economist to figure out which scenario ends up being more expensive. We may learn to perform these same procedures more cheaply over time (the same way we’ve figured out how to make computers cheaper) but as the cost per procedure decreases, the total amount spent on each procedure goes up because the number of procedures performed goes up. Laparoscopic cholecystectomy is 25% less than the price of an open cholecystectomy, but the rates of both have increased by 60%. As technological advances become more widely available they become more widely used, and one thing we’re great at doing in the United States is making technology available.

Overutilization of health care resources by both patients and health care providers themselves. We can easily define overutilization as the unnecessary consumption of health care resources. What’s not so easy is recognizing it. Every year from October through February the majority of patients who come into the Urgent Care Clinic at my hospital are, in my view, doing so unnecessarily. What are they coming in for? Colds. I can offer support, reassurance that nothing is seriously wrong, and advice about over-the-counter remedies—but none of these things will make them better faster (though I often am able to reduce their level of concern). Further, patients have a hard time believing the key to arriving at a correct diagnosis lies in history gathering and careful physical examination rather than technologically-based testing (not that the latter isn’t important—just less so than most patients believe). Just how much patient-driven overutilization costs the health care system is hard to pin down as we have mostly only anecdotal evidence as above.

Further, doctors often disagree among themselves about what constitutes unnecessary health care consumption. In his excellent article, “The Cost Conundrum,” Atul Gawande argues that regional variation in overutilization of health care resources by doctors best accounts for the regional variation in Medicare spending per person. He goes on to argue that if doctors could be motivated to rein in their overutilization in high-cost areas of the country, it would save Medicare enough money to keep it solvent for 50 years.

A reasonable approach. To get that to happen, however, we need to understand why doctors are overutilizing health care resources in the first place:

1. Judgment varies in cases where the medical literature is vague or unhelpful. When faced with diagnostic dilemmas or diseases for which standard treatments haven’t been established, a variation in practice invariably occurs. If a primary care doctor suspects her patient has an ulcer, does she treat herself empirically or refer to a gastroenterologist for an endoscopy? If certain “red flag” symptoms are present, most doctors would refer. If not, some would and some wouldn’t depending on their training and the intangible exercise of judgment.

2. Inexperience or poor judgment. More experienced physicians tend to rely on histories and physicals more than less experienced physicians and consequently order fewer and less expensive tests. Studies suggest primary care physicians spend less money on tests and procedures than their sub-specialty colleagues but obtain similar and sometimes even better outcomes.

3. Fear of being sued. This is especially common in Emergency Room settings, but extends to almost every area of medicine.

4. Patients tend to demand more testing rather than less. As noted above. And physicians often have difficulty refusing patient requests for many reasons (eg, wanting to please them, fear of missing a diagnosis and being sued, etc).

5. In many settings, overutilization makes doctors more money. There exists no reliable incentive for doctors to limit their spending unless their pay is capitated or they’re receiving a straight salary.

Gawande’s article implies there exists some level of utilization of health care resources that’s optimal: use too little and you get mistakes and missed diagnoses; use too much and excess money gets spent without improving outcomes, paradoxically sometimes resulting in outcomes that are actually worse (likely as a result of complications from all the extra testing and treatments).

How then can we get doctors to employ uniformly good judgment to order the right number of tests and treatments for each patient—the “sweet spot”—in order to yield the best outcomes with the lowest risk of complications? Not easily. There is, fortunately or unfortunately, an art to good health care resource utilization. Some doctors are more gifted at it than others. Some are more diligent about keeping current. Some care more about their patients. An explosion of studies of medical tests and treatments has occurred in the last several decades to help guide doctors in choosing the most effective, safest, and even cheapest ways to practice medicine, but the diffusion of this evidence-based medicine is a tricky business. Just because beta blockers, for example, have been shown to improve survival after heart attacks doesn’t mean every physician knows it or provides them. Data clearly show many don’t. How information spreads from the medical literature into medical practice is a subject worthy of an entire post unto itself. Getting it to happen uniformly has proven extremely difficult.

In summary, then, most of the increase in spending on health care seems to have come from technological innovation coupled with its overuse by doctors working in systems that motivate them to practice more medicine rather than better medicine, as well as patients who demand the former thinking it yields the latter.

But even if we could snap our fingers and magically eliminate all overutilization today, health care in the U.S. would still remain among the most expensive in the world, requiring us to ask next—

WHAT VALUE ARE WE GETTING FOR THE DOLLARS WE SPEND?

According to an article in the New England Journal of Medicine titled The Burden of Health Care Costs for Working Families—Implications for Reform, growth in health care spending “can be defined as affordable as long as the rising percentage of income devoted to health care does not reduce standards of living. When absolute increases in income cannot keep up with absolute increases in health care spending, health care growth can be paid for only by sacrificing consumption of goods and services not related to health care.” When would this ever be an acceptable state of affairs? Only when the incremental cost of health care buys equal or greater incremental value. If, for example, you were told that in the near future you’d be spending 60% of your income on health care but that as a result you’d enjoy, say, a 30% chance of living to the age of 250, perhaps you’d judge that 60% a small price to pay.

This, it seems to me, is what the debate on health care spending really needs to be about. Certainly we should work on ways to eliminate overutilization. But the real question isn’t what absolute amount of money is too much to spend on health care. The real question is what are we getting for the money we spend and is it worth what we have to give up?

People alarmed by the notion that as health care costs increase policymakers may decide to ration health care don’t realize that we’re already rationing at least some of it. It just doesn’t appear as if we are because we’re rationing it on a first-come-first-serve basis—leaving it at least partially up to chance rather than to policy, which we’re uncomfortable defining and enforcing. Thus we don’t realize the reason our 90 year-old father in Illinois can’t have the liver he needs is because a 14 year-old girl in Alaska got in line first (or maybe our father was in line first and gets it while the 14 year-old girl doesn’t). Given that most of us remain uncomfortable with the notion of rationing health care based on criteria like age or utility to society, as technological innovation continues to drive up health care spending, we very well may at some point have to make critical judgments about which medical innovations are worth our entire society sacrificing access to other goods and services (unless we’re so foolish as to repeat the critical mistake of believing we can keep borrowing money forever without ever having to pay it back).

So what value are we getting? It varies. The risk of dying from a heart attack has declined by 66% since 1950 as a result of technological innovation. Because cardiovascular disease ranks as the number one cause of death in the U.S. this would seem to rank high on the scale of value as it benefits a huge proportion of the population in an important way. As a result of advances in pharmacology, we can now treat depression, anxiety, and even psychosis far better than anyone could have imagined even as recently as the mid-1980’s (when Prozac was first released). Clearly, then, some increases in health care costs have yielded enormous value we wouldn’t want to give up.

But how do we decide whether we’re getting good value from new innovations? Scientific studies must prove the innovation (whether a new test or treatment) actually provides clinically significant benefit (Aricept is a good example of a drug that works but doesn’t provide great clinical benefit—demented patients score higher on tests of cognitive ability while on it but probably aren’t significantly more functional or significantly better able to remember their children compared to when they’re not). But comparative effectiveness studies are extremely costly, take a long time to complete, and can never be perfectly applied to every individual patient, all of which means some health care provider always has to apply good medical judgment to every patient problem.

Who’s best positioned to judge the value to society of the benefit of an innovation—that is, to decide if an innovation’s benefit justifies its cost? I would argue the group that ultimately pays for it: the American public. How the public’s views could be reconciled and then effectively communicated to policy makers efficiently enough to affect actual policy, however, lies far beyond the scope of this post (and perhaps anyone’s imagination).

THE PROBLEM OF ACCESS

A significant proportion of the population is uninsured or underinsured, limiting or eliminating their access to health care. As a result, this group finds the path of least (and cheapest) resistance—emergency rooms—which has significantly impaired the ability of our nation’s ER physicians to actually render timely emergency care. In addition, surveys suggest a looming primary care physician shortage relative to the demand for their services. In my view, this imbalance between supply and demand explains most of the poor customer service patients face in our system every day: long wait times for doctors’ appointments, long wait times in doctors’ offices once their appointment day arrives, then short times spent with doctors inside exam rooms, followed by difficulty reaching their doctors in between office visits, and finally delays in getting test results. This imbalance would likely only partially be alleviated by less health care overutilization by patients.

GUIDELINES FOR SOLUTIONS

As Freaknomics authors Steven Levitt and Stephen Dubner state, “If morality represents how people would like the world to work, then economics represents how it actually does work.” Capitalism is based on the principle of enlightened self-interest, a system that creates incentives to yield behavior that benefits both suppliers and consumers and thus society as a whole. But when incentives get out of whack, people begin to behave in ways that continue to benefit them often at the expense of others or even at their own expense down the road. Whatever changes we make to our health care system (and there’s always more than one way to skin a cat), we must be sure to align incentives so that the behavior that results in each part of the system contributes to its sustainability rather than its ruin.

Here then is a summary of what I consider the best recommendations I’ve come across to address the problems I’ve outlined above:

1. Change the way insurance companies think about doing business. Insurance companies have the same goal as all other businesses: maximize profits. And if a health insurance company is publicly traded and in your 401k portfolio, you want them to maximize profits, too. Unfortunately, the best way for them to do this is to deny their services to the very customers who pay for them. It’s harder for them to spread risk (the function of any insurance company) relative to say, a car insurance company, because far more people make health insurance claims than car insurance claims. It would seem, therefore, from a consumer perspective, the private health insurance model is fundamentally flawed. We need to create a disincentive for health insurance companies to deny claims (or, conversely, an extra incentive for them to pay them). Allowing and encouraging aross-state insurance competition would at least partially engage free market forces to drive down insurance premiums as well as open up new markets to local insurance companies, benefiting both insurance consumers and providers. With their customers now armed with the all-important power to go elsewhere, health insurance companies might come to view the quality with which they actually provide service to their customers (ie, the paying out of claims) as a way to retain and grow their business. For this to work, monopolies or near-monopolies must be disbanded or at the very least discouraged. Even if it does work, however, government will probably still have to tighten regulation of the health insurance industry to ensure some of the heinous abuses that are going on now stop (for example, insurance companies shouldn’t be allowed to stratify consumers into sub-groups based on age and increase premiums based on an older group’s higher average risk of illness because healthy older consumers then end up being penalized for their age rather than their behaviors). Karl Denninger suggests some intriguing ideas in a post on his blog about requiring insurance companies to offer identical rates to businesses and individuals as well as creating a mandatory “open enrollment” period in which participants could only opt in or out of a plan on a yearly basis. This would prevent individuals from only buying insurance when they got sick, eliminating the adverse selection problem that’s driven insurance companies to deny payment for pre-existing conditions. I would add that, however reimbursement rates to health care providers are determined in the future (again, an entire post unto itself), all health insurance plans, whether private or public, must reimburse health care providers by an equal percentage to eliminate the existence of “good” and “bad” insurance that’s currently responsible for motivating hospitals and doctors to limit or even deny service to the poor and which may be responsible for the same thing occurring to the elderly in the future (Medicare reimburses only slightly better than Medicaid). Finally, regarding the idea of a “public option” insurance plan open to all, I worry that if it’s significantly cheaper than private options while providing near-equal benefits the entire country will rush to it en masse, driving private insurance companies out of business and forcing us all to subsidize one another’s health care with higher taxes and fewer choices; yet at the same time if the cost to the consumer of a “public option” remains comparable to private options, the very people it’s meant to help won’t be able to afford it.

2. Motivate the population to engage in healthier lifestyles that have been proven to prevent disease. Prevention of disease probably saves money, though some have argued that living longer increases the likelihood of developing diseases that wouldn’t have otherwise occurred, leading to the overall consumption of more health care dollars (though even if that’s true, those extra years of life would be judged by most valuable enough to justify the extra cost. After all, the whole purpose of health care is to improve the quality and quantity of life, not save society money. Let’s not put the cart before the horse). However, the idea of preventing a potentially bad outcome sometime in the future is only weakly motivating psychologically, explaining why so many people have so much trouble getting themselves to exercise, eat right, lose weight, stop smoking, etc. The idea of financially rewarding desirable behavior and/or financially punishing undesirable behavior is highly controversial. Though I worry this kind of strategy risks the enacting of policies that may impinge on basic freedoms if taken too far, I’m not against thinking creatively about how we could leverage stronger motivational forces to help people achieve health goals they themselves want to achieve. After all, most obese people want to lose weight. Most smokers want to quit. They might be more successful if they could find more powerful motivation.

3. Decrease overutilization of health care resources by doctors. I’m in agreement with Gawande that finding ways to get doctors to stop overutilizing health care resources is a worthy goal that will significantly rein in costs, that it will require a willingness to experiment, and that it will take time. Further, I agree that focusing only on who pays for our health care (whether the public or private sectors) will fail to address the issue adequately. But how exactly can we motivate doctors, whose pens are responsible for most of the money spent on health care in this country, to focus on what’s truly best for their patients? The idea that external bodies—whether insurance companies or government panels—could be used to set standards of care doctors must follow in order to control costs strikes me as ludicrous. Such bodies have neither the training nor overriding concern for patients’ welfare to be trusted to make those judgments. Why else do we have doctors if not to employ their expertise to apply nuanced approaches to complex situations? As long as they work in a system free of incentives that compete with their duty to their patients, they remain in the best position to make decisions about what tests and treatments are worth a given patient’s consideration, as long as they’re careful to avoid overconfident paternalism (refusing to obtain a head CT for a headache might be overconfidently paternalistic; refusing to offer chemotherapy for a cold isn’t). So perhaps we should eliminate any financial incentive doctors have to care about anything but their patients’ welfare, meaning doctors’ salaries should be disconnected from the number of surgeries they perform and the number of tests they order, and should instead be set by market forces. This model already exists in academic health care centers and hasn’t seemed to promote shoddy care when doctors feel they’re being paid fairly. Doctors need to earn a good living to compensate for the years of training and massive amounts of debt they amass, but no financial incentive for practicing more medicine should be allowed to attach itself to that good living.

4. Decrease overutilization of health care resources by patients. This, it seems to me, requires at least three interventions:

* Making available the right resources for the right problems (so that patients aren’t going to the ER for colds, for example, but rather to their primary care physicians). This would require hitting the “sweet spot” with respect to the number of primary care physicians, best at front-line gatekeeping, not of health care spending as in the old HMO model, but of triage and treatment. It would also require a recalculating of reimbursement levels for primary care services relative to specialty services to encourage more medical students to go into primary care (the reverse of the alarming trend we’ve been seeing for the last decade).

* A massive effort to increase the health literacy of the general public to improve its ability to triage its own complaints (so patients don’t actually go anywhere for colds or demand MRIs of their backs when their trusted physicians tells them it’s just a strain). This might be best accomplished through a series of educational programs (though given that no one in the private sector has an incentive to fund such programs, it might actually be one of the few things the government should—we’d just need to study and compare different educational programs and methods to see which, if any, reduce unnecessary patient utilization without worsening outcomes and result in more health care savings than they cost).

* Redesigning insurance plans to make patients in some way more financially liable for their health care choices. We can’t have people going bankrupt due to illness, nor do we want people to underutilize health care resources (avoiding the ER when they have chest pain, for example), but neither can we continue to support a system in which patients are actually motivated to overutilize resources, as the current “pre-pay for everything” model does.

CONCLUSION

Given the enormous complexity of the health care system, no single post could possibly address every problem that needs to be fixed. Significant issues not raised in this article include the challenges associated with rising drug costs, direct-to-consumer marketing of drugs, end-of-life care, sky-rocketing malpractice insurance costs, the lack of cost transparency that enables hospitals to paradoxically charge the uninsured more than the insured for the same care, extending health care insurance coverage to those who still don’t have it, improving administrative efficiency to reduce costs, the implementation of electronic medical records to reduce medical error, the financial burden of businesses being required to provide their employees with health insurance, and tort reform. All are profoundly interdependent, standing together like the proverbial house of cards. To attend to any one is to affect them all, which is why rushing through health care reform without careful contemplation risks unintended and potentially devastating consequences. Change does need to come, but if we don’t allow ourselves time to think through the problems clearly and cleverly and to implement solutions in a measured fashion, we risk bringing down that house of cards rather than cementing it.