Health Care vs. the Profit Principle

It’s always nice to see the President take a principled stand on something. The man formerly known as “43,” and now perhaps better named “29” for his record–breaking approval rating, is promising to battle any expansion of government health insurance for children – and not because he hates children or refuses to cough up the funds. No, this is a battle over principle: private health care vs. government-provided health care. Speaking in Cleveland this week, Bush boldly asserted:

I strongly object to the government providing incentives for people to leave private medicine, private health care to the public sector. And I think it's wrong and I think it's a mistake. And therefore, I will resist Congress's attempt … to federalize medicine…In my judgment that would be -- it would lead to not better medicine, but worse medicine. It would lead to not more innovation, but less innovation.

Now you don’t have to have seen “Sicko” to know that if there is one area of human endeavor where private enterprise doesn’t work, it’s health care. Consider the private, profit-making, insurance industry that Bush is so determined to defend. What “innovations” has it produced? The deductible, the co-pay, and the pre-existing condition are the only ones that leap to mind. In general, the great accomplishment of the private health insurance industry has been to overturn the very meaning of “insurance,” which is risk-sharing: We all put in some money, though only some of us will need to draw on the common pool by using expensive health care. And the insurance companies have overturned it by refusing to insure the people who need care the most – those who are already, or are likely to become, sick.

I once tried to explain to a Norwegian woman why it was so hard for me to find health insurance. I’d had breast cancer, I told her, and she looked at me blankly. “But then you really need insurance, right?” Of course, and that’s why I couldn’t have it.

This is not because health insurance executives are meaner than other people, although I do not rule that out. It’s just that they’re running a business, the purpose of which is not to make people healthy, but to make money, and they do very well at that. Once, many years ago, I complained to the left-wing economist Paul Sweezey that America had no real health system. “We have a system all right,” responded, “it’s just a system for doing something else.” A system, as he might have put it today, for extracting money from the vulnerable and putting it into the pockets of the rich.

But let’s not just pick on the insurance companies, though I wouldn’t mind doing that-- with a specially designed sharp instrument, over a period of years. Sunday’s Los Angeles Times featured a particularly lurid case of medical profiteering in the form of one Dr. Prem Reddy, who owns eight hospitals in Southern California. I do not begrudge any physician a comfortable lifestyle – good doctoring is hard work – but Dr. Reddy dwells in a 15,000 square foot mansion featuring gold-plated toilets and keeps a second home, valued at more than $9 million, in Beverly Hills, as well as a $1.4 million helicopter for commuting.

The secret behind his $300 million fortune? For one thing, he rejects the standard hospital practice of making contracts with insurance companies because he feels that these contracts unduly limit his reimbursements. (In a battle between Aetna and Reddy, it would be hard to know which side to cheer for.) In addition, he’s suspended much-needed services such as chemotherapy, a birthing center and mental health care as insufficiently profitable. And his hospitals are infamous for refusing to treat uninsured patients, like a patient with kidney failure and a 16-month-old baby with a burn.

But Dr. Reddy-- who is, incidentally a high-powered Republican donor – has a principled reason for his piratical practices. “Patients,” the Los Angeles Times reports him saying, “may simply deserve only the amount of care they can afford.” He dismisses as “an entitlement mentality” the idea that everyone should be getting the same high quality health care. This is Bush’s vaunted principle of “private medicine” at its nastiest: You don’t get what you need, only what you can pay for.

If government insurance for children (S-CHIP) isn’t expanded to all the families that need it, there is no question but that some children will die – painfully perhaps and certainly unnecessarily. But at least they will have died for a principle.

Comments

[Stacy Smallwood]

As I finish reading this, feeling painfully frustrated and disheveled due to the fact I too, am uninsured along with my unisured children. You see, I make too much money for any government program ( $ 32,000 yearly) but I cannot afford to pay $800 a month for a family plan with a $2000 deductible. So, we try not to get sick, or injured, or even think about getting prevenative care. Unfortunately, my daughter fell on her ankle a few years ago, and now she is constant pain and can only wear certain shoes( she just turned 16) So who knows what that injury will be like when she is thirty. Needless to say on her Christmas list last year all she wanted was "Health Insurance"! That my friends is the honest to God's TRUTH!
But unbeknown to my daughter, the really sad issue is that even if we had it now, her injury would be "Pre-Exsisting" and she couldnt get treatment anyway. Why should I break her heart too? Her Ankle was enough. Have we as a Nation had enough? My story is one of many, so we need to make a stand!!! We are not living but merely exsisting!! Thank you Barabra for all your work. Sincerely, Stacy

[Maureen Rogers]

Hard to know where to begin with this one, given that our health care system is such a cluster. Whether insured or not, no one should have to sell their soul in order to pay a big medical bill.For the smaller stuff, wouldn't we all like to see a system of low cost clinics - perhaps staffed by nurses and PAs rather than expensive MD's - that could take care of day-to-day matters and minor emergencies at a cost that most everyone can afford: $10 or $20 bucks.

But with all the technological advances, and the ability to keep people alive longer and longer, we are definitely going to have to make some hard decisions about who gets what. Care is, of course, already being rationed informally - and, in some cases explicitly by the crud you wrote about, "Dr" Reddy. But it will no doubt get worse as the "staying alive" technology improves.

I shudder to think of the rich Boomers all hitting the "market" for new organs at the same time, and trying to justify why the 85 year old Boomer who can "afford" the new heart is more deserving than some poor schlub who's only 25 but doesn't have the scratch. That's when it will truly get ugly.

(I'm a Boomer, but I sure hope I have the grace to say "enough", or give the younger folks a chance, when the time comes.)

[Maya's Granny]

I didn't have health insurance when I was raising my children and we were very lucky that our needs were few. I went over 20 years without seeing a doctor even once. Most people would not be able to do that.

[Prem Reddy, MD, FACC, FCCP]

The LA Times article, “Hospital Group Rejects System…”, by Daniel Costello dated July 8, 2007 is full of distortions that portray me in a very negative light to sensationalize a story. Many statements I made during interviews with Mr. Costello were misrepresented in the article and were taken totally out of context. As a practicing physician for over 30 years, I take serious offense to Costello’s gross assertion that I stated “that patients may simply deserve only the amount of care they can afford.” This is preposterous and I was simply misquoted. It is my firm belief and strong conviction that every patient deserves care based on the nature and severity of illness and should not be based on financial status. The statement comparing the need for healthcare services to other essential needs was completely erroneous. Prime Healthcare Services and I stand by the belief that healthcare is a basic human right. This philosophy has guided our operations and business practice of more uninsured patients being seen in our emergency departments and more charity care provided in our hospitals, compared to both for-profit and not-for-profit competitors. I am especially troubled because thousands of patients and employees of Prime Healthcare Services’ hospitals may be deeply hurt by this inaccurate, biased, and sensationalistic article. Prime Healthcare Services and I will continue to provide excellent patient care and will meet the goals and needs of our patients, the local communities, and the State of California.

Prem Reddy, MD, FACC, FCCP
Chairman of the Board
Prime Healthcare Services, Inc.

[Laura]

I live in Cleveland, and was outraged when I heard a snippet of Bush's speech on the local news, in which he said that people need to take more responsibility for their health, and that a good way to start is by people using health care savings accounts. Yes, I agree, that there are things people can and should do to lower their health care costs - eat healthier, exercise, don't smoke or drink, etc., however, not all health problems are avoidable, and the average person (especially here in Cleveland, one of the poorest cities in the nation) simply does not have hundreds of dollars a month lying around to sock into a health care account, whether the account is tax-free or not. And having employer-sponsored health insurance is no panacea either. I slipped and fell on a patch of ice here in Cleveland back in February, and broke my right wrist. I have medical insurance through my employer, but still ended up with nearly $1,000 in bills that my insurance would not cover for various reasons. I am very blessed to have an employer that covers the full cost of my medical insurance premiums, but the copays, deductibles, poor prescription coverage, and other exclusions, mean that every time me, my husband or my children need medical care, that I end up with a mountain of bills, leaving me perpetually in debt to hospitals and doctors. Several years ago I quit my job to stay home with my daughter who had developed asthma and was in and out of the hospital. I carried the family medical insurance through my job and so I lost my coverage when I quit. The cheapest family medical insurance plan (and a lousy one at that) my husband's employer offered was over $500 a month, which we had no hope of affording without two incomes. My diabetic husband went without insurance for month, unable to afford his medication, and I watched my daughter's asthma worsen until I was finally able to get her onto our state's Medicaid program. My husband and I made "too much money" to qualify for Medicaid ourselves. Clearly, our health care system in the U.S. is broken. Private medical insurance is increasingly unaffordable for employers, too difficult and expensive for workers without employer sponsored coverage to get, and for those with private insurance, still does not provide an adequate safety net. Yet, Bush thinks all will be fine if Americans start being responsible and start socking all their extra dollars into health care savings accounts. For someone who makes $600,000 a year (not to mention all the wealth from his family's oil company ties), and access to the best healthcare in the world for free, of course that looks like a solution. Bush is clueless and out of touch with reality. If he had given his health care speech in Cleveland in front of the average, working-class people of this city, instead of a carefully staged group of executives, he would have been booed right out of the room.

[Curly Earl]

Doctors are allowed to "own" 9 hospitals ?

Sounds like Dr. Wealthy is adept at defending his position on a regular basis. Hot air is what it is.

I smell a rat.

[Hattie]

Dr. Reddy is rich and has all those flashy possessions. Does his profession as a healer not fulfill him to the extent that he could be happy living in more modest circumstances? Why does he need so many things? And what is the truth about qualifying for treatment with his health services?
I think Ms. Ehrenreich has got it right. This is a doctor who has seen the enormous profits to be made off the sick, and is helping himself instead of letting the insurance companies get the big bucks.
That's called "greed." Now those who think greed is good will of course admire Dr. Reddy.

[meow]

Dr. Reddy: It is unfortunate that you and your words may have been taken out of context, but it is obvious from your comment here and in the larger picture that you have no idea what a great many in the U.S. face in terms of health care challenges. If you sold just one of those homes, and put it where it counts, you would make a world of a difference. Better yet, network in the world that you are privileged in and come up with a group of people who actually want to provide health care to those who can't even come close to having a safety net. Oh wait even better, get politcally involved on their behalf. You have the type of money that speaks volumes.

[lilalia]

From an outsider’s point of view, it is often hard to understand why anyone (i.e., the millions and millions of insured Americans) would want private medical insurance. The coverage of this topic usually mentions the greed of insurance agencies, the doctors’ over-inflated sense of the level monetary recompense they deserve for their services, the unfortunate people who can’t afford insurance, those that have insurance but are not compensated because of some bureaucratic loophole, and those, like you, who wish to be insured but are refused because of some unfortunate pre-existing condition. I’ve always questioned why the, presumably, millions and millions of satisfied patients, who receive good health services for reasonable prices from dependable companies, are not heard.

Then, Stacy Smallwood writes how she is expected to pay $800 a month for a family plan with a $2000 deductible on $32,000 annual income. By my humble calculations, she is expected to pay 30% of her salary for the possibility of major health difficulties occurring sometime in the future. Yes, only for the possibility, because with $2000 deductible that policy does not include preventive medicine (e.g., pap tests) or lingering flu symptoms that just won’t go away.

If there are no millions and millions of satisfied patients out there, why aren’t you all out in the streets demonstrating? All developed countries, other than the States, feel that everyone has the right to good health and education: not just children and the disadvantaged, though certainly the children and disadvantaged.

Social medicine is not free. Everyone pays what they can pay (in Germany approximately 10-12% of our salary, unless you are rich and then you pay much less, but still more than an average earner). No one is getting handouts here. We pay into a system that costs far less than yours does and we get more out of it. We can go to visit our general practitioners any time we are feeling sick. We can go to specialist any time we require either preventative tests (e.g., mammography, stress ECG, ultrasounds) or diagnosing for acute illnesses. That is what a modern medicine system should offer their citizens. All their citizens.

[barbsright]

Lilalia, Americans are 'sheeple'. They do not complain because they follow their 'air headed' leaders who they trust because they are in a 'leadership' position. Reagan, who said the Berlin Wall should come down against the wishes of the so called 'elites' in foreign policy, was the only U.S. president in my lifetime to have a brain. Americans fear smart people so they elect buffoons. Understand this, and you understand the USA.

[gaby]

Some things just aren't meant to be for profit. Healthcare is one of them.

[Tina]

Please! Let's stop saying "government provided", and start saying "publicly provided". Government officials aren't out moonlighting to pay the bills---it's OUR MONEY!

Big Daddy is a parasite, not a patron.

[shari]

Let me preface my comments by stating that I would welcome a single payer health care system that provided government immunity for providers (similar to that extended to firefighters or police), though when it occurs, I will probably retire and retrain as a school teacher.

Last year I took a new position as a neurologist in private practice, but made the mistake of agreeing to see children with medicaid on the same terms as other patients. However medicaid does not pay office overhead, let alone physician salaries. Since government mandates, and legal liabilties make the usual office overhead about 120,000/year (not counting physician salaries) this required that I increase the number of patients I saw. I did so, however I was not willing to see a new patient in less than 45 minutes or a follow up in less than 15 minutes, so my office times reflected this. (I took no breaks, and did not eat lunch). I worked 8-5 on the above schedule (and spent another 2 hours a day on unreimbursed telephone calls). I also spent every other evening and weekend at my hospital (where I was required to take call without expectation of payment - most ER visits are not reimbursed, due to the high volume of illegal alients and other insured) However, despite working over one hundred hours a week, and seeing my children for only snatches of time every other weekend I found myself making only about 50,000 after paying my staff. This is not an inconsiderable salary, however it does not go very far when one has to pay for night time child care coverage, and student loans.

I was therefore reluctantly forced to limit the number of medicaid patients I see. I now have 3 slots a week for new patients, which is more than any other neurologist in this area. This means that it takes 6 months for a medicaid patient to get in to see me, while blue cross patients can usually get an appointment in 2-3 weeks.

I believe that physicians should see the poor. But let us call medicaid and governement provided care what it is: Charity provided by the physician, with a minimal but less than cost token payment.

[JD]

Reddy is successful because he has henchmen like Mark Bell to do his bidding. Mark Bell is the director for “EMA” a group of ER doctor own by Mark Bell and Irv Edwards. These group of doctors will do anything Reddy says or else they will loose the contracts at his hospitals. Reddy’s specific instructions are to admit all insured patients for expensive work ups and up code the diagnosis to fleece medicare and insurers more than full price. People who protest this fraud are fired or buried in lawsuits which usually settles. Reddy is a smart business man, because these doctors are the real ones commiting the frauds, but
Reddy is well insulated and protected. He could say, “I’ve never told them that.” Mark Bell sold out his patients and dignity to make a lot of money for Reddy.

[AK]

Reddy is successful because he has henchmen like Mark Bell to do his bidding. Mark Bell is the director for “EMA” a group of ER doctor own by Mark Bell and Irv Edwards. These group of doctors will do anything Reddy says or else they will loose the contracts at his hospitals. Reddy’s specific instructions are to admit all insured patients for expensive work ups and up code the diagnosis to fleece medicare and insurers more than full price. People who protest this fraud are fired or buried in lawsuits which usually settles. Reddy is a smart business man, because these doctors are the real ones commiting the frauds, but
Reddy is well insulated and protected. He could say, “I’ve never told them that.” Mark Bell sold out his patients and dignity to make a lot of money for Reddy.

[Reddy Business model]

1. Cancel HMO 2.Forbids the ED from transferring insured patients to other hospitals. 4. Admit these patients for expensive workups and overinflated prices. 5. Up code the diagnoses to charge Medicare and insurers fradulantly. 6. Do very minimal screening and tests on noninsured patients and throw them out the ED. Any physicians or workers who protest will be fired or buried in lawsuits, which usually settles. 7 Reddy ingratiates himself with the politicians with his filthy money. See his personal website.

[Solo]

"Sheeple"...I'll have to remember that one. It fits?

Why is it that viewers of a TV show were able to rally themselves to send 50,000 pounds of nuts to a network to protest cancellation of a program, but won't make themselves heard on the subject of affordable, accessible healthcare?

Though I do believe that times are changing.

As for Dr. Shari something is off. Her attitude reflects that of a lot of younger physicians who seem not to understand how tough it is for some folks.

I'm aware of one physician in his first year of private practice declaing to his staff: "If they don't have health insurance, they must have money" He then proceeds to order numerous and, maybe, unnecessary tests the patients can't afford. His attitude has had a very negative effect on the office patient load.

[Don Bemont]

I wanted to chime in to say how much I appreciated this read. I can only wish that the thousands of undecided citizens would read this rather than watch Sicko. The point is NOT that Americans need to rethink their attitudes towards socialism in general or Castro in particular. (Moore has an unfortunate habit of making an excellent point, and then adding some politically poisonous frosting to his argument.)

As you say, the real point is that health care is one area where private enterprise does not work. And without getting all theoretical about it, it is for the same reason that private enterprise would be a poor way to provide fire fighting services.

One error that must be avoided this time around, though... We must not go after the Dr. Reddys. If publicly provided health care works (Thank you, Tina, for an important distinction), then private, elitist alternatives should only be a minimal threat. Further, by not trying to outlaw the competition, as happened last time, we avoid a lot of the fear that comes from taking away at least the idea of choice.

As Moore's movie made clear -- and from what I understand, this is the pure truth in France and mostly the truth in Britain and Canada -- once in place, very few people would ever want to go back.

[Actuarily Unsound]

When HSAs (Healthcare Savings Accounts) were introduced, in President G. W. Bush’s first term I believe, I wondered who HSAs were for. After all, anyone with a job that provided a decent health care benefit would not have the prerequisite employer’s HDHP (high deductible health plan), they would have a low- or no-deductible plan, right? Then I learned what the HSA “incentive” really means and who it is for:

At the beginning of 2007, employees of Deere & Company (the John Deere farm and heavy equipment manufacturing firm) found themselves in the HSA wonderland. Some didn’t find out until they stopped at the financial checkout desk upon leaving their health care clinic. These employees expected to make a nominal co-payment and said to the clinic staffer, “I have insurance through John Deere.” “Yes, you do," the staffer replied, “and you now have a $4,800 deductible on your family plan.” The employee makes his payment arrangements and walks away stunned.

Deere employees woke up this year to a monthly premium of $225 per month, or $2,700 per year, for family coverage under their new health plan (not bad as today’s employee benefits go), but the company has replaced their former health care plan with an HDHP plus an HSA. The employee’s HSA is, of course, designed to give him a “tax break” to help cover his new deductible, which is $4,400 to 4,800 per year! Under the new plan, prescription co-pays are $10 to $30 per prescription in addition to the premium and the deductible. So, depending on the medical issue, and given a few ongoing prescriptions for the family, the employee could face out-of-pocket costs of up to $8,000. (Some other “details” in the plan could push the annual out-of-pocket to $10,000.) One estimate is that Deere’s new HDHP + HSA arrangement amounts to at least a 4% pay cut for the employees. That estimate of the effective pay cut certainly assumes that you remain very healthy.

Now I know what the President’s HSAs are all about: paving the way for corporations to shed the burden of health care benefits, and allowing them to do so before we have the universal health care system that must replace employment-based benefits. If this profitable major corporation is doing this to its employees, will the rest of employers be far behind?

[chris]

Barbara writes:

“Now you don’t have to have seen “Sicko” to know that if there is one area of human endeavor where private enterprise doesn’t work, it’s health care.”

It is astounding that Americans will believe that in Cuba, a poor dictatorship locked 50 years in the past, modern medical care is available to all. One only needs to consider that Castro is near death because treatment of his intestinal problem was botched. Really botched.

At that point you know the Cubans are no better at medical care than they are at car manufacturing, energy production, agricultural production, housing construction and maintaining a free society. Why would anyone believe any statement from the Cuban government other than one noting the hardships Cubans must endure while their moronic socialist experiment fails?

By the way, whom is Fidel going to sue for malpractice? Not that it matters in his case. Does anyone know the fate of the doctors who bungled his surgery? Alive? Dead? Harvesting sugar cane?
If the dictator of Cuba can’t get decent medical care, who in Cuba can? A truer picture of medical treatment in the island prison would include mention of the need for families to bring their own sheets to hospitals where relatives are admitted.

Barbara writes:

“Consider the private, profit-making, insurance industry that Bush is so determined to defend. What “innovations” has it produced?”

No segment of the insurance industry produces “innovations.” However, many insurance companies advise their clients on ways to improve performance and reduce the errors that lead to payouts for mistakes. They investigate practices and procedures that offer better outcomes.

She writes:

“In general, the great accomplishment of the private health insurance industry has been to overturn the very meaning of “insurance,” which is risk-sharing:”

Nonsense. This concept may hold for life insurance or property & casualty insurance, but not health insurance. There is no cap or limit on what maladies can behalf the rapidly increasing number of US citizens. There is no cap or limit on the potential costs of “unlimited” care.

Life insurance (an odd name for a financial product that is redeemed at death) pays a fixed amount at the death of the insured. Property & casualty insurance also pays an agreed-upon amount following various impairments or calamities affecting the properties.

In other words, pay-out limits are set. However, if an insured party wants higher limits, the insured party must pay higher premiums. Meanwhile, people with bad driving records pay higher premiums to insure themselves behind the wheel. This arrangement seems to satisfy most observers.

Life insurers know with 100% certainty that every insured party will die. The risk faced by life insurers is predicting how long the insured party will live. However, no matter when that party dies, the pay-out is the same.

With medical issues, who the heck knows what will happen or when problems will arise. First, the nature, extent and occurrence of medical problems is unknown and knowable. Second, the medical world is innovative. Thus, more and more problems become treatable every year.

In short, there’s no end to the arrival of new treatments for an expanding list of medical maladies. Costs will continue to soar as a result.

Barbara writes:

“We all put in some money, though only some of us will need to draw on the common pool by using expensive health care.”

More nonsense. There are so few people who see a doctor only the day they’re born and the day they die that they don’t count.

She writes:

“And the insurance companies have overturned it by refusing to insure the people who need care the most – those who are already, or are likely to become, sick.”

This is an area in need of improvement. But let’s face it, a person with a bad driving record pays more for insurance, for obvious reasons. Does anyone object? No.

Barbara writes:

“I once tried to explain to a Norwegian woman why it was so hard for me to find health insurance. I’d had breast cancer, I told her, and she looked at me blankly. “But then you really need insurance, right?” Of course, and that’s why I couldn’t have it.”

Norway is a welfare state of 4.5 million people, about half the population of NY City. It has fully exploited its oil and gas reserves to generate cash. It created a massive investment pool with the money that rolls in from international energy sales. If the US were to exploit its energy reserves as Norway has, we would have much of the funding needed to provide the level of healthcare critics expect. But wacky green politicians have stopped energy companies from exploiting our entire base of energy reserves. At least 80 billion barrels of oil lies under protrected territory, and its thus off limits. Brilliant.

However, the one country in the world that is truly resistant to welfare-state practices like those in Norway is the US. No matter how much press healthcare receives, support for universal healthcare is minimal. Healthcare reform has had no impact on presidential elections in the past.

She writes:

“This is not because health insurance executives are meaner than other people, although I do not rule that out. It’s just that they’re running a business, the purpose of which is not to make people healthy, but to make money, and they do very well at that.”

The healthcare insurance industry shows a net profit margin of less than 10%. The number is unimpressive. In contrast, Microsoft enjoys a net profit margin of almost 25%.

She writes:

“Sunday’s Los Angeles Times featured a particularly lurid case of medical profiteering in the form of one Dr. Prem Reddy, who owns eight hospitals in Southern California.”

Every hospital has an owner. So what if he owns eight, ten or 50.

She writes:

“The secret behind his $300 million fortune? For one thing, he rejects the standard hospital practice of making contracts with insurance companies because he feels that these contracts unduly limit his reimbursements.”

Think what you want, but there’s no indication he’s committed any crimes. Moreover, there’s no evidence his patients are dissatisfied. Those two points count for a lot.

She writes:

“In addition, he’s suspended much-needed services such as chemotherapy, a birthing center and mental health care as insufficiently profitable.”

Even thought this statement is inaccurate, what of it? He’s not obliged to lose money. Frankly, doctors all over the country are steering clear of OB-GYN work because the lawsuits are so punitive and malpractice insurance for that specialty is so high.

She claims:

“And his hospitals are infamous for refusing to treat uninsured patients, like a patient with kidney failure and a 16-month-old baby with a burn.”

Oh. Infamous. I see. Which hospitals are FAMOUS for treating uninsured patients?

She writes:

“If government insurance for children (S-CHIP) isn’t expanded to all the families that need it, there is no question but that some children will die – painfully perhaps and certainly unnecessarily. But at least they will have died for a principle.”

New York City pays out about $500 million a year to settle liability claims against the city. The single largest chunk results from medial malpractice suits filed against doctors working for the state.

There is great lunacy in believing the state can operate a vast medical system that would meet the needs of the 300 million people who live in the US.

Take the public school system in NY City. It attempts to educate 1.1 million students. Teachers and administrators are all college graduates. Many have masters’ degrees. Some Ph.Ds. Nevertheless, no one – inside the school system or out – would claim the system is good. People who know the statistics know the NY City system is doing a poor job of educating a large minority of students.

If healthcare outcomes were similar to education outcomes, the nation would truly suffer. Is there any reason to believe that doctors will make fewer mistakes if they work for the state? They will make more mistakes because they will have less accountability. That's the hallmark of all bueaucracies. No accountability.

Thus, some big questions need answering.

Why would doctors embrace a universal healthcare program? If Medicaid indicates what is to come, a pay cut for doctors is in the offing.

Why would voters agree to add 45 million uninsured people to the rolls of those receiving healthcare benefits if the cost of their care was distributed among those who already pay for their own healthcare as well as making their tax-payer contributions to Medicaid expenditures?

What would happen to malpractice awards? How high would they go?

Who would qualify for the insanely generous benefits many people believe they should receive? Would illegal aliens get coverage? If an illegal alien female gave birth in the US, thereby creating a new US citizen, would the illegal-alien parents also enjoy the healthcare rights of the new infant citizen who cannot be deported?

[JP Merzetti]

Well now, I can imagine that if you added up all the related tuition and fee costs earned by the educational system from every single person who wishes to have a medical career, this would come to a consider amount of booty. To make these costs attractive to the participants (students) there has to be a golden carrot at the end of the stick, um?

And in the great historic tradition, once something like the medical industry has become so firmly entrenched in profiteering (that's how we got our railroads) then you have something so obviously difficult to budge.
Of course it makes perfect sense to those in other civilized lands - to remove health care from the vicious profiteering corporate model, but America will bellow its individuality with great disdain.
That this is so firmly entrenched in the minds of even those who are hurt by how we do things - is obvious.

Is it time for a change?
(I'm not old enough to know exactly how the average worker was affected by this issue 30 or 40 years ago...) but my gut response is this:
If the corporate and political bellowing about our "modern" global love-fest is to be believed, well then, I'd say it's time to observe and follow how other "civilized" nations in the West do things...(better)

[Chris S.]

This issue is complicated. I'm low income with no insurance but I also have no dependents and no debt. My visits to the doctor are few and far between and I pay cash when I do go. This is not the best way to do it I know and yet I'm one of the luckier ones. There are people in my situation that aren't healthy and do have uninsured dependent children.

[shari]

"Solo" thinks I don't understand how tough it is for some folks. He's probably correct.

However I suspect Solo does not understand how tough it is for me either.

All jobs offer varing amounts of hassle, appreciation and money, and consume time, money (upfront costs) and energies.

Physicians today graduate between 150,000 and 200,000 dollars in debt. That needs to be paid. Due to malpractice and due to government requirements about medical record keeping, most non-VA offices spend approximately 120,000 per physician in support staff costs. Somebody has to be paid to type the notes, answer the phone, deal with dozens of different insurers, and make sure that the tens of thousands of rules are followed.

Thus, before you see your first patient on your first day of work you have already commited to a debt of 270,000 to 370,000 before you earn anything. If you decide to work at a free clinic one day a week (as I used to do) then that debt will grow.

If you choose (like Dr Reddy) to see only insured patients you can usually pay off your debts in about 10 years and have a salary in the 300,000 range.

If you choose (as I used to) to see all comers, then your practice will rapidly become all Medicaid and uninsured as there are plenty of folks who will gladly see a physician for free (the person above who has not yet obtained medical care for his child for example) but who will not do so if they have to pay. When this happened you will end up losing money and will either go out of business or will choose to run a mill, seeing patients at 10 minutes a pop.

I managed to make 50,000 because I was still seeing some insured patients, however the long waits necessitated by the rush of the uninsured and Medicaid drove the insured patients to physicians (like Dr. Reddy) who did not have a 3 month waiting list.

By deliberately maintaining some time in my schedule for medicaid and uninsured, but by seeing insured patients on a preferential basis, I have reduced my waiting time for folks who actually bring in revenue to 1-2 weeks, while increasing the waiting time for what is essentially charity care to 6 months. I make more than I did (though a good deal less than I could).

However, this does not change the fact that while I now make enough money to pay my student loans and to see my kids through college, I am still working 12 hour days, and I am still on call for free, and don't get to see my kids. Physicians are not paid for being on call to the ER, where most patients are uninsured or have medicaid.

Further, currently anybody could sue me and confiscate my salary and my kids college money even if I didn't do anything wrong. This happens all the time, because physicians are attractive deep pockets.

For all of these reasons, my plan is to work as hard as I can for the next period in order to become debt free, and to ensure that my kids college tuition is there for them, and to then go be a high school science teacher.

Because then, I would have the time, and time is also important.

I would also be much less likely to be sued by the patients whom I see for free (Emergency rooms generate more lawsuits) and safety is also important.

Frankly most physicians I know who are over the age of 50 plan to leave medicine in the next five years for precisely these reasons.

I could leave it a lot sooner if I behaved like Dr. Reddy. I'm not willing to do that. However I'm also not willing to bancrupt myself and my children in order to be an unpaid public service for the poor, or for those who chooose to spend their disposable income on something other than medical insurance.

What salary do you think is appropriate, for a physician to receive who works 12 hours a day, and gets very little sleep every third night, and every third weekend due to unpaid care?

[shari]

The proposed salary that folks offer should include consideration of repayment of the 100,000 to 200,000 student debt, the hours, and the fact that everything you worked hard for could be taken away at any moment by a drunk driver who comes into the ER with a head injury, and decides to sue you because he feels that the consequences of his head injury would have been less severe if you had gotten to the Emergency room 10 minutes faster.

So, lets hear it? Whats a fair price for a physician? Because I know that I can make about 37,000 working as a high schol teacher. Should I switch, I will enjoy equal benefits to those that I enjoy as a physician, and I will work less than 8 hours a day, and I will not have call or weekends or liability.

And I will still be doing an important job, that I will enjoy doing. And I do enjoy medicine. However I am pretty sure that I will enjoy teaching, which is why I am studying the subject.

[chris]

shari asks:

"So, lets hear it? Whats a fair price for a physician?"

What's so tough about estimating a fair wage? What do other professionals with similars levels of education and responsibility earn?

New attorneys from good schools who join major law firms START at about $150,000 a year. They often work 80 hours a week or 4,000 hours a year. Thus, on an hourly basis, they're earning $37.50.

But there are no competent legal practitioners who charge less than $150 an hour.

Entry level Investment bankers earn similar amounts, but their pay rises sharply every year, easily hitting $500,000 before the worker turns 30.

Psychiatrists charge $100 or more an hour.

There's no reason a physician with a year's experience should earn less than $100 an hour.

I don't mean billing $100 an hour. I mean earning $100 an hour.

HOwever, an entrepreneurial doctor, like Reddy, is likely to earn far more.