Rearranging Chairs

I have been asked by patients, readers, family members, and by fellow bloggers what I think about the bill passed by the House of Regurgitants Representatives yesterday.  I resent this.  I have tried hard to remain neutral as possible, finding equal cause to point and sneer at both conservatives and liberals.  It\’s much more fun to watch the kids fight than it is to figure out which one is to blame.
But given the enormous pressure put on me by these people, as well as threatening phone calls from Oprah and Dr. Oz, I will give my \”radical moderate\” view of the HC bill.  My perspective is, of course, that of a primary care physician who will deal with the aftermath of this in a way very few talking heads on TV can understand.  The business of HC is my business, literally.  So, reluctantly, I take leave of the critic\’s chair and take on the position where I will be a target for any rotten fruit thrown.

1.  It\’s not Armageddon.

We are all still alive and breathing, and will continue to do so after this law is passed and signed.  The bill does not change things as radically as the shrill voices on the right suggest.  It does not constitute a government takeover of HC, nor does it seem to extend any government programs by a whole lot.  It is really not about HC at all, but instead about health insurance.

The goal of getting more people insured is a good one.  Our system clearly (from my perspective) makes my services unaffordable – especially if you consider what people pay for procedures and medications I order.  The lack of affordable insurance does harm people; I see it every day.  The system is broken and needs fixing.  Anyone who says otherwise needs to get a urine drug screen ASAP and then seek professional help.

Beware of the fear-mongers who make this out to be the \”pro-death panel\” legislation.  It\’s really not that bad.

2.  It\’s not Nirvana.

It\’s actually more like the Foo Fighters…no wait, that\’s another blog post.

There are folks on the Left who think that we are entering a golden age because of this.  Some suggest this is the \”Waterloo for the Republicans.\”  No, this bill is simply a rearrangement of how money is being spent, not a fount of blessings to those in need.  Some people will benefit from this – especially those with no insurance – but most people won\’t see a whole bunch of change from it.

This bill addresses the problem of the uninsured, but does not deal with the much more important issue of cost.  If anything, it may worsen the problem that is actually at the core of the troubles: out of control spending.  Figuring out how things are going to be paid without controlling what is being paid for is like rearranging chairs on the Titanic.  The reason people cannot afford insurance is not because there are enough insurance options, it is because of the incredible amount of waste in the system.  Agreeing to cover more with insurance without controlling cost will make the situation worse, not better.

3.  The process was a national embarrassment.

The debate in DC did not seem to be about people getting the care they need; it seemed to be about which side would win.  The lack of bipartisanship is a condemnation of both sides, an indication that power is more important to our representatives than is representation.  Why didn\’t the Democrats agree to tort reform (which nearly everyone supports)?  Why couldn\’t the Republicans concede that having people with no insurance is a problem the government should address?

We have a terrible situation in our country: a HC system that is out of control in its cost and that will bankrupt us if nothing is done.   Yet what this difficulty has won us is not a national resolve to fix this problem, it is an increase in the partisan screaming and a worsened environment to effect real and beneficial change.

To me, the debate turned debacle is a very good argument for term-limits for members of congress.

4.  It missed the point.

The real problem in healthcare, again, is not who is paying.  The real problem is that it costs far too much.  We are not in a crisis because of insurance; we are in a crisis because of what is being paid for by insurance.  For legislation to have a real chance for fixing this problem, it must find a way to control spending.

The problem of health insurance is far easier than that of cost.  Here\’s why I think cost-control is going to be an even harder thing to tackle:

  • There are industries making billions of dollars off of the inefficiency and waste in HC (see my post about the Sea Creatures).  Devices that don\’t really help people, and specialty procedures that are unproven are paid for while primary care gets the shaft.  People like shiny technology and legislators have a hard time saying \”no\” to it – especially with the lobbyist dollars that will protect this waste-eating industry.  It\’s boring to promote primary care and doesn\’t play well to the constituents.
  • We don\’t have the IT to do it.  Any attempt at cost control will fail without good health IT.  Doctors control a huge percentage of HC costs, yet most are operating blindly.  We rely on the word of the patient for what happens in other HC settings.  If you are going to expect physicians to make prudent medical decisions and eliminate waste, you must give them adequate information.  Unfortunately, the current push for EMR is not about delivering information to physicians, but instead about letting doctors document more efficiently.  Use IT to inform, not conform.  Use IT to enable docs instead of burdening them more.
  • \”Rationing.\”  Any control of cost will be about denying care.  I believe that denying care that harms patients is a good thing to do, as is suggesting cheaper alternatives if they are equal in benefit.  Patients are angry when they can\’t get Nexium covered by the insurance company, but OTC Prilosec is just as good for them.  Patients are angry when they can\’t get an MRI for their back pain when it is really not appropriate for 98% of back pain sufferers.  People don\’t want to be denied.  Americans want an all-you-can-eat buffet of medical care.  Unfortunately, any change for the positive will inevitably involve some sacrifice.

So, what do I think about the legislation?  I honestly don\’t think it\’s that big of a deal.  I think it\’s good that something is being done about those without insurance, but I worry that nobody is checking the balance on the credit card.  I like the arrangement of chairs on the deck, but perhaps the hole in the boat merits a little consideration.

35 thoughts on “Rearranging Chairs”

  1. Politics is an imperfect art, [just like medicine]. That fact that a reform of such importance needs to go through such messy process (on top of the unfortunate compromises/concessions necessary to get it passed) speaks plenty of the state of [moral] degradation in Congress, IMO. On the flip side, it's democracy not dictatorship that our country stands for; votes still matter, by Regurgitants and Representatives alike.

  2. I HOPE that this will be challenged and make its way to the supreme court. The government is forcing people to purchase something just because they are alive. It's one thing to force the people to have car insurance. A person chooses to drive a car and puts others at risk. A person can choose not to drive a car and therefore not be forced to pay for insurance. In this case, mere existence allows the government to force a person to make a purchase that they may not make.

    In the past, I have been laid off and been without medical insurance. I chose not to opt in on COBRA. That was my choice and any consequences that may have occurred were my own. In fact, I did have to seek medical treatment while uninsured for something that was relatively minor. I paid out of pocket at urgent care.

    It is unconstitutional to force citizens to purchase something simply because they exist. What's next, forced pelvic exams simply because I am female? Forcing me to have a pelvic may save money in the long run because something may be caught in an early stage and therefore, cost less money to treat.

    I read on a legal blog the following:

    “They say EVERY Democracy has ended in a Dictatorship…I used to laugh at that…
    I’m not laughing any more!”

    Though that was said about another Obama issue that was unconstitutional, it is applicable here as well. Imagine forcing me to purchase something that I do not even use simply because I exist.

  3. Wow, I'm just reeling over your comment “I honestly don't think it's that big of a deal.” Have you read any of this bill? Are you able to pay your overhead with the reimbursement provided by entitlement programs? Can you see more patients than you're seeing now and do a good job of it?

  4. Wow, I too am just reeling over your comment.

    The scare tactics is so high school (and 'Republican')!

  5. I do agree that the government should not force people to do things that are not necessary for the sake of the people. The government forces us to not kill, but that's OK. The government forces us to pay taxes, but there is reason behind that. So the question is: is insurance a necessity or is it like the government saying we must live in a certain place or worship a certain god? To answer this, you have to see the consequences of people who are uninsured. Are they the only ones who bear the consequences of their own decisions? I don't think so. Nobody is truly uninsured, as a person going to the hospital will have to be covered. People who don't buy insurance are simply relying on the government to bail them out for their bad decisions.

    That's why the courts won't rule against this.

  6. Agree, but I don't think the partisanship that has evolved is representative any more. The two-party system with primaries has made the sides become increasingly polarized.

  7. Dr. Rob,

    Respectfully, I disagree with your comparison regarding murder or taxes. It is like comparing apples to oranges, or worse, apples to moon rocks. As human beings and as Americans, we have a unalienable right to the pursuit of of life, liberty and happiness as enumerated in the Declaration of Independence. No one has the right to take it away and obviously, murder pretty much squelches any hopes of life, liberty or happiness. Taxes are allowable as detailed in the 16th amendment to the U.S. constitution.

    Here's an article that you may find of interest and it is from a legal point of view. The author, Randy E. Barnett, teaches constitution law at Georgetown University. Here's the link:

    You may be incorrect in that this won't be overturned as being unconstitutional. I hope you are incorrect.

    That all being said, I agree that I am not in the position you are in seeing the consequences of people who are uninsured. I rarely make use of medical care and the few times I have, I either paid for it out of pocket or I have insurance through my employer. I have recently been reading medical blogs and have become somewhat educated as to the problem of the uninsured and the abuse of ER. I am not sure forcing Americans into a binding contractual relationship with a private company is constitutional. As it stands now, I can choose if and whom I desire to enter into a contractual relationship with. If it is not challenged, the government now can force Americans to enter into a contractual relationship with a private company.

    You also use the argument that I don't see the effects of the uninsured and you are correct. You base your argument on the uninsured have to be treated and it costs society to treat them. Using that very argument, why not force people to undergo preventative treatment as it is costly to treat something that could have been caught and treated if people were forced to seek preventative care? Forced contractual relationships with private insurers benefits society and by the same token, forced preventative care also benefits society. Preventative care saves money in the long run.

    It's really a sad day for this country when her citizens are being forced to enter into contracts.

  8. To the conservative, the reform does strike at the heart of their small-government principles.

    The problem, though, is that government is the ONLY entity big enough to stand as a counterbalance against the overgrown influence of insurance industry (from payment to denied coverage, you name it) in American healthcare system.

    I too am unlike to directly benefit from the reform (pretty well-covered), but for once, am glad that the government has finally stand oppose to the uncontrolled (that is, poorly regulated) growing influence of industry and special interest groups.

  9. Here is a more balanced article on how the politics is played out between GOP the obstructionist and the not-that-unified Democrat front. If you want to talk politics, i would say it's indeed MESSY; if you want to discuss potential impact of the reform bill, i would HOPE that it would be the be the beginning of the cascade events that get the healthcare system back to the hand of the people and providers, where it matters.

  10. Politics aside and quoting from the article you posted, this is what I take great umbrage with “The more contentious ones, including the mandate for the uninsured to obtain coverage, do not take effect for years. ” The government is forcing her citizens to enter a binding contractual relationship simply because they exist. I have no problem with fixing the insurance issues of denying coverage because of preexisting conditions, denying treatment, etc. That needs to be fixed as it is unconscionable for an insurance company to deny a treatment prescribed by a physician or cut someone off because of their illness and denying coverage because of preexisting illness. Despite these issues having never affected me as I have been healthy, I understand the need to fix that problem and they need to be fixed.

    I pay car insurance because I CHOOSE to drive a car. I don't have to pay car insurance if I choose not to drive. I am really shocked and dismayed that folks don't have a problem with being FORCED to enter into a contractual relationship and simply allow the government to force that upon them. Should I lose my job and find myself uninsured (and it has happened), I am now facing spending money that I otherwise would spend on living expenses and being FORCED spend it on something I do not want to spend it on.

    Unbelievably, the IRS will be charged with enforcing this new law. IRS and healthcare. Makes my blood boil — heck, I may need medical care after all. No one sees a problem with the IRS being an enforcer and requiring Americans to provide sensitive personal information to the agency charged with taxation? Are you kidding me?

    This country now officially sucks!

  11. The alleged HCR-IRS link is the product of GOP's fear tactics.

    There is NO, repeat NO, primary source that can verify such connection.

    No wonder so many constituents get so unnecessarily boiled up over such disinformation….

  12. So I could not drive – choosing to take a Taxi to work? That's a distinction without a difference. It's like saying that to avoid taxes on food, you could not eat. There is a huge segment of the population that just couldn't function without a car (myself among them). We are forced to do a lot of things. Again, if you get sick without insurance, the government is FORCED to pay for your care. They can't let you die. So it's OK for you to force them, but not OK for them to force you to pay if you can afford to or give you insurance for free if you can't?

  13. From

    Palin Facebook's 'Death Panel' to
    Wilson's spontaneous 'You lie' to
    Neugebauer's (age: 60) 'Baby Killer!'
    Now the alleged but unverifiable* “HCR-IRS” link

    Wonder what the next round of GOP stunt would be.

    * i just made a few calls; there doesn't appear to be much solid backing for such a wild claim.

  14. I don't care what Palin's facebook states. I have not bought into that death panel nonsense even though I am a conservative. Despite what you state, (There is NO, repeat NO, primary source that can verify such connection) there will be enforcement of the new bill. Basically you're saying that there will be no enforcement of this new reform. So those gradual increases in fines for those folks that do not have the mandatory health care insurance is simply a scare tactic. Too bad traffic laws are not the same. I've spent enough time in traffic school over the years and would love to have the same lack of enforcement as this new health care reform.

    Are you kidding me? This huge new reform is going into effect and they're not going to bother enforcing it?

  15. Food tax is a bad example. Only two states (I believe Alabama & Mississippi though I could be wrong on which states) apply taxes on food purchased for home consumption. Thirty some odd states do NOT tax food for home consumption at all. A few states (I believe 5 or less) offer credit on food tax for home consumption but their taxes on grocers are at a lower rate than other businesses and give credit to consumers for those purchases. My numbers may be off a bit.

    Even so, the government DOES let people die for lack of insurance. Example (one of many), a man who was self employed with a family saw his family doctor who ordered an expensive test. Took the guy over 2 years to save up to pay for the test. Sadly it was too late. He had end stage cancer. Extremely sad case.

    The government has declared that all who show up in an ER must be treated. Well, we all see those abuses by folks that show up for the most minor of symptoms. Some women show up for a pregnancy test costing us tax payers thousands of dollars when they simply could run to the local drug store and purchase an over the counter pregnancy test. I have read of reports where folks have called an ambulance to their local hospital only to walk off the ambulance to visit a friend who happens to live close to the hospital. In my state alone, several hospitals have closed their ER doors because of these abuses. And for some reason, we Americans are placing our trust in the government to fix these problems. We all must have fallen off the stupid tree and hit every branch on the way down if we really think the government can fix this for us.

    Like you, I live in a state where I must have a car as public transportation is not a good option unless I want to take hours getting from one place to another and still I would be limited in where I can travel. Yet, it is still a choice I make so I can have the ability to live my life as I choose.

    The government is NOT forced to pay for my care if I become ill. They made that choice. And sure, they can let me die as they have others. I do not expect them to care for me. There is no requirement that the government act as a parent or nanny and provide medical care to folks that choose not to be insured. If I choose not to be insured, then I should be allowed to face the consequences of my actions. It's one thing to provide an opt-in insurance plan for those that wish to have it but quite another thing to force people to have insurance if they don't want it. I only have insurance because I am employed and contribute very little towards the premium. In my over 5 years at my job, I have never made use of my medical insurance (and I'm not young, I am certainly in the second half of my life). If I choose to leave my job to travel or stay at home, the government will force me to spend money on something I neither want nor will make use of. The point is, my choice of medical insurance should be mine and not something I am forced to purchase. My choice to not to seek preventative health care is my choice despite the fact that I have excellent insurance. Ironically, the few times that I have sought medical treatment, I have been without insurance. I have paid out of pocket. It did not occur to me to have someone provide me free service.

    In any event, we'll have to wait and see what happens. I do know some states will be filing suits against the federal government. It will be interesting to see how it plays out and how the federal government can force citizens to purchase something for their personal use that they might otherwise not choose to purchase.

  16. >> The reason people cannot afford insurance is not because there are enough insurance options, it is because of the incredible amount of waste in the system.

    There is waste, but even if there weren't there still wouldn't be enough money. The reality is that we don't have enough healthcare dollars to pay for every bit of healthcare that every person in this country could justifiably consume. We must ration health care – but we must do it in the right way. It needs to be transparent and up-front, not done through occult insurance denial and appeal schemes. Insurance says they will pay for everything that is “medically necessary” but then fights over items claiming that they aren't really necessary, after the services are already provided. The system needs clear up front guidelines that are known by all.

    I agree with your point about expensive toys in the operating room. Biomed companies have incredible incentive to make new toys to use, and they rarely offer any real benefit – but us surgeons love them. The DaVinci robot is a good example. I love using it, but it is hugely expensive and doesn't allow me to do surgery I could not accomplish without it. It does allow the same surgeries to be done less invasively, but at incredible cost. So is that medically necessary? Arguable. Its better for patients, but would that additional money spent on the robot be better spent on other people for something else? Probably.

  17. I would actually argue it was the way the media covered the activities surrounding the bill that gave us all the impression the process was despicable. Pew Research found three times as much time was given to coverage of strategy and politics as to the content of the reform. I'm a total legal procedure geek, so this has been heaven for me. What everyone else seems to despise is endlessly fascinating to me.

  18. Ok Dr. Rob, I'm going to have to ask you to marry me again. This sane, sensible, balanced post is brilliant. I love brilliant.

    Americans want to have their cake and eat it too. They want what they want when they want it, but they don't want to pay for it. Or be 'forced' to have insurance so someone else can pay for it. Take your chances with no insurance? Would you expect to develop Multiple Sclerosis at the age of 50? Or trip on something on your patio and shatter your shoulder? Well both those things have happened to me, previously healthy my entire life. My medicines for MS and it's symptoms cost over $4000 a month. I have had three surgeries on my shoulder to the tune of approximately $30000 each. My insurance has covered almost all of this. Not being covered is a chance no one should take, because you never know what could happen.

    Something had to be done to get things under control. This bill isn't perfect. But it is a start. The hysterics and the lawmakers who kept putting up roadblocks should be ashamed of themselves. We have to be united in this. It IS embarrassing the way our legislators have conducted themselves. And it is embarrassing to see the lies and half-truths the hysterics are willing to believe.

    P.S. Did Oprah really call you!?!

  19. I can see what you are saying. I should lay blame at the feet of the press – it wouldn't break me up to do that. Still, I think the partisanship is going to destroy us. I really believe that politicians who put party above who they represent are a very destructive force.

  20. No calls from Oprah yet. I think she's jealous and ignoring me to spite me.

    It's actually a theme I have kept going – kind of like the llamas.

    You put things succinctly as well. Thanks!

  21. Well, Oprah doesn't know what she's missing. Sad really. There are few things uglier than jealous, spiteful quadrillionaires.

    BTW, people who are consumed with terror over the new bill should log onto They do a great job sorting fact from fiction. Just type in 'health care reform' and you will get a host of articles debunking the lies being told about this legislation.

  22. Below is a link to HR3590 at the Library of Congress. This is the 906 page “reconciliation” document that Nancy Pelosy and our President signed enacting Healthcare. In 906 pages there are over 110 references to the the Internal Revenue Department, mostly having them amend, change or add to the tax code.….

    I think there is a link between Healthcare Reform and the IRS.
    I am not a GOP…

  23. Dr. Rob, I'm afraid you're right–this partisanship will destroy us. We're degenerating into a nation of tribes and the increasingly vicious tone of some of our elected officials is fostering that. When you have members of Congress yelling “baby killer” and “you lie” at each other and the president, is it any wonder people on the street feel free to yell racial and sexual slurs at members of Congress? I heard on the news tonight that a propane line was severed at the home of a brother of a Congressman. That's terrorism. And Sarah Palin tweeting that her followers should not retreat but RELOAD? That's hate speech. She knows she's throwing gasoline on a fire. And Karl Rove calls this collective hate “growing pains.” Yeah sure, and the planes smashing into the World Trade Center were “fender benders.”

  24. Healthcare and its reform are very complex issues:
    1. There should be no income ceiling for the Medicare tax
    2. There should be no income ceiling for the SS tax
    3. These taxes should be on prededuction income
    4. The US government should be charging the countries of origin for healthcare costs for illegal aliens
    5. Half of the uninsured are children who don't puchase insurance
    6. Parents can buy cheap insurance for their kids thru their school system for injuries
    7. Those that choose to not purchase even catastrophic insurance should not be allowed to declare bankruptcy
    8. The working poor should have a graduated insurance premium based on income
    9. HIV/AIDS, ESRD, and the disabled should be on Medicaid, not Medicare; it's cheaper for the US and better covered financially for the patient
    10. Big Pharma has made absolutely not big compromise on drug costs. Something must be done with these “drug dealers”
    11. It is outrageous that the US gov't can negotiate drug costs for the VA and the DoD but is not allowed by law for Medicare!
    12. Medical and Surgical specialists, and especially subspecialists, are vastly overcompensated for their services
    13. Primary care physicians are vastly underpaid for their services
    14. Primary care must deal with multiple complaints, multiple medications, and multiple conditions; subspecialists only deal with one organ system, limited meds and complaints, and most of the work up has already been done by PCPs
    15. Home health agencies over and are over reimbursed/paid
    16. Durable medical equipment suppliers overcharge and are over paid
    17. Hospice is great but has become more like a HHA or NH more interested in income than terminal care
    18. Physician extenders who act like and present themselves like physicians(PCPs), should be held accountable liability-wise
    19. Insurance company executives are paid outrageous salaries and bonuses
    20. Pharmaceutical executives are also paid outrageous salaries and bonuses
    21. Hospital administrators are paid outrageous salaries and bonuses
    22. Many patients are at fault insisting upon tests and treatments not recommended by their physicians. When they don't get their way, they threaten to change doctors
    23. Most Plaintiff Attornies believe that every negative outcome is someone's fault. This leads to many unnecessary suits which results in large amounts of money, time, and angst wasted, as well as, the practice of defensive medicine
    24. The medicolegal systems financially rewards plaintiff and defense attornies more than helping injured patients
    25. No price tag can be placed on pain and suffering, but lawyers and patients treat this as a lottery jackpot
    26. There are non-MDs and non-DOs who desire to cash in on insurance income e.g. Optometrists like an Ophthalmologists, Nurse Anesthetists like an Anesthesiologist, Podiatrists who want to ascend the leg like an Orthopedists, Nurse Practioners like a Physician, Physician Assistants like a Nurse Practioner, etc. These people cannot handle their complications and then medicolegally hide behind the excuse that they are only a __________, and not a physician.
    27. Academic institutions frequently repeat tests and procedures previously done locally because they didn't perform them
    28. Politicians will pass whatever they think will get them the most votes for re-election
    29. I doubt any US Comgressman/Senator has read all 2700 pages of the proposed Healthcare Reform legislation or understands all its implications

    These are only the tips of the iceberg problems confronting health care reform. I sent 15+ recommendations to the Oama administration, AARP, AMA, American College of Physicians, and the Society of Hospital Medicine; result, zilch

  25. Well said; sorry I missed original post. Saw it today via ACP blog…

    So let's summon the 'call to action' of all primary care physicians. Disorganized medicine notwithstanding, there is strength in numbers. Without delivery system transformation, the Titanic metaphor will be major league on point. See:

    We have a little planning group with the nameplates in the health 2.0 and direct practice world who are colluding to make a difference, fwiw. And Vince Kuraitis did all of us transformers a big favor by parsing the innovation (pilots and demo's) in the PPACA:….

    Absent the granular innovation encouraged by this Act, that balance on the credit card will no doubt continue it's accelerated uptrend.

    Thanks Rob!

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