Wednesday, April 1, 2015


Every day someone tells me he has been screwed by Obamacare: The costs of his medications have risen; the MRI machine was so loud it made his ears hurt; his flood insurance went up; he got a smaller refund on his income tax; his daughter's cheerleading team cannot afford to go to the national competition in Oklahoma City this year. It's all Obamacare, or at the very least government. Government has replaced Satan as the catch-all for what ails us. 

Where does this come from? You know very well: Mr. Limbaugh and fellow travelers including but not limited to Mr. McConnell and Mr. Boehner and all those Republicans federal and local, all reading from the same hymn book. They have seized control of the brains of the masses. They rule the waves, the airwaves that is, and they have as much penetration into gray matters as Big Brother ever dreamed of.

Paul Krugman recently illuminated how wrong Republican doomsday sayers have been about Obamacare, which they have been trying to convince us is a disaster.

He is correct, of course, Obamacare is way better than what we had, despite its bizarre complexity, a chimera of private health insurance and public funding which is a reflection of the way our government works: All the players are payers and as long as everyone gets his cut, the bill becomes law.

So people like my self-employed son in Brooklyn now have really good health insurance for half what really terrible health insurance used to cost him. That means if he gets sick, he may not drag the entire family, his parents and everyone, down into bankruptcy.  So, as far as payment systems go, it has been a success. 

But American healthcare is structurally disordered, and no Obamacare or any system of payment has yet steered its boat away from the rocky hazards toward which it is sailing.

Older doctors have always carped about how the system is going to pot, but there are signs this time their criticisms of current trends are on the mark now.

The structural problems are:
1. Doctors are motivated by profit and profit is generated by fee for service which drives the system into ever expanding services in search of fees.

2.  The English, decades ago, figured out how to use generalists and non physicians effectively. We have not learned from the Brits nor from anyone else who might be doing medicine better than we are,  because, in  our hubris   we have convinced ourselves we have  the "best medical system in the world." That declaration might make John Boehner feel all proud, but it means we have not learned from others. 

3. Innovation, which once came from university medical schools, now comes from profit centers, from drug and device companies and the kind of innovation which emanates from these profit driven sources  is not likely to benefit the public health, no matter how much it improves the bank accounts of those corporations.

Someone once said, "Medicine is too important to be left in the hands of doctors." Our problem currently may be that the hands of the doctors are nowhere felt now, and in their place are the hands of the bankers, the MBA's, the politicians and the entrepreneurs. Not that these people have nothing to offer, but whose hands should be on the steering wheel?

At root, it's a problem of values. The high energy, hard edged entrepreneurs, who think that the world, all parts of the world, ought to be run by dollars look at public health as a soft and fuzzy and inefficient ideal of commonweal and they want to apply principles of natural selection to doctors and patients.  They want "lean and mean" and they abhor socialized medicine and look at healthcare in Britain, Sweden and all those "welfare state"  European nations as failed programs. The Europeans know better: They look at our system and see a system that fails 90% but serves 10% admirably.  

The inner city clinic I ran for 13 years  in Washington, D.C. provided low cost care to people who could not afford to see doctors, during the 1980's and 1990's as a quid pro quo mandated by the DC government. The hospital from which it ran was in a swanky part of town, a maternity hospital which delivered the babies of the affluent. Well, the DC government said, if you are going to make money in this territory, you have to pay the rent.

That, of course, was, as Mr. Limbaugh would say, is just another example of the nanny state taking from you and me and the hard workers and giving to the undeserving slackers.  

Does Ms. Clinton, or any other Democrat, save Elizabeth Warren, have an answer for this? 

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