Self-Help: A short-short story about health care

I offer a short-short story about health care as my PsychologyToday.com contribution today.

Your Health Care, America's Health Care, Today and Tomorrow

Already, a New York Times/CBS poll reports  that the Affordable Care Act (ObamaCare) has resulted in decreased access and increased cost. How can you cope? What should America do? My PsychologyToday.com article today 
attempts to tackle those thorny questions.

Reinventions: My best ideas on jobs, education, health care, and campaign reform

I hope to write a book, Reinventions, consisting of my ideas for reinventing 30 of society's linchpins.

My agent suggested I first write an article presenting a few of my best ideas. I've done so and thought you might enjoy seeing the article. HERE is the link.

My Top Ten Ways to Improve the World

#10. Radical election reform: Replace bought politicians with wisely selected ones. I'm undecided between two approaches:

1. All campaigns would be two to three weeks long, 100% publicly funded, and consisting only of a neutral body such as C-Span or Consumer Reports posting the candidates' voting records and positions on key issues, plus a broadcast debate followed by a simulation of the candidates running a meeting.

2. Our government officials would be selected using passive criteria, like a stock index fund. For example, it might consist of the most newly retired of the nation's 10 largest nonprofits, a randomly selected CEO of the S&P MidCap 400, the Police Officer of America's Cop of the Year, the School Principal of the Year, the most award-winning scientist who finished her/his Ph.D. in the last decade, plus five random citizens.

You protest, "The incumbents would never allow it--the foxes are guarding the hen house." My approach would be to get the media to urge voters to vote against candidates that oppose a fairer electoral system.

#9. Replace ObamaCare with NemkoCare. Patients having (ahem) skin in the game is key to cost control: the invisible hand of 300 million people voting with their feet. So, all but the truly indigent would pay fee-for-service except for catastrophic care, which they'd pay for with private insurance.

To empower consumers to make good decisions, all health care providers would be required to post patient satisfaction rates and success rates for procedures, adjusted by severity of illness.

Caring for the millions of currently minimally cared-for patients will require more doctors, nurse practitioners, etc. To provide them while improving quality, provider training would be shorter and practical--wrested from the university and provided by master practitioners. Physicians, let alone nurses, do not need a year each of college-level inorganic chemistry, organic chemistry, calculus, and physics. Their training should be provided by the finest clinicians, not by academics, who mainly do research on esoterica.

#8. Replace curricular esoterica with essentials. Kindergarten-through-grad-school curriculum has long been selected primarily by professors, a group that has deliberately opted out of the real world and loves esoterica. Hence today, nearly all high schools students, even those reading on a fifth-grade level, must study the doppelganger, quadratic equations, stoichiometry, the Peloponnesian Wars, etc., even if that means they leave school unable to make change, critique an editorial, resolve conflicts, or prioritize ethics over expediency. Essentials must be prioritized over esoterica.

I'd wrest curriculum choice from the academics and replace them with a diverse panel of people from plumbers to CEOs, nurses to, okay, professors, who have been issued the following mandate: That which is most important for living must be taught and learned before teaching the less important.

#7. Require schools and colleges to post their report card. We require students to receive report cards every few months. We even require tires to have "report cards" molded into their sidewalls.

Well, if education is as important as everyone claims, shouldn't schools and colleges be required to post a report card on themselves? For example, shouldn't they be required to report their students' average annual growth in reading, writing, critical thinking, and mathematical reasoning, compared with national norms for schools with similar student bodies?

Shouldn't colleges additionally be required to post their four-, five-, and six-year graduation rates (disaggregated by high school record and SAT score,) and the actual average total cost of a degree, after financial aid, broken down by family income and assets? Shouldn't all schools and colleges be required to post the results of a student satisfaction survey and a summary of the accreditation visiting team's report?

#6. Replace a nation of variable-quality teachers with online top teachers. The nation has, for example, 30,000 high school math teachers, some magnificent, most not. Why not have ten of the nation's best teachers team-teach courses on video, available on the Internet, with local paraprofessionals or even teachers on site to answer student questions and provide the human touch. That would enable every child, rich and poor, urban and rural, to be taught by a dream team of teachers.

Of course, the reason that hasn't happened is that the teachers' unions have used their mammoth political clout to quash such proposals. Perhaps movies like Waiting for Superman will start to awaken the public that the teachers' unions are children's enemy.

#5. Create an Assistance Army. This would solve the employment crisis while improving America's quality of life. The government should fund a series of public service announcements encouraging people to hire a tutor for their children, personal assistant for themselves, and companion for their elderly relatives. Encouraging that Assistance Army would create millions of ethical, society-improving, widely doable jobs with minimal expenditure of our tax dollars, unlike with government-created jobs.

#4. Replace the media as brainwasher with the media as fair informer. Much wisdom resides left of center but much also exists right of center. Yet, except in the increasingly marginalized Fox News, the largest mindshare, especially among the influential class, is held by liberal media outlets: for example, CNN, New York Times, the TV networks, even Google searches, which on sociopolitical topics, in my experience, generate heavily liberal results, unlike the results of Yahoo! searches, which seem more even-handed.

The media has enormous power to affect our thinking and in turn, public policy. Not long ago, most members of the media felt a near-sacred obligation to present the full range of intelligent views on an issue or candidate. Today, with their professors' encouragement, most journalists consciously or unconsciously manipulate their audience into believing what they believe. And what they believe is overwhelmingly liberal thought because most journalists, like professors, have opted out of the real world and thus have been exposed mainly to the leftist thought hegemonic in universities and especially in prestigious journalism schools. Journalism schools should encourage their students to pull on ropes of restraint and make all efforts to fairly present intelligent perspectives from both right and left of center.

#3. Replace legal advocates with legal fact finders. In our legal system, two advocates devote their considerable intelligence and energy not to getting to the truth but to getting their side to win. That means that the side with the better lawyer has an unfair advantage. I believe that greater justice would be served if, as in the European Court of Justice, along with the judge, the two attorneys were charged with getting to the truth, not advocating, a priori, for one side.

#2. Embrace behavioral genetics. Real solutions to social problems require us to acknowledge that they have both environmental and genetic roots. Just as a VW Bug cannot run like a Ferrari no matter how well tuned-up, a person won't behave intelligently and responsibly unless both genes and environment are sound. Every mother of two or more children knows that each child emerged at birth with a distinctive, enduring personality: No matter how much effort parent and schools make, laconic infants rarely become high-energy, retarded toddlers rarely become intelligent, hyperactive children rarely become laid-back adults.

So we must not reflexively reject genetically oriented approaches to reducing social problems. We tend to viscerally reject such approaches because they evoke comparisons with the horrific Nazis' attempts to create a master race. But there's an infinite difference between the Nazis, who wanted to kill all non-Aryans, and a society that would, for example, attempt to reduce teen pregnancy by making available in schools not only comprehensive sex education but abortion and birth control, including new implantables such as the easily-insertable/removable five-year-lasting Jadelle.

We should even consider, fair-mindedly, the wisdom of funding research that would give parents the uncoerced option, subsidized for the poor, to ensure that their children be born without strikes against them: with high cognitive ability, immunity to cancer, and even perhaps the ability to love.

#1. Legislators must steward our tax dollars as carefully as their own. As every triage medic knows, we must prioritize investing our resources not in those with the greatest deficit but in those with the greatest potential to benefit. Yet we often don't. For example, our hearts reach out to children who are most at-risk, those with the biggest deficit: special education children, inner-city kids, etc. So we've reallocated huge percentages of education spending from the now-eviscerated programs for gifted kids to the lowest achievers. We've spent literally trillions of dollars in a failed attempt to reduce the achievement gap: everything from Early Start to Head Start, No Child Left Behind to dropout prevention, adult literacy to job retraining programs.

Perhaps the most blatant example of poor stewardship of our tax dollars and of our freedoms is that government is making ever more massive efforts to attempt to cool the planet with insufficient analysis of the likely extent of benefit, the opportunity costs, etc. Environmentalism has moved beyond science to religion.

If legislators and policy makers were investing their own money, I predict they'd invest differently.

I welcome your comments.

A Good Question About ObamaCare

My wife forwarded this to me.

Let me get this straight . . . .

We're going to be "gifted" with a health care
plan we are forced to purchase and
fined if we don't,

which purportedly covers at least
ten million more people,
without adding a single new doctor,
but provides for 16,000 new IRS agents,

written by a committee whose chairman
says he doesn't understand it,

passed by a Congress that didn't read it but
exempted themselves from it,

and signed by a President who smokes,

with funding administered by a treasury chief who
didn't pay his taxes,

for which we'll be taxed for four years before any
benefits take effect,

by a government which has
already bankrupted Social Security and Medicare,

all to be overseen by a surgeon general
who is obese,

and financed by a country that's broke!

'What could
possibly go wrong?'

FreedomCare: How I'd Do Health Care Reform

I believe that the following simple plan would be infinitely more helpful to patients than ObamaCare and challenge you to make a legitimate case why I'm wrong:

1. Per the post I just wrote, make health care provider training shorter and more practical. That would improve quality while reducing cost and increasing supply of providers.

2. Except for the truly indigent and for catastrophic health care, health care would be paid directly by the consumer. If consumers had most of the money at stake, 300 million Americans would be exerting the power of the invisible free hand of the market to drive down costs and improve quality. The good quality, cost-effective providers would succeed, the bad ones driven out of business.

3. To ensure that those consumers had the information needed to make smart choices of health care providers and procedures, there would be outstanding, easily accessible consumer information on all licensed doctors, nurses, hospitals, etc: for example, patient satisfaction (disaggregated by condition,) the provider's risk-adjusted success rates for different procedures, etc.

So what do you think of this plan?

Doctor, Dentist, Nurse Training Should Be Shorter, More Practical

Training for health care providers is long and arduous...and unnecessary. I've spoken with many top health care providers (including top doctors at UCSF) and many admit that they'd be better trained in far less time if instead of the endless theory- and arcana-filled program, all that was required was a one to two year program in diagnosis and treatment of the most common situations, training in how to use medical information software to help with non-standard situations, plus guidance, of course, on when to seek help from a specialist.

That approach to training would not only be less expensive, time consuming, and painful, it would also increase the number of providers. That would lower their salaries and in turn our health care costs. It would also help accommodate the large number of additional people who will be getting health care under ObamaCare.

Why did the status quo of absurdly long, arduous training come into being? Do health care trainers let alone their students really believe, for example, that a physician needs organic chemistry, calculus, physics, four years of extremely demanding medical school, 100-hour-per-week internships, plus two-to-four-year residencies? The reasons for the unnecessarily demanding programs are:

• Universities like the tuition that come from longer training programs
  
• The programs are developed by university professors, an anomalous group of people who just love academic learning, arcana, and learning for learning's sake. So they believe, for example, that it would be nice for registered nurses to take a year of inorganic chemistry.
  
• The professional associations for doctors, nurses, dentists, physical therapists, etc., favor longer training because their profession obtains more prestige. And any added requirements don't apply to existing members--they get grandfathered in, so those associations' leaders, who make the decision to require the additional training, reap the prestige benefits without having to put in any more work.

I've written other pieces asserting that higher education is America's most overrated product. This is merely one more example.

A Demonstration of Twitter's Power

One reason I'm blogging less is that I'm tweeting more. I'm finding that for many ideas, Twitter's 140-character limit results in my offering more help per my minute of my work and per minute of the reader's time.

Here are my 90 tweets. It should take you about 10 minutes to read them all. I believe you'll find that a rewarding use of ten minutes. Let me know if you agree.

If you do find my tweets useful, just click on the "Follow me on Twitter" button near the top of this blog and you'll get all my subsequent ones.

Solve doc/dentist/nurse shortage while improving quality: Replace long, abstract-science-based training with a short practical program.

The right health care reform: consumers have the most skin in the game, their choices abetted by excellent, accessible consumer info.

First it was storefront, then truck, now cart. Next? Backpack. e.g., In high-foot-traffic area, wear cute cap w. dozens in your pack.

Looking for a college? A commnty coll honors pgrm may be THE wisest choice--even if you're rich and kid is Ivy-level. http://bit.ly/a4quVF

Career coaches & counselors must often go beyond career: Help clients craft a life: esp. relationships, avocations & developing perspective.

Worried? Feeling sorry for yourself? Fill your time helping others and otherwise being productive.

In selecting an employee, these things count far more than experience and knowledge: intelligence, drive, ethics, kindness, and being low-maintenance.

The Repub. win reflects not just anger at big govt but voters resisting the media's efforts to manipulate them into voting Dem.

Do not begin a note with, "My name is XXX." That makes a terrible first impression because it's redundant with your signature line.

Meg Whitman would have won if instead of spending her $140M on ads etc., she donated it to charity. She'd have won while being a hero.

There's no good answer to how to increase US jobs when avg US income is 50K + generous benes & protections while the worldwide average is 1K.

Tip for establishing eye contact: What's his eye color? Does her eye area look kind or mean--eyes are a window to one's soul.

Many colleges market themselves as unscrupulously as a sleazy business might: http://bit.ly/aZl8YO.

Odd coincidence that the Giants representing the U.S's most liberal city beat George Bush's Texas Rangers on election eve. An omen? ;-)

Are you cut out for self-empl? 1. Would you sell and sell well? 2. Are you a self-starter? 3. Have the knack of buying low, selling high?

When setting a phone interview, have the person call you--that makes him feel he/s pursuing you. You'll more likely get what you want.

Want to be a better speaker? I used to tout Toastmasters but I'm now more impressed with Speaking Circles: http://bit.ly/cXfZRI

Love is feeling good when you're just sitting next to a loved one. My doggie, Einstein, is sleeping next to me at my desk now. I feel love.

Before prepping for a job interview, put yourself in that employer's shoes, "Would you hire you for that job?"

When it's out of your control, let it go. Let the river run, my friend.

Try pitching yourself to a RELATED field: For example, higher ed. reporters quote me because I'm a career counselor not another professor.

I've been watching many candidates on C-Span and I'm finding, in general, the Republicans vaguer and less direct.

How to get promoted even in this market? "Think two steps ahead of your boss and give her what she needs." Maya Mavjee, prez, Crown Publ.

Sign of the times: I've heard this so often: "I'm thankful to have any job." Scary.

It seems EVERY field is hypercompetitive. Ex: A guy wanted to make promo videos for realtors. Alas, many already do it well and cheaply.

Good Google-searching can make you more expert about your situation than are most experts.

Obama's racial policies are getting ever crazier and more unfair to Asians and whites: http://bit.ly/aRsylG

Be kind where possible, tough where necessary. It all comes down to that.

Would we have better political leaders if they were selected by a panel of 20 for-profit, non-profit & govt leaders plus random citizens?

Bringing a drug to market costs average $1.2 billion--FDA requires 3 truckloads of docs collected over 12 years.

Most older people don't mind a young boss. They mind a young boss who's inferior and thinks s/he's superior.

I've noticed that drivers of status cars (e.g., BMW, Jag, MB) are more likely to be mean to other drivers--e.g., won't let them into lane.

Language matters. That's why, for example, Dems changed "liberal" to "progressive." The liberal media picked it right up.

To uncover what's wrong with an organization, ask employees; "What's bothering you?" It can also be a good Q to ask of anyone.

Career counselors act as if IQ & its proxies SAT/GRE, etc don't matter. They think "Just merge skills, interests, values." Wrong.

Voting is the ultimate crowd-sourcing but it is near-impossible to be a fairly informed, not brainwashed voter.The media is so liberal-biased..

Glut of degree holders. Now, 17M w. B.A. are janitors, car parkers, waiters. 5,000 janitors with PhD. .http://bit.ly/aZEluG

Why should anyone be paid more than anyone else? Their success is largely preordained by their genetics, parenting, and birthplace.

I've been working with some constrained people. Encouraging them to sing unconstrained is making them live less constrained.

Better than franchising: Talk to non-local bizes top-rated on Yelp, etc. Merge their best ideas. Use the best as your consultant.

Don't let ego or embarrassment keep you from asking your network for help landing a job (or anything else) These are tough times.

Key: Publicly funded campgns w. only a debate, simulation (run a meeting on key issue,) & a doc w record & platform. http://bit.ly/bNxLu3

You can't be honest re race/ethn. e.g., NPR's Juan Williams got fired for saying he feels nervous on seeing full-garb Muslim get on plane.

Would we elect better leaders if we banned political TV and radio commercials?

Classes have bad ROI. Screaming need for online ed filled w must-have content, immersively, interactively guided by transformational tchs.

New use of offshoring: Even many large accounting firms outsource U.S. tax return preparation to India--at 80% savings.

My goal when writing how-to: Maximum fresh, valuable ideas per minute of the reader's time.

Mortgage paperwork "scandal?" No/minimal wrong foreclosures yet Obama + 49 AGs investigating--poor use of taxpayer $. It's all politics.

Teach for America tch: "I'm tired of dealing w soiled pants, burning garbage cans, and yard fights. Their problems are too big for me."

Interesting how the term "hoodlum" changed to "disadvantaged" and now "underresourced." It mirrors our externalizing responsibility.

Think twice before saying no. Is there any way you could twist it around so you could say yes?

When employed, it's worth building a network. When unemp, It takes too long to turn strangers into source of good job.http://bit.ly/96HASB

Good way to identify your ideal target job: list your job non-negotiables and your "nice-to-haves."

Phillip Roth: "It's hard to give up what you've been doing for 55 yrs...I'm kind of a maniac. How could a maniac give up what he does?"

I have many physician clients. That has led me to believe, alas, that many docs prioritize making money over quality of care.

Do you find that Google search results on sociopolitical topics are biased toward liberal perspectives? I do.

League of Women Voters used to be a neutral. Now, I got calls from them advocating CA props. and they funded a biased voter "info" site.

Job seekers: Don't overdress for interviews. It makes you look like you're selling, and no one wants to be sold. Ask what's appropriate.

Linkup.com, which aggregates job listing from individual employers' sites, now includes federal job openings from 341 divisions!

Cold contact is not working. http://bit.ly/ab1St4

DC schools spend 30K per kid, #1 in world + SuperSupt Rhee yet st. ach. is worst. Tch unions are everywhere, so that's not it. What IS it?

Write one charming note per week: to a friend, coworker, client, employer. Even if it yields nothing, it contributes to a kinder society.

Today, the norm is to not respond to queries. A polite, quick, no is so much more humane.

An anesthesiologist told me he started using drugs to cope with a romantic breakup. Sometimes I wonder whether relationships are worth it.

I don't know if it's just the Bay Area but here, many people take offense so easily. The culture of offense-taking offends me. ;-)

Twitter's turning out to be a way to archive my ideas. And I use my week's tweets on my radio shows.http://bit.ly/cFc0rz

If the govt provided NO safety net, would the private sector step up and provide a better one or worse one? I dunno.

When I was young, I was sure that giving good advice, even if unwanted, was wise. I'm not so sure anymore.

They say "Outsource your low-level work" but I clean my house. That offers exercise, tangible accomplishment, break from the intellectual.

When you wake each morning, you have a choice of mindsets: gird for battle or enjoy each moment. Which you choose makes all the difference

Good counselor Qs: Your best hope? What diff. would that make? What's already helping? What would be the next sign of progress?

The best artists are self-taught. Teachers make you mechanistic and/or follow the teacher's preferences--all disempowering.

Esp. when applying for a high-level job, writing a thank-you can make you seem obsequious. Perhaps don't.

Cool avocation for sports nuts: Announcer for kids' sports league. How fun for a kid to hear his/her name over loudspeaker.

How to be a good salesperson: Listen more than talk. When you explain the product, pretend you're talking to a 6th grader.

Hire teachers who are NOT a natural: http://bit.ly/b3SA2H

My blueprint for a breakthrough, reinvented general education curriculum. http://bit.ly/dfoJNK. Feedback welcome.

HOW you receive a businesscard can make all the difference: #businesscardetiquette http://bit.ly/9X0Coq

Cool career: book packager: come up with title, angle, structure (table of contents,) look and feel, marketing.

Biz idea: organic perfume. http://bit.ly/aK7v9c

Choosing a career is like choosing a college. It matters far more whether you make the most of it than which one you choose.

Unlike say MD, most careers don't have obvious labels. To find em: search indeed.com using skills you want to use.

Mainstream media can only thrive if providing rich multimedia content. Otherwise, bloggers, tweeters, etc will trump. http://bit.ly/aIUEjU

Obama technique: He holds his chin up. It appears authoritative.

Obama's fatal flaw: insistence that major taxpayer $$$ to have govt rejigger, regulate, and prohibit, will be a net good

A fad: "Making a Difference." See my blog post: http://martynemko.blogspot.com/2010/09/fad-making-difference.html

Keys to landingajob today: walk in, usajobs.gov, write a White Paper, start a low-risk biz (e.g., an gourmet sandwich/salad cart, then clone it)

Again, if you found these tweets worth your time, just click on the "Follow Me on Twitter" button near the top of this blog and you can get my subsequent tweets as soon as I post them.

Will Health Care Reform Kill You?

The H1N1 flu non-crisis is long over--just in time for the government to roll out a massive "get vaccinated" campaign. Until now nothing, but in the last week, I've seen countless "Get Vaccinated" ads and billboards.

And when you or someone you love has a heart attack, stroke, etc., you're going to trust a heavily government-regulated, incomprehensibly complicated system with tens of millions of patients not paying into the system, to save your life?

The ObamaCare Questions I'd Ask at a Town Hall Meeting

President Obama, you've said, again and again, that ObamaCare would not cover illegals. Yet ObamaCare has no money allocated to verifying that a patient is a legal resident of the U.S.

And to the extent illegals wouldn't be covered under ObamaCare, you have repeatedly said you plan to make all illegals legal: the so-called "path to citizenship." So won't all these 13 to 20 million illegals become legal and thus covered under ObamaCare?

And is that fair? Today, every year(!), medical errors result in more than 100,000 deaths and hundreds of thousands of additional people who stay sicker or get sick because of those errors.

Indeed, two months ago, a dear friend, a healthy 54-year-old woman, went in for routine surgery and came out a near-vegetable--the surgeon nicked a critical blood vessel.

With the same number of doctors, nurses, MRI machines, and operating rooms, ObamaCare will attempt to provide health care for 47,000,000 additional people--a group with high health care needs and low ability to pay. Thus, many more medical errors will occur and so, many legal residents who took care of their health and paid into the system will die, get sicker, or stay sicker because you, Mr. President, are forcing us to share our health care with a cohort of 47,000,000 high-use people, whether they are legal or not, whether they pay or not.

I ask you, Mr. President, what would you say to those countless people who unnecessarily will get sick, or to the family members of those who die because you decided to provide health care without regard to people's legality or whether they paid their fair share?

Isn't it fairer to have a basic public plan for the poor and a much higher-quality plan for those who pay into the system? Isn't it unfair to make legal residents pay for illegals, thereby endangering those legal residents' lives?

And a final question: Do you really think that ultimately, we will have a more just country, a better life for our residents, when you force the responsible taxpayer to reward the lawbreakers (the illegals) the wild-risk-takers (people who borrowed beyond their means and the banks that lent to them) and the incompetent (the US car makers)?

Economic Armageddon, Here We Come?

The Obama administration admitted today that the federal debt will, over the next decade, grow wildly larger than it had previously said--so much for a recovery. Now the estimate is $9 trillion!

And that doesn't count the $1.0 to $1.6 trillion Congress is contemplating spending on ObamaCare.

Nor does it count the massive additional new spending Obama has promised, for example, legalizing the 13-20 million illegals, who will thereby become eligible for ObamaCare, increasing the debt further.

And Obama is considering "Stimulus" 3. For our trillion dollars, "Stimuli/Bailouts" 1 and 2 have resulted in the highest unemployment rate since 1983 and wildly accelerating debt, yet he contemplates Grandson of "Stimulus"/Bailout.

China owns ever more of America and the U.S. is becoming ever less creditworthy. Just the interest on the national debt is approaching the total budget for national defense!

And federal spending is accelerating?! Will we, not to mention our children and grandchildren, suffer profoundly from our government's profligacy?

Government programs (yes, Republican-initiated programs, for example, the Bush bailouts and the Iraq War, are equally at fault) are usually terribly inefficient. Think Amtrak, the Postal Service, the public schools, the nearly bankrupt Social Security and Medicare, the Bailouts, $85 hammers, the Bridge to Nowhere.

Many government programs are actually negative in effect. Consider, for example, Cash for Clunkers: dangling taxpayer dollars in front of people poor enough to own bad-gas mileage clunkers so they can go deeply in debt to buy a new car (80% of which have been foreign, by the way). And of course, dumping much of their toxic components and fluids into landfills is an environmental disaster. Plus, car dealers are screaming that they have laid out the $4,500 per car to customers and often have not yet been paid by the government, thereby killing their cash flow, a business's lifeblood. The government can't even write a promised check in a timely manner and it wants to run a "public option" health care system?

An individual and especially a nation in debt is at-risk. A nation that has assumed unprecedentedly, incomprehensibly mammoth debt is doomed. Even Keynes did not imagine this magnitude of government spending. To pay for its metastasizing number and scope of programs and interest on its soon-to-be $9 trillion debt, the government will, unchecked, continue to raise taxes and print ever more money, thereby decreasing the value of our life's savings and purchasing power.

As a result, American workers will likely end up joining most of the world's workers in earning a net $1 an hour. As reported in a recent blog post, we already work into August just to pay all the costs imposed by government. Does anyone really think we get fair value for the government's taking over half our money from us each year?

Our only savior is for us to demand that the government to return most our tax dollars to us and for government to live within its then more modest means: scale down so it can balance its budget and pay down its debt. Anything else is too likely to lead us to economic Armageddon.

A Modest Health Care Reform Proposal

Most of me thinks that two health care reform options are most worthy:
1. Consumer-paid fee-for service with a spartan government-provided safety net for the poor. OR
2. A single-payer system.

But I met a primary care physician involved in health care reform planning whose views represent a more middle-of-the-road approach that seems a good balance between concern with quality and cost. So I invited him to summarize his key recommendations in 500 words and that if I thought the document was worth your reading, I'd post it.

Here it is. As always, comments are welcome.

Health Care Reform: Viewpoint from a Primary Care Perspective
by Michael Rosenblum, M.D.

There are three essential issues for health care reform in the United States

1) We need a uniform national digital health record--Many errors are made due to illegible handwritten entries in patient records.A majority of prescriptions are still written by hand, and a majority of outpatient medical records are written by hand. We could greatly improve the quality of care, and save a considerable amount of money, by having national standards for digital data entry and making all health care records accessible from any point of care in the nation. There are political barriers to instituting this policy. Proprietary electronic systems would have to yield to uniform national standards. There are concerns about the privacy of patient records. We need to overcome such obstacles and get health care into the digital age.

2) We need to re-emphasize primary care—In the United States we are culturally addicted to the latest technological advances. We spend a disproportionate amount of the health care dollar on the latest laser surgery and the latest high-tech drugs. To provide health care to all citizens, we need to train more primary care doctors like pediatricians and internists and family doctors. The importance of the primary care doctor in providing preventative care, and coordinating the patient’s journey through a complex system, cannot be overemphasized. Insurance reimbursement needs to be increased for primary care, and decreased for specialists if we are to achieve this goal.

3) We need to fix Medicare and Medicaid before establishing costly new federal programs—The Medicare “trust fund” is on the verge of insolvency. Medicaid (MediCal in California) reimburses doctors and hospitals typically at 20-30% of the current market rate, resulting in poor access for patients. Both of these programs need to repaired and reinvigorated. Fortunately, this can be achieved without creating vast new federal agencies and hiring hundreds of thousands of new federal employees, as would be needed for the new programs proposed by the administration and Congress. The infrastructure for these programs has been in place since the 1960s. We merely need to fund them and they can reach their full potential. For example, Medicaid could be made available to uninsured adults up with incomes up to 400% of the Federal Poverty Level, rather than the current 125%, to make a large proportion of currently uninsured adults eligible. There are huge political barriers to reforming Medicaid. For example, Medicaid uses a formulary of generic drugs, and there would be strong opposition from the pharmaceutical industry to increasing funding for this program. Funding for Medicaid is partly from the states, and they are pushing back on any increase in the program that would require them to fund more health care. Clearly, the federal government will have to shoulder the fiscal burden of Medicaid expansion, but this is cheap by comparison to setting up a whole new program.

The Unspoken Key Issue re Health Care Reform

The medical establishment already kills over 100,000 people every year as the result of medical errors. Countless more people stay sick longer or get sicker because of such errors. For example, someone just told me that because of an error in surgery, he became blind.

Under President Obama's health care proposal, we'll be providing health care for 45 million more people with the same number of doctors, nurses, hospitals, MRI machines, etc. That 45 million has greater-than-average health care needs while having lower average income, and thus will often get low-cost or free health care under the Obama plan. The result will be that even more of the people who do fully pay into the system will stay sicker longer, get sicker, or die.

From where I sit, the answer is a two-tier system: a basic level of care for everyone and a higher level of care for those who pay into the system. Alas, I doubt seriously whether the Democrats could ever support such a plan. Their core principle is that equality trumps merit.

My Plan for Reinventing Health Care

I'm scared. Yes I believe health care is a right but fear that extending that right to all U.S. residents could kill me.

Already, errors by doctors, nurses, etc., kill over 100,000 people a year who shouldn't have died. Countless more get sick or stay sicker longer because of medical errors. Some of that is caused by shortages of health care providers, especially highly qualified ones.

If President Obama keeps his promise to extend health care coverage to the 48,000,000 U.S. residents who don't have health coverage, many more people will become victims of medical errors and all of us will have to wait longer for care, perhaps for inferior care.

My liberal side says all people have the right to health care but my libertarian side says I worked hard so I could afford to pay the many thousands of dollars in health care premiums in hopes of living longer and healthier. So why should I be forced to pay even more tax dollars to subsidize 48,000,000 people getting health insurance, including 13,000,000 illegal immigrants, and millions of others who took welfare instead of a job or refused to delay gratification and took a part-time and/or low-paying job rather than getting a degree and then a full-time professional job so they could afford health insurance? Worse, my paying for them to get coverage will mean that I am at greater risk of morbidity and mortality because of medical errors and long waits, for example, for an MRI exam or to see a specialist.

There's no perfect answer but if President Obama asked me (fat chance) to propose the ideal approach to reinventing health care in the U.S., here's what I'd propose:

1. Here's how I'd address the shortage of health care providers that would result from providing health care to all. Currently, training programs are unnecessarily long and expensive, largely because they're provided by university faculty, who want to teach their academic specialties (chemistry, calculus, etc.) Many a potentially good health care provider has been lost to the profession because of the training's unnecessary length and difficulty. Training should be shorter and based in hospitals, doctors' offices, homes, and other medical facilities, supplemented by a few courses taught at community colleges.

2. Everyone would, as a right of being human, get a basic-level single-payer health care--no paperwork required, no questions asked. "Basic-level" means, for example, that everyone would get exams and routine care not by a physician but by a physician assistant not of their choice,. They'd be entitled to receive cost-effective treatments administered by health care providers not of their choice. Wait times for non-emergency care would be moderate to long. That safety net of basic national health care would be funded as a surcharge on income tax--That would ensure progressivity.

2a. Individuals could purchase a higher level of health care on a fee-for-service basis or with private insurance. Those people could choose their doctor and other health care provider, have shorter wait times, and obtain less cost-effective treatments for example, an 80-year old who'd prefer bypass surgery over treatment with drugs.

3a. People with preexisting conditions would pay the same insurance premium as those without--It is wrong that a person already suffering with a condition should have to suffer additionally by having to pay more. However, insurance companies could add a surcharge for smokers and for people who abuse drugs or alcohol.

4. Health care providers would be incented to focus on primary prevention: weight, smoking/alcohol/drug prevention and cessation, teen pregnancy prevention. They would also be incented to focus on secondary prevention, for example, having medical assistants call patients to ensure they're taking their medication.

5. Health care providers would be paid a salary rather than piecework so there's no incentive to overtreat.

5a. Tort reform would limit physician liability, which would also reduce the expensive overtreatment and defensive medicine that is widespread.

6. Electronic medical records should yield improved medical care at lower cost. A patient's information, diagnoses, treatment, and outcomes are entered into a computer, using nationally adopted software. The results are aggregated anonymously, which provides health care providers with evidence-based data on the meaning of symptom clusters and on what treatments work best and most cost-effectively for what diagnoses. Of course, electronic medical records also benefit individual patients: records are readable (no physician scrawl) and instantly transferable to other health care providers. Patients would have access to efficacy data on individual health care providers, hospitals, and treatments--crucial to making informed choices.

Do you like my plan? Have a suggestion for improving it? Care to propose a totally different approach?

Canada's Single-Payer Health Care is Nothing to Emulate

Obama, before running for president, when he could be more candid, favored a Canadian-style single-payer, government-run health care system. Now, he's pulled back--at least until he's elected.

He might want to check on how the Canadian system is working. A new article reports that the chair of the committee that created Canada's single-payer system now says that the system has such serious deficiencies that no rationing of care or mass infusion of tax dollars can solve the problem. He now advocates replacing the system with a private one in which people have more choice. Another article presents another of those nightmare anecdotes in which a patient reports that the Canadian system is so overwhelmed that she couldn't get off the months-long waiting list even though she was losing her sight. And the average wait time to see a specialist is 18 weeks.

And that's in a country that is much easier to provide health care for than the U.S., which has many millions of new immigrants with extraordinary health care needs but with little money to pay into the system.

The Deadly Downsides of Insuring Everyone

The soundbite "Health Insurance for All" generates widespread assent. But like most bumper-sticker rhetoric, closer analysis is required. Let me ask you a question:

It's well-acknowledged that the U.S. health care system is creaking under its weight. For example, over 120,000 people die annually as the result of healthcare-practitioner errors. Now, what do you think will happen when we ask our health care providers to add 47 million uninsured to their patient rolls, a group that has above-average health care needs but pays little taxes and will likely pay little into the new government-mandated system that will almost assuredly be enacted under a Democrat presidency?

Not only will more deaths result, but there will be long waits for health care, and refusal to provide care in such gray-area situations as a 75-year old male needing and wanting bypass surgery. Lest you think I'm making that assertion based only on the well-publicized nightmare experiences of some people in Canada who, for example, desperately needed surgery but couldn't get it, let me refer you to the U.S.'s current experiment in covering everyone: Massachusetts. And lest you think my source of information about the Massachusetts insurance-for-all system is some conservative rag, my source is the New York Times.

I do believe that basic health care is a right, but we cannot provide it for the whole world, including the 13 million and skyrocketing number of illegal immigrants. (And once we do, the number of illegal immigrants will accelerate further.) However we decide to reform health care, it is only right that there be tiers: basic health care for all, but, for moderate cost, other people should be covered for a wider range of procedures, allowed to choose their health care providers, and have faster access to them.

To increase the number of qualified health care providers, we need to realize that doctor, nurse, and allied-health practitioner training programs (currently designed primarily by academics rather than by top clinicians) can be significantly shortened with minimal impact on patient care. In fact, if those training programs were developed and taught by top clinicians instead of by academics, I'd predict that care quality would actually improve.