Monday, March 22, 2010

so, health care reform

I've been staying away from this for a while because it's just such a divisive topic around these parts that I felt the better part of valor would be just to keep my head down and thoughts to myself. I would probably feel differently if I still lived in Manhattan (aka Liberal World *) but the fact of it is that I work in Georgia where I often feel that my political views are in the minority and thus in the interest of fitting in and not getting into crazy scream fights with people, I'd best just go about doing my job without the political side-conversation. But then the health care reform bill passed yesterday, and I've been writing this blog entry in my head all night. So here it is, apologies if it's rough, but this is not a multiple-draft proofread missive, I'm just spooling it out here.

The healthcare system needs reform, and I cheer the passing of the bill. There is tons that I could talk about, see here for more wonkish details (I am not the expert on this topic by any means, nor do I pretend to be), but the reason I stand behind the idea of healthcare reform is a simple philosophy, perhaps too jejune for most, is this idea: "The essence of civilization is that the strong have a duty to protect the weak." ** (In fact, I think that's part of what I was trying to say about the issue of vaccinating, which brings up very similarly contentious issues about personal freedoms and taking responsibility for others--not to stir that pot again.) "The essence of civilization is that the strong have a duty to protect the weak." Do I believe that? Yes I do. Working in medicine, this is a version of what we do every day.

This bill affects me personally, of course, though not in the same was as many people. For instance, I have health insurance. I make an income above what would qualify me for the expanded Medicare benefits proposed. In many ways, the passage of this bill into law will be detrimental to me personally, at least when it comes to my bottom line. When Joe starts making his attending salary and adds to our household income, our taxes will go up quite a bit. Decreased compensation for the work that I do under the Medicare reimbursement scale will mean that I make less money. (Anesthesia practice as whole is particularly vulnerable to this beyond most other specialties, see: "The 33% problem." For more, read this or other memos from the president of the ASA.) As the most junior member of a private practice anesthesia group, do I worry that such financial implications could endanger the very fact of my job? Yes, I do. I have two young kids at home, how could I not worry about it?

But--and again, I can feel that this is going to come off as irrepressibly naive, but to hell with it, as a young doctor, don't I deserve to play Pollyanna for a little bit longer?--there are bigger issues at play here. The world is bigger than just me and my family. Or even from a more selfish standpoint: it could be me. If there's one thing that Joe's bout with myocarditis this past summer taught me, even more than working with patients all day, is that as young and healthy and invulnerable as we may feel, we are all just one breath away from catastrophe. And if catastrophe landed in my front yard, wouldn't I be glad to live in a society that didn't just champion the notion of "every man for himself"? The essence of civilization is that the strong have a duty to protect the weak. Call it socialism, call it communism, whatever you like. I may be strong now, but I know that could all change at any point, and it gives me comfort to know that if and when it does, this is not a society that will turn its back on me.

Do I have reservations about parts of the bill? Of course I do, it's far from perfect. In particular, I am very nervous about any move towards cost-containment in healthcare (and of course it is undeniable that healthcare costs are, everyone's favorite verb, "skyrocketing") without addressing the incredible cost of practicing defensive medicine. The cost of malpractice insurance, performing procedures that tests that in all honesty do not need to be performed, the Cover Your Ass style of defensive medicine, all because anyone who has ever watched any form of daytime television can tell you that there are hoardes of slavering law firms out there ready and willing to sue your doctor for any old thing.

I am nervous about the prospect of undervaluing the work and expertise of doctors in the name of cost-containment, and the judgments made that paraprofessionals of all stripes can readily step into the roles that doctors once occupied for the simple fact that mid-level providers are cheaper. I don't like the idea that non-medical people may be making judgments on the importance or value of certain aspects of care, and I don't like the idea that hospitals and doctors may be penalized (general practitioners nonwithstanding) and devalued while being expected to accommodate the huge influx of sicker patients that this new law may avail of healthcare. And, of course, the size of federal deficit makes me nervous. I didn't even get a credit card until halfway through med school, because the idea of debt made me so uneasy. So there's that, too.

From a more detached point of view, though, it's really an interesting time to be starting out in my medical practice. Watching some of my more senior colleagues reacting to these imminent changes, part of me is glad that, as a rookie who just stepped into the ring, all I really know is how to do my job. (And even that, at times, is questionable. Kidding! Sort of.) But seriously, there are obviously going to be changes coming down the pike. What these changes will be and how they impact our lives remains to be seen, but I'll be here, and I guess we'll all figure it out together.

So the bill. It's not perfect. I don't love everything about it. But societally, it's a huge first step, and overall a good one. Not everyone agrees with me, particularly in this neck of the woods, but that's OK, we can disagree and listen and try to convince each other and then talk about it some more. And in the end, isn't that one of the key things about living in a democracy?

* "Don't you see the rest of the country looks upon New York like we're left-wing, communist, Jewish, homosexual pornographers? I think of us that way sometimes and I live here." -- Woody Allen, in Annie Hall

** This quote was taken from a speech by George W. Bush. Yes, you read that right. Of course, he was talking about something else, but still, the sentiment is generalizable.


  1. Overall I agree with you. This being said as a formerly more conservative Republican.

    I'll interpret your use of "paraprofessional" in not a pejorative way when describing PAs and NPs.

  2. Not pejorative, means someone who assists (as in a Physician Assistant).

  3. Anonymous1:13 PM

    I think it's awesome to help those who can't afford health care to receive it. However, it seems like the real issue here isn't poverty, it's the obscene cost of health care and health insurance in this country. Where is all the money going? The insurance companies are getting rich, the lawyers are getting rich... the only people not getting rich are those actually giving and receiving the health care, the doctors and patients.

    This is going to be an endless cycle until we address the root cause. We can't just throw money at the problem with premiums increasing 30-40% a year.

  4. I really don't mean to be overly sensitive or digress from the point of the entry (which was excellent), but I would be doing an injustice to my profession not to say something.

    paraprofessional: (n) nonprofessional helping with professional work: a trained assistant to a professional person

    A Physician Assistant, although the word assistant is in the title, is not an actual assistant. I'm not getting a masters degree to be considered a nonprofessional assistant. A medical assistant is an actual assistant. PAs have medical licenses to practice medicine. It is the role of the PA to provide medical care to their patients and consult/refer to physicians as needed. I understand that as an anesthesiologist you mainly see surgical PAs in the OR, where the assistant side of the profession seems more obvious than the provider aspect. The original name of the profession was Physician Associate until the AMA threw a fit.

    I just wanted to clarify the very common misconception. The public needs to have an accurate view of what the profession is if the PA profession is to be as effective as possible.

    Love you!

  5. I agree, cost-containment can't just be simplified to "just pay the doctors and hospitals less." If reimbursements go down while malpractice premiums keep going up, the practice of medicine will not be sustainable.

  6. Anonymous4:20 PM

    Michelle, There's a reason I've read your blog for six years. You write with grace and humor and intelligence about so many things. Thank you.

  7. Higher taxes -- BOOOOO!!!!

    But hey, if people can actually get insurance (and thus not be made destitute by one hospitalization) if they are a) unemployed, b) self employed, or c) have been sick ever before in their lives, I think it's a step in the right direction.

    Yes, we do need to address cost-containment issues, tort reform, etc. But this was a good place to start.

    I'm a) excited to see how it all pans out, b) terrified as to what it will do to my future salary as a doctor (but I was planning on doing something low paying anyway), and c) a little worried about my future taxes. But overall I think it was the right thing to do.

  8. As a medical student considering applying for residency in the US, I'm quite interested to know what effect political decisions have on actual practice. I have lived my whole life in a country which has very good (and affordable) universal health care (even if it is at times a bit bureaucratic), and find it hard to imagine not having such a service. I'm glad the bill passed and agree with the 'good first step' sentiment. I can't wait to read about the consequences.

  9. Anonymous5:37 PM

    Thank you, thank you. Like you, I personally will not benefit from this bill but I do support it because I believe that, as MLK jr said "Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane". I agree with you that it is FAR from perfect, but it does give me some hope that, if I were to lose my job, my family would be able to find insurance -- one of my sons has preexisting conditions including being born with a congenital heart defect and having epilepsy and my husband is a small business owner. Now they can't use his preexisting condition as a reason to deny insurance to our family.
    I actually believe that we have to pay doctors higher salaries -- particularly family practitioners. In San Francisco, it is almost impossible for a GP to make a living wage, especially when student loans are thrown into the equation. So, in 7 years, I've gone through 7 GPs (they've either moved or gone into conceirge care, a model I don't support) and I currently, once again, have no primary care doc.

  10. Anonymous7:56 PM

    Thanks for posting this (and for your blog)...I totally agree. The bill is far from perfect, but it's a start. You should be able to afford/obtain healthcare, even if you already have an illness (gasp!), lose your job...

  11. "I don't like the idea that hospitals and doctors may be penalized (general practitioners nonwithstanding) and devalued while being expected to accommodate the huge influx of sicker patients that this new law may avail of healthcare."

    I really thought you phrased this thought particularly well in this quote. It's something that concerns me, the devaluing of physicians and their contributions to the overall picture. The abandonment of Medicare patients by many general practitioners, simply because they can't stay afloat financially, is a harbinger of failure in my eyes, particularly if the government intends to further cut Medicare reimbursement. Theoretically, is this supposed to be offset by increases in salaries for PCPs? Similarly, will medical education be heavily subsidized? It certainly needs to be, with a potential $250,000 price tag.

    I agree with the benificence of the bill, and with our commitment to protecting and helping others. I think it reflects this country's best ideals and is commendable how Obama fought so hard to put it into action. I worry, however, about how we achieve that end, and at what cost.

  12. I'm worried for many reasons - I don't support much of this bill as a more conservative person. The decreased (potential) income, the lack of mal-practice reform, the increased taxation, etc scare me silly at times. Though, being in residency will likely make the changes less startling than it will be to those in practice for years and years.

    And I think that Pending PA-S needs to understand that just because he gets a degree from a PA school, that he is not the same or close to a physician. You just aren't - no matter how people try to confuse the topic. There should be physician oversight on all mid-level providers regardless of training. Because you're not a doctor.

  13. Anonymous10:35 PM

    "Not everyone agrees with me, particularly in this neck of the woods, but that's OK, we can disagree and listen and try to convince each other and then talk about it some more. And in the end, isn't that one of the key things about living in a democracy?"

    from an NAACP email I received today:
    "Last Saturday, while Representatives filed through a House office building on their way to watch President Obama deliver a health care speech, some extremist protesters turned vicious. Civil rights legend and Georgia Congressman John Lewis was repeatedly called "ni**er" by the crowd, while fellow Congressional Black Caucus member Emanuel Cleaver was spat on. Longtime NAACP champion and openly gay Representative Barney Frank was called a "fa**ot." This is not only outrageous behavior -- it is un-American.

    Stand with Representatives Cleaver, Lewis and Frank. Sign our Petition today and let it be known these outrageous personal attacks have no place in our nation's political discourse. Saturday's incident is just the latest evidence that a lack of civility is undermining our democratic process. Last August protesters painted a swastika on the district office of Georgia Representative David Scott. Later that fall Congressman Joe Wilson shouted, "You lie," as President Obama delivered a speech before the joint Houses of Congress. These sorts of outbursts serve only to bully our elected officials and undermine our democracy.

    Like many of the hot-button political issues of our day, health care reform has inspired passion in supporters and opponents alike. Indeed, it is this passion that kept us determined to keep fighting for reform, even on the days when it looked like we might not win. While the NAACP respects the passions that inspire political movements of all kinds, we know that when civility breaks down, communities of color are often the first to be hurt.

    Please, join me in signing the civility petition today. Stand alongside Representatives Cleaver, Lewis and Frank, and take a stand for civility in our political discourse.


    Benjamin Todd Jealous
    President and CEO

    I hope people can bring it back down to civil talking. This post ( brings up a good point near the end that hopefully dialogue in the future *will* be more civil, given the track record of other "hot topic" issues (not the latest in teeny-bopper fashion).

  14. I actually laughed out loud.

  15. RAG - I didn't read anywhere in Pending's post that he was, is or is going to be a doctor. From whence does your defensiveness arise? PAs are well aware of their "place" in the health care community - As licensed professionals who provide health care under the supervision of a physician. No one wants to change that. I am excited to go to work with a physician who wants to train and mentor me - that I may provide the best possible care to my patients for years to come. It's a shame there are some who care too much about staking their territory. Let's hope that under the new law, patients can get the care they deserve and providers can continue to make a decent living.

    To clarify:
    I Phooey, hereby acknowledge that I am not a doctor. In fact, I'm not even close. As a physician assistant(in training) my aim is to treat my patients to the current standard of care, continue to grow and learn as a professional and enjoy my time doing so. Anything that distinguishes me from a doctor after that is purely intentional.

  16. I love reading your blog and spent the better part of an hour reading through all the vaccine comments today. I'm with you on your feelings of being in the political minority. I live about two hours north of you in TN, where "liberal" is a bad word. I've wondered what health care professionals thought of this bill, but I haven't found any who wanted to share their thoughts. Thanks for doing that.

  17. Kamala4:20 AM

    I completely agree that this is a good first step-- but the question is, when will we get to the second step?

    I'm glad this bill passed-- something is better than nothing-- but I hope that within the next 10 years the US moves to a single-payer system (unlikely, but I can hope). A public option could have really helped with pursuading people that government-run healthcare can work well.

    I live in a country with universal healthcare, and the thought that the world's richest nation has so far been disinclined to give its citizens access to healthcare (for what frankly seem like ridiculous reasons) is just...well, embarrassing. And while single-payer systems do have their problems, things aren't nearly as bad as Fox News wants people to believe.

  18. Anonymous6:42 AM

    Bravo Michelle!
    and great George W Bush quote (an oxymoron!)

    I'm an Australian GP and must say that I'm fiercely proud that my country offers free health care to all. Not that we don't have our problems (and personally I have private health insurance) but at least we're starting from the right place. Almost no-one goes bankrupt from overwhelming medical costs, they could always switch to public treatment if things got too expensive.
    I'm really glad to see that Obama has managed to get something so downright fair and right passed.

  19. Sigh. Michelle, I am a long time reader/lurker. I admire you and your blog, and I appreciate your sense of noblesse oblige and altruism, truly, I do. Perhaps I could be glad of this bill, too...if only this bill was really about health care at all, but it just isn't. It is all done under the guise of warm and fuzziness..."think of the *children*" and "no pre-existing conditions!" If you would read what is actually in the bill, though, you would know that health care was the last thing about which anyone writing (and passing) this bill was thinking.

    Yes, it is a step...a step away from indivudual freedom and toward large government mandates. It not only threatens our profession, but our entire, American way of life. It tromps solidly on the very tenets upon which we were founded. It isn't about paying a few more taxes so "the poor" can get what they need to survive. I would never say that health care reform was not needed, but this bill...this bill is simply a Trojan horse. Nothing more, nothing less.

  20. Dr. Whoo?- could you be a little more specific? Which parts of the bill threaten our "American way of life"?

  21. RAG. You are a Republican. What a surprise.

  22. Let's keep it civil all up in here! Obviously we don't all agree all the time, but it we did, we wouldn't need votes and representation and government. Instead, we could just all go forth and accomplish things in sync using our giant hive mind. And then a bear would come and eat all our honey.

    But anyway, I definitely understand the different points of view, and I don't think I know anyone in medicine who isn't at least a little uneasy about the bill and what's it's going to mean for us in actual terms.

  23. I agree with all you've said, Michelle, and don't have much to add to it.

    I'd like to briefly respond to the comments about "lawyers making all the money" and the lack of malpractice reform. I am an attorney (on the defense side) and do medmal defense, so I've seen more than my fair share of doctors being sued for malpractice. I've also done research in the area of medmal reform, and I'm here to tell you several things:

    1) not many lawyers are "getting rich" off of medmal cases. The defense lawyers certainly aren't because the insurance companies pay us anywhere between $120 and $150/hr, which is fairly low for attorney compensation. Maybe that burns some of you because it seems high, but the truth is that it's fairly low when compared to what lawyers could be making through privately-funded defense (insurers pay much less than market rate for comparable defense attorneys).

    So you must be referring to plaintiff's counsel then, right? Right. But even plaintiff's attorneys don't make as much as you think. Sure, you hear about the big cases for big bucks (in my neck of the woods, for example, there was recently an $18 Million settlement for medmal involving a doctor's decision to use an inappropriate instrument during a splenectomy on a child). You know what you don't hear about? You don't hear about the more than 50% of cases that receive defense verdicts (meaning no damages and no finding of malpractice). So yes, I know you'd like to vilify all the lawyers as greedy, but the reality is much, much different than your perception of the reality.

    2) The amount paid out in settlements for medmal over the past ten years has decreased by over 50%. Yes, that's right. Of course, you never hear Rush Limbaugh or any of the conservative commentators mentioning this fact (and yes, it's a fact NOT my opinion) because that doesn't fit into their little "tort reform" schema too well.

    Even though I practice on the defense side, I could not be more opposed to tort reform. How would you feel if your child was permanently disabled due a doctor's negligence and hubris and your pain and suffering damages were limited by tort reform? I hope the answer is that you'd feel terrible. We have a type of tort reform in my state, and the end result is that their P&S damages are capped at $250,000, so the Plaintiff's attorney's fee comes out of future medical expenses. Great for the kid, huh?

    I think it's sad that doctors have to practice "defensive medicine." I don't think that tort reform is going to change that fact. In my opinion, what will change it is better communication between doctors and patients, the ability for a doctor to spend more time with a patient, and the revival of actual "doctoring" (rather than just waiting for the tests to do your work for you). And the only way for those things to happen is for insurance companies to not drive healthcare and instruct doctors to spend only 10 or 15 minutes with each patient. When patients feel "heard" and "cared for," they are much less likely to sue their doctors. One way for doctors to prevent malpractice claims is to actually talk to their patients candidly about mistakes that may have been made (always with the advice of the hospital's general counsel, mind you) and to APOLOGIZE if the patient feels wronged.

  24. Michelle,

    RAG was being a jerk pure and simple. I disagree with Dr. Whoo but he expressed his opinion without demeaning people.

    BTW, as someone who writes (and loves words), you need to go back and correct your use of the word "paraprofessional". It simply is the wrong word. Non-physician providers might work, but paraprofessionals no matter how much you used it innocently is demeaning to the professionals that you are referring to. Whether their scope of practice should allow them to provide services traditionally reserved to physicians is a different question. (If lawyers could do surgery then it would be ghastly, but they still would be professionals.)

  25. Interesting, info, Ariella! For sure, real mistakes are made, and real people are injured as a result of what we as doctors do (or do not do, as the case may be), and I agree with you that good communication between doctors and patients is key.

    In response to your info, I wonder how much time and expense is spent in the 50% of cases that you mentioned that receive defense verdicts? I don't know anything about law (outside of having read "To Kill a Mockingbird") but are there just MORE cases being brought to court overall--cases with various degrees of merit (hate to use the word "frivolous")--that, despite being found in the favor of the defense, soak up time and funds and resources nonetheless?

    I am just thinking of all the daytime television "sue your doctor" ads that I see that are the equivalent of "HAVE YOU EVER TAKEN [insert drug] AND HAD [insert known adverse effect of said drug--blood clots with birth control pills, for example]? THEN YOU COULD BE ENTITLED TO COMPENSATION [insert picture of pile of hundred dollar bills]!" I always wonder how many of these cases actually go to litigation and how much time is spent reviewing them. I'm just trying to figure out where all the money is going!

    (Some of my best friends are lawyers, by the way. I know that sounds lame, but I just mean that I have no animus towards the law in general.)

  26. Elliot,

    Fair enough, I had no idea the word "paraprofessional" was so loaded! I guess I meant it in the same was as people say "mid-level provider" or "physician extender," (or "non-physician provider" if you wish) to mean PAs, NPs, CRNAs, AAs, and all the other people that are working alongside me on the team. Thanks for the info!

  27. Anne~ For each of the 2700 pages, I could probably find at least one example, but I will speak in generalities for simplicity's sake. Constitutionally, we were not set up as a "democracy" (rule of man), we were meant to be a constitutional representative republic, (rule of law). In part this was to ensure that "everyman" would have governmental representation, through elected officials, who would then have to comply with "checks and balances" that established the law of the land by referendum. The Democrats in power flouted this first and foremost by cajoling, bribing, and then down-right strong-arming members of their party to vote for the legislation, in the name of "saving" Obama's presidency, voices of their constituents be damned. Depending on the polls you read 70-76% of the American population was opposed to this legislation.

    All altruistic definitions aside, in the rights defined by our constitution, "health care insurance" is not a right, and by forcing the American people to purchase this "good" (not "right") by mandate (like forcing us all to only buy GM cars for examples) oversteps the bounds of the Constiution as it applies to Congress. The commerce clause does not give the Government the authority to regulate health care (which is actually a service, provided by physicians and other "practitioners") even though health care insurance can be classified as a "good." With me so far?

    The "tax" or fine on people who do not choose to purchase insurance is a violation of the 16th amendment. By taxing only those who don't do "as they are told" you start down a very slippery slope If this were to hold, then, in theory, Congress can ignore any Constitutional limits, and tax you for doing anything that they may not like...a direct affront to individual liberty and the ability to choose for yourself how you spend your income.

    There are several parts of the bill that limit your individual freedoms and rights, including a tax 0.5% as it stands now, but can go up to 3.8% with reconciliation on investment income, trusts, and estates...but only on the "super-rich," right? Wrong...this applies to those making $250,000 filing jointly, $200,000 filing as an individual. The tax will go pay for health care insurance subsidies for people making up to $88,000 dollars a year. "The Poor?" Hardly.

    Whoever said above that now the insurance companies won't be mandating what physicians do? You are right. Now the government will. The Secretary of HHS is given the ability to compile information on your individual practices and "resource management"...for "informational purposes. Riiiiiggghttt? By dumping more patients on the system, without increasing the number of practicing physicians, we will have overall less time to spend with patients, less payment for those that we do see, all the while paying for those receiving it out of ever-increasing taxes. Sooner or later, the smartest of us will discover that it is better to work less, make less, get taxed less, get sued less, and therefore less overall health care will be available to the millions more with insurance (but not necessarily increased access to care). At least in a *true* universal health care system, tort reform is reflexive and physicians have little to worry about in the way of lawsuits except for getting reprimanded.

    The worst thing about the whole thing is that it is, by design, unsustainable...therefore setting up a "health care crisis" in which the government will be ready to swoop in with vast reaching socialist reform to the health care system...the *ultimate* goal.

  28. Anonymous7:37 PM

    As someone who comes from a country who has healthcare for everyone (Australia) I really don't understand how a civilised country can not have a system where healthcare is affordable and accessible. As far as my population health lectures have shown me, the US spends the largest percentage of their GDP on health of any developed nation. And yet they still have the highest infant mortality rate in the developed world.

    Maybe it's my lack of understanding about the system, or lack of appreciation for a very different political system in the US, but those can't be stats that anyone is proud of. This current bill is a step forward. A massive, ballsy step forward, but there is stil a long way to go- as you have pointed out. But I am still at a loss how people can see neighbours, family members and acquaintances loosing everything to pay medical bills (after loosing a family member- and some would argue, already loosing their world) and not think that there is a problem with the system.

    Not to say that the public healthcare system in Australia is flawless. It is far from that. And financially, costs keep going up- that's how it is always going to work, with new technology and demands on the system. But to go from being the only developed nation that didn't provide healthcare to their citizens to joining the rest of us- it's an historic moment. One to be applauded. Call it socialism, communism or whatever you want. I call it Human Rights. The ability to access health care when you need it is a basic human right.

  29. Oh, and I am a "she." :)

  30. Michelle,

    Paraprofessional has a specific meaning and part of that meaning is sorta like but most certainly "not professional". A profession generally has extensive training and licensing requirements. The term isn't "loaded"; it is just wrong if you mean to describe professionals.

  31. I have yet to see anyone losing "everything" to pay medical bills, I am not saying that it does not happen, but it is more rare than you would imply. Most people who can't afford it simply do not pay, and hospitals "absorb" the cost by jacking up the prices that they charge everybody else (8 dollar band-aid, anyone?)

    Of course it is not good, and no one is saying that the system does not need serious overhaul...BUT *this* legislation, done under the guise of "helping," does nothing to guarantee "health care access to all." Simply, health care *insurance* (mandated) for all.

    As for access to health care (you'd think people were dying in the streets outside the hospitals around here with the way y'all talk) we already have this, by the way. There is not a person in this country that does not have access to health *care.* How it is paid for is another matter entirely, and while it is important to address, this health care "reform" does little to address access to care at all.

  32. Kamala8:53 PM

    dr. whoo?: Of course, because you don't see it happen, it just doesn't exist! Around 1.5 million people in the US go bankrupt every year, and 60% of them go bankrupt because of medical bills. (source:

    Obviously, 900 000 people out of 300 million doesn't seem like that much-- but is it right that ANYONE goes bankrupt because they had to pay for cancer treatment or other medical expenses?

    We can't keep pretending that healthcare operates exactly the same as any other industry in the free market. To paraphrase Anthony Weiner (D-NY): if you have appendicitis, you need an appendectomy. You don't have the time or opportunity to shop around to see who will give you the best deal, and you can't CHOOSE not to have one... because you'll die.

    "There is not a person in this country that does not have access to health *care.*"
    Sure, you can go to the ER if you have a heart attack, and you'll get treated. But without money/insurance, you won't get adequate follow-up treatment or drugs. And lack of access to preventative care is a huge problem: if you can't afford to go to the doctor, you won't know that your cholesterol or BP is a problem, or what to look out for. Instead you'll just hope and pray that nothing goes wrong till you hit 65 and can get Medicare.

    Anonymous at 7.37: I'm Australian too, and completely agree with everything you said, except that the US is really not "joining the rest of us". This bill doesn't provide universal health care, only insurance, and in the meantime, and the only way to really solve a lot of these problems is by instituting a single-payer system.

  33. Interesting debate here...

    1) Paraprofessional should not be offensive. According to the dictionary a paraprofessional is "a person trained to assist a doctor, lawyer, teacher, or other professional, but not licensed to practice in the profession." i.e. PA's are not licensed to practice medicine. The big difference in my opinion (and I've been both a physician and an engineer) is that while assistants can always refer back to the professional, we have the ultimate responsibility to make decisions and deal with the results.

    2) To dr. whoo? - The essential problem with the American system (you equate it to buying GM cars) is that you see it as a service to be purchased, like a car. We here in The Great White North (Canada) see it differently. Access to high quality health should be available to everybody and we understand the whole of society is better because of it.

  34. As I stated, it is not that it (bankruptcy due to medical bills) does not happen, but it is rare. So, using your numbers, that is 900,000 (or is it 1.5 million, can't decide?) out of 300 roughly 0.3% of the country's population (and what percent of that is here legally?) Would you define that as "rare" or "common?"

    Why should general health care *not* operate the same as free market principles? Is it not a *service* or a *trade*? Forcing me to provide my expertise and training without compensation (for "free") is *robbery and extortion.* Free groceries for all, next? I mean, you *need* food to survive! It is only humanitarian to provide everyone with *food,* right??

    Charity is something completely different. Charity is not forced upon us by the heavy hand of government. If we could go back to fee for service, and people had a personal stake in the cost of their health care, costs would be driven down by competition. If you can't compete, you won't survive. What is so bad about that? Physicians win, patients win. Insurance companies lose, oh well!

    So, no, if you need an appendectomy? You go to the ER and the surgeon on call for the ER does your surgery and provides your post-operative care...usually without direct compensation. People who meet the definition of "poor" do have insurance in the way of Medicaid, not to mention access to health care (preventative care included) that is provided for "free" in each county health department.

    Being able to afford preventative care is not the only, or even primary thing that keeps people from seeking preventative care. Most Amercians do not see it as a priority, health insurance or not.

    I don't know that you can really speak to the status of health care in this country when you do not live it it. All you can see is what certain media outlets report. It isn't the whole picture, not by a long shot. I, again, do think that some reform is in order, but this legislation does not provide it.

  35. How many Americans are traveling out of the country for better healthcare?

  36. Kamala10:37 PM

    dr. whoo: Terrorist attacks are also pretty rare. Does that mean we just shouldn't bother trying to prevent them?

    "using your numbers, that is 900,000 (or is it 1.5 million, can't decide?) out of 300 million"
    Read over what I said. 1.5 million people go bankrupt; 60% of these bankruptcies are due to medical expenses. 60% of 1.5 million is 900,000. Therefore, 900 000 people go bankrupt because of medical expenses.

    No one is forcing doctors and other medical personnel to work for free. Even in countries with socialised medicine, doctors get paid. And yes, it IS humanitarian to provide the poor with food when they can't afford it. Which is why there are soup kitchens and food stamps and welfare payments, etc.

    "I don't know that you can really speak to the status of health care in this country when you do not live it it."
    That's like saying Americans can't judge anything that happens in any other country in the world, because all they know about it comes from the news. Yet plenty of Americans form their impressions of, say, universal healthcare in the UK/Canada from what they see on Fox News. Or they think that an invasion of Iran is necessary...because of what they see on the news. In any event, I used to live in the States, but left many years ago.

    Ultimately, I think you and I will have to just agree to disagree, because neither of us seems likely to change our minds.

  37. Murray - PAs do have licenses to practice medicine, and DEA numbers in most states, and whose scopes of practice are defined by their supervising physician's. This means they do have a scoop of practice. They don't just assist. Many patients are seen by just the PA without a physician. This isn't something "non-professionals" do. It is true that we go to our SP when we feel a patient needs more expert care. This is a role we embrace. I am more than happy to go to a physician for their opinion. (Guess what, many physicians will even ask PAs for their opinion too- the smart and humble physicians at least.)

    Would you treat the Secretary of State with such disregard because they're not the President, and don't actually call the shots, even though they are just a "secretary."

    I understand that you're from Canada (according to your profile) so you may not be fully aware of the profession. I'm just looking to be treated with the respect I think I've (I'm) earned(ing), and not like some without a brain.

    Again, I'm sorry michelle for flooding you comment section with this.

  38. Kamala,

    Stay on message. Applying your analogy of Terrorism to this bill, it would be like creating a 2700 page piece of legislation titled "The Terrorism Prevention Act" with a $1 Trillion price tag that did nothing to prevent terrorism.
    No one is opposed to health care reform, actually, the vast majority of Americans are for it. What we are saying is that this is a bad piece of legislation that reduces liberties, raises the cost of healthcare and taxes, reduces quality of healthcare and still doesn't accomplish it's main goal of covering all Americans. We can do better. We must.
    Are people risking their lives to immigrate illegally to Australia, UK or any other country on the planet? You may not like our healthcare system, foreign policy or our arrogance, but we are the first country everyone turns to when they have a national disaster or military threat. This is for good reason, we're rich and we kick ass. You keep your healthcare, your taxes and your righteousness, we'll keep our liberty and our "broken system" that millions flood to every year.

  39. Michelle,

    Please accept my apology for my brash delivery. I believe in American exceptionalism and have a low tolerance for Anti-American tones.

  40. Anonymous5:25 AM

    Hahaha arrogant American eptiomises why non Americans dislike Americans even post Bush. (another aussie)

  41. Kamala5:45 AM

    Arrogant American: My terrorism point was about bankruptcies, not the healthcare situation itself; I was saying that something terrible happening to a small number of people is not excusable.

    It certainly is true that the majority of Americans want healthcare reform, but here's the thing: what kind of reform do you want? I completely agree with you that this bill doesn't do enough to control costs, nor does it actually cover everyone. If people are genuinely against single payer AND a public option, what can be done to achieve healthcare goals in the long term? As long as healthcare is solely in the hands of people who seek profit, prices will keep rising.

    Furthermore, I don't see what was "anti-American" about my tone. It's hardly anti-American to think that US citizens deserve healthcare when they need it. I certainly don't believe in American exceptionalism, though.

    "Are people risking their lives to immigrate illegally to Australia, UK or any other country on the planet?"

  42. Pending, PA-S - I mean no disrespect. I am an anesthesia resident and we work very closely with respiratory technicians in the OR and I have worked with PA's also. I have learned as much from RT's as I have from staff anesthesiologists.

  43. Heather10:09 AM

    "The essence of civilization is that the strong have a duty to protect the weak. Call it socialism, call it communism, whatever you like. I may be strong now, but I know that could all change at any point, and it gives me comfort to know that if and when it does, this is not a society that will turn its back on me."

    My thoughts exactly. Thank you.

  44. Docs,

    You need to be hit with a cluestick here. Calling someone a paraprofessional when they are a professional may be ok out of ignorance, but when your mistake has been pointed out to you and you insist on relying on dictionary definitions that are not precise enough, you are going to start insulting people.

  45. Kamala,

    Thank you for clarifying. The prices of everything rise over time. Our challenge is to keep the cost growth of healthcare in line with most other things...right now it is floating away like a loose balloon.

    I think most people want the same thing (including me), quality healthcare at affordable prices. Nothing is free, whether the government provides it and raises your taxes to pay for it or the private sector provides it and you pay out of pocket, the argument becomes which route provides the best solution. For me, this is where it boils down to the basics of capitalism and the role of government.

    Acknowledging that action needs to be taken to address reform, I am a firm believer that the private sector delivers a better product at a lower cost than the federal government. I believe in self reliance and the liberty to choose my own path. I wouldn’t begin to decide what is best for you in your life nor do I want some group of politicians 1500 miles away deciding how I should spend the money I earn or what kind of health care I should have. I was born with the right to choose that for myself. As Dr. Whoo quoted above, no less than 70% of Americans polled were opposed to THIS bill, yet they passed it anyway.

    Debating economics and style of government is another issue.

    Healthcare in America isn’t solely in the hands of those who seek profit. We already have a combination of private and public care. Would you like to compare the cost efficiency and treatment efficacy of the two? Even for non-profit providers, cost is an issue worldwide so putting the government in charge isn’t the silver bullet.

    A couple of common sense solutions that I think would bring down costs have been proposed (and ignored).

    1. Removing the government’s anti-trust exemption from health insurance companies. This would allow insurance companies to compete with each other across state lines (like every other industry). The people would then have the option of shopping policies nationwide as we do for any other type of insurance or product. The competition not only drives down prices for consumers but by nature encourages new insurance providers to enter the marketplace.
    2. Real Tort reform. The states that have successfully passed this legislation have reduced the practice of defensive medicine and, in turn, insurance premiums and lawsuits have dropped dramatically. (see Mississippi, Texas, Ohio)

    Let me be clear, I have no intentions to offend. While I am very proud of my citizenship, it is unfortunate that “Anonymous” couldn’t see my presentation as making a point.

    Why would you believe in American exceptionalism? Wouldn’t that be a little strange? I think Americans should believe in it, though. We’re a stronger Nation for it. Those who do not, are invited to live where they think it is so wonderful. That’s another beauty of America, one is free to leave. Suum Cuique.

  46. What I'm trying to say is that it's not as cut-and-dried as people try to make it out. Yes, medical malpractice premiums have increased and insurers CLAIM it's from increased lawsuits and settlements, but the numbers don't actually bear that claim out. And I wonder whether the increases in premiums have more to do with lining the insurers' pockets than with any actual increase in expenses that the insurers have experienced. Just my two cents.

  47. I think what you said here was well said. I think it's important to know what doctors feel about this change and I really love the reminder that you mentioned "we are all just one breath away from catastrophe". So true, so true.

  48. Ariella, as a Plaintiff's lawyer I commend what you said. You summed it up very well.

    Our malpractice and overhead are enormous as well, so there is very little getting rich amongst the lawyers in my age group. Digging out of student loan debt is more like it.

    I think this post is excellent. We have massive problems and we have to start somewhere. This may not be perfect but it is a start.

  49. Anonymous12:06 AM

    Michelle, nobody is against you wanting to be compassionate and charitable. On the contrary, please provide as much charity as you can, in free labor and private donations. You can always live in a smaller house, send your kids to public school, give up that fancy camera... and so on. But if you can't do that, if you can't give up "all you possessions" to feed the poor while telling me what a civilized person you are, I am sorry to tell you that you are a just a hypocrite who wants to feel good about herself. You're no Mother Theresa, let's face it. And if instead of 600.000 a year you will make "only" 500.000 combined, you want me to shed a tear for you ? Wow, what a big sacrifice, to settle for the 1 mil house instead of the 1.5 mil house ! What a big soul you have !
    You should be worried about your kids freedom and the unflattering way they will judge your ignorance when they will get older.

  50. laura2:20 AM

    wow, Anon (12:06) - why the attack?
    it seems so out of tune with her post that i hardly think it's worth responding, but here's this:
    She never claims compassion or charity for her view on the bill's passage; never asks for a pat on the back, much less comparison to Mother Teresa. I'm pretty sure Michelle wasn't complaining, but just noting the effect the new changes would have on her such a way as to emphasize that these things (higher income taxes, less job security) pale in comparison to the greater good this bill promises to do.

    Also, I think Michelle is one of the last people who needs to worry about her kids growing up to judge her ignorance - you, on the other hand...

  51. Anonymous:

    Do you feel better now that you got that out of your system? Good! Now we can talk about healthcare reform.

    Thank you everyone, excellent comments on this one, and a lot of good stuff to think about.

  52. Just a second year11:08 AM

    I'm just worried that now that the government's in charge, my doctor's office is going to be about as efficient and pleasant as the DMV.

  53. On the other side of that same thought, my concern is that with a fixed workforce and increased patient load, the quality of care I will be able to provide will drop. There's nothing worse that feeling rushed when you're with a sick patient.

    I read in the New York Times that they're opening up a few new med schools around the country to train more doctors to address the workforce issue, particularly with respect to primary care. I seem to remember (and this is all sort of hazily recalled information, so please correct me if you know more about this) that there was a similar push to "crank out more doctors fast" in the 1970s when my parents trained, which is why they powered through med school in about three years, forgoing summer vacations. (This was at Albert Einstein in New York City, by the way.)

    Any thoughts on this? Is "more doctors" the answer to address disparities in access to care? I'm not so sure. One one hand (this one's for the Personal Freedom people) you can't force people to go into primary care, though you can obviously provide incentives (student loan forgiveness, partial subsidy of training, etc.). That said, I'm not sure where that money is going to come from, of if it's to be at the expense of those who pursued subspecialty training. Is it fair then, for example, to levy a tax on neurosurgeons in order to crank out more family practitioners?


  54. The way it works here is that for every graduating medical class there is quota of places in each of the specialty residencies. Those are divided between the universities by the number of senior medical students there are per university. (To clarify, there is no moving around after medical school, you do your residency at the same school). I'm happen to be at the largest medical school in the country, so the largest number of residencies for each specialty will be here aswell.
    We are required to decide what we would like to specialise at the end of our second to last year and then there are interviews and selection tests etc in January. Everyone knows how many people are competing and how many spots there are, so you know what you're up against. After the January selections most of the slots are filled, with the top choice applicants, some people are told they will not be getting a place and the other few compete for the last few spots. Those who are told they will not be able to start in their first choice can decide to go for a different specialty or do general practice (which doesn't have a top limit, as it is also unpopular here, though just under 40% end up in it). Those who are in, are in of course, and those who are still competing can also change specialties, go to general practice or wait for the final selections in March. (They get to know what place they are on the selection list).

    I'm sure this seems quite limiting, but it works quite well. I'm just not sure how easy it is to change specialties later on, I'll find out soon enough.

  55. Anonymous12:01 AM

    Great response to the outburst from Anonymous (12:06). I admire your ability to not take it personally and to let the comment slide without trying to defend yourself.

    As a Canadian, I just wanted to say that just because the government is involved, it doesn't mean that health care has to come to a grinding halt. Sure, there are inefficiencies up here, as I'm sure there are down there (just different kinds). Yes, you would have to wait several months to get your rotator cuff repaired. The nice thing is that no matter what tax bracket you fall into, you can get that surgery, as long as you're willing to wait. But don't worry, if you need emergent surgery, you will get it (you just bump everyone else down on the OR slate). So yes, wait times are longer up here, but we still have excellent care.

    And as a family practice resident, I wanted to say that there is a shortage of primary care physicians up here as well. There are lots of factors why people chose subspecialties over primary care... e.g. biased exposure to specialists during training, lack of respect for family doctors, the need to keep up-to-date on so many different topics, and yes, the difference in income. I think that the problem is starting to get better, now that the governments are changing fee codes so that family doctors are more fairly compensated for the work that they do (e.g. adding codes for management of complex care of chronic diseases).

    The laws of supply and demand are also making family medicine a great choice. Family practice residents have patients asking them where and when they are going to set up shop - as they are desperate to get a family doctor. Preceptors are asking if we're willing to do their locums, or take over their practices. And yet some of our (older) friends in subspecialty residencies or fellowships are having difficultly getting a job offer. So it may not have to come down to taxing the neurosurgeon to crank out more family doctors.

    - Another Michelle

  56. Just re-read my own comment, and wanted to make it clear that I am not suggesting *actually* levying a specific tax on subspecialists, I just meant that that is in effect what would happen if you decreased subspecialty reimbursements in order to cover other healthcare costs, and I was playing devil's advocate.

    (Just wanted to clarify before the inevitable catcall of "Tax and Spendocrat!")

  57. Anonymous6:51 PM

    Two points:

    1. The best thing about this bill is ability for anyone to buy into pools to take advantage of insurance-negotiated discounts.

    Last year I had some tests done. I was responsible for everything, as I had not met my deductible. It was $9.61 on top of a $25 co-pay, a total of $34.61.

    I was shocked to see that the hospital billing rate--the rate non-insured people get--was $441.78! So while I paid entirely out of pocket, the very fact I had insurance saved me over 12 times!

    2. Salaries across specialties absolutely have to be made more equal. Sorry, as I know you're an anesthesiologist, one of the most lucrative specialties.

    The discrepancies are non-sensical. A radiologist looks at a scan and diagnoses cancer. A pathologist looks at a cell biopsy and diagnoses cancer. The radiologist earns twice as much.

    I recently paid $88 plus $25 co-pay to see my family doctor, whom I can't say enough positive things about, for half an hour. She referred me to a neurologist. I paid $185 plus $25 co-pay to see the neurologist for about half an hour, and the neurologist even said she wasn't familiar with my disorder and referred me to yet another neurologist.

    Last time I checked, both of them did four years of med school and three years of residency. So why does one earn twice as much?

    There are other specialties that are also underpaid or overpaid relative to the others.

  58. Anonymous9:51 PM

    I agree with the poster above. Why is a 20 minute procedure compensated better than 20 minutes spent talking to a patient about overall health and preventative medicine? The latter is just as (perhaps MORE!) important. And the preventative counsel saves everyone money over time.

    But evening out compensation across physician specialties is merely a part of the solution. There are only 30,000 new MDs trained every year. There are 35 million new people coming onto insurance by 2014. NPs and PAs train in two to three years, and they provide excellent care. (Many patients, in fact, prefer their NPs' care to their MDs' care). These are not "paraprofessionals"; quite the alternative, in fact: they are the front line professionals we will without a doubt rely on to meet the needs of our patients. I can understand why MDs feel threatened by them, but we are not in an MD-centric health care universe any longer.

  59. Anonymous2:20 PM

    I agree that NP's and PA's can be good. My family doctor has a fantastic NP do regular women's health exams.

    But a great family doctor, like mine, is worth his or her weight in gold. A great NP is better than a bad family doctor, but a great family doctor is much better.

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