Remember When?

Before the "Great Society" programs of the Johnson Administration, the United States truly had the best health care system in the world. What are some of the differences between then and now?

1. In 1965, doctors got 67% of their revenues directly from the patient. Why is this an important? Have you ever heard of the "Golden Rule?" Not the biblical one, but the one from Disney's Aladdin, "he who has the gold makes the rules." Doctors could be more responsive to the needs of the patient because the patient was the source of most of their money. So the patients were in control. Insurance companies were involved when there was a catastrophic need. When the patients are in control of the process, the free market can work.

Solution:
I repeat what I have said before. If I go to my doctor and leave with only advice, there is no reason why I should have to file a claim with my insurance company. I don't file a claim with my auto insurance when I change the oil in my car. I don't make a claim with my home insurance when I paint the house. Insurance should be for catastrophic trouble only! Fewer claims mean lower prices and more accessibility. Don't cover routine doctor visits, or prescriptions. Don't cover eyeglasses or contacts. Focus on prevention, but offer premium discounts instead of reimbursements.

2. The population was younger. Why is this important? Even if you sew your wild oats night after night, problems rarely happen. If you don't crash your car or bike, nothing will happen. When you are under 45, you are invincible. Lower risk means lower prices for insurance and greater accessibility. Also, like homeowners and auto insurance, discounts should be given to people that take steps to lower their personal risk.

Solution:
There is little we can do about the population pyramid other than have more babies and bring more immigrants into the system. Let's get busy. If you have fewer than 3 kids and you are still in child bearing years, have another. Just kidding, of course. But our failure to realize that all the money we spend on children will come back to us is one of the biggest failures in modern society. We need younger workers to cover the older ones and the retirees. We should aggressively recruit the "invincible" crowd into insurance plans to reduce the risk.

3. There were fewer lawyers. Malpractice insurance does not directly add a lot of money to your medical bill. But your doctor orders a ton of unneeded CYA tests just in case he is sued. There is the belief that doctors have deep pockets and they become easy targets for law suits.

Solution:
We need medical tort reform. Doctors and other providers need to be held accountable for mistakes that they make, just like the rest of us. But limit the amount of money that can be collected. Also, if a doctor has to renew his license every year, than a lawyer should as well.

4. End of life issues did not exist. Something that we must understand: There is a difference between extending life and delaying death. In 1965 we had little power to do either. It is difficult and painful and emotional to realize that this line has been crossed, especially if it is your mother, father, brother, sister or child; but expecting other people to pony up when that line has been crossed is just as immoral as letting someone die before the line is crossed. The difference between 1965 and today is that we had little choice but to let people die. Many procedures we take for granted now were new back then.

This is likely the most controversial thing I have ever blogged on this site. But there is a "most miraculous ever" threshold. Once it has been crossed, say goodbye and let people go. There have been some high profile cases in the news in this area, and there is always someone waiting for the next miracle. If you have the means to keep your loved one alive forever and not be a burden to taxpayers or society, go ahead. But don't expect insurance companies and taxpayers or even your church to pay the bill. Costs for this type of care are expensive and escalate exponentially.

Solution:
Be sure that you have a will and a medical end of life directive on file. Ensure that family knows where those documents arrive. One of the big problems in prominent end-of-life cases is that family was unaware of the actual desires of the patient.

5. Doctor to patient ratios were realistic. Do you know when the last new medical school was accredited in the United States? Here is a trivia question: where is the newest medical school in the US? (Hint--They are one of the lesser known Universities in the Miami area.) They open just this fall and are the first new medical school in this country in many years. There are only 131 medical schools in the United States to server all 400,000,000 of us. We are not training enough doctors. Soon, baby boomer doctors will begin to retire and we will not be able to replace them. We also do not have enough nurses or enough pharmacists, or just about anyone. Who does not know someone who would have made a brilliant doctor that could not get into medical school?

Solution:
We need more medical schools and everything that they provide. We also need a lot more nurse practitioners and physician assistants. They can lower the overhead and free a doctor from many of the routine problems that take a doctor's time.

Trivia question answer: http://medicine.fiu.edu/index.php

6. Emergency Rooms. When people had a non life-threatening emergency, where did they go? It was not the ER. It was their local doctor. When my dad was 9--1952--he was knocked silly on the playground and the doctor came to his house! (He tells the story much better than I could.) And not only that, Grandpa did not go bankrupt because of it either.

Solution:
We have got to stop using the emergency room for every little problem. If you don't have to call 911, don't visit the ER!

7. Paying for service. Back to that story about my dad. My Grandparents were not Rockefellers. I know that my Grandad would exchange services with many people in the community. He was an exterminator. All of his medical bills were paid and the town doctor never had mice at the office or grasshoppers in his orchard. This is often how small business people got what they needed back in the day.

Solution:
If you can't pay your medical bills, there should be a way to work them off. The doctor provides you a service you can not pay for, you work a Saturday morning at the food bank. The doctor gets a tax write off. It's a win/win. No one, no matter what their circumstances are, is entitled to free medical services. If you can't pay, then you can serve. Even organizations like St Jude and Primary Children's Hospital should find some way for patients (or their parents) to pay forward the services they have received.

Think of these seven solutions, does any of this involve the Federal Government? Again, here are the 7 points of the plan:

1. Catastrophic-only insurance. Government as a last-resort safety-net. Providers should get the majority of their revenues directly from the patient.
2. Diffuse the risk. Bring low-risk populations that are not currently covered into insurance plans. These populations include immigrants, college students and younger workers. Reward those who take steps to lower their personal risk by joining gyms, loosing weight, etc.
3. Tort reform to end unneeded CYA testing.
4. Realistic end-of-life care that focuses on extending a quality of life instead of simply delaying death.
5. Train more providers. Introduce more competition into the system.
6. End the use of the Emergency Room when an unplanned medical problem arises.
7. Patients who can not pay for their medical bills should work them off through community service in lieu of forcing them into bankruptcy. No one gets a free ride. End the practice of just writing-off unpaid bills. End the expectation of a free ride.