Come Down To My Basement…I’ve Got Candy Down There…
Organized medicine is certainly facing a little bit of a faith crisis. From those they’re supposed to represent come cries that the AMA, specialty and state societies do not do enough for [put individual specialty here]. From the interested public and other interest groups comes cries that the AMA, specialty and state societies move to benefit the physician over the patient.
Throw amongst those pragmatic concerns the intellectual and long held criticism that organized medicine suppresses the supply of physicians and the scope of non-physician practice and is thus inherently anti-free market.
I’ve ignored this topic for long enough considering my considerable involvement in leadership roles within organized medicine and my libertarian leanings.
The clamoring from far right wing free market speakers like the late Noble Laureate above (who I respect considerably, despite the little joke above) and crazy think tanks like the Ludwig von Mises Institute is that the AMA is essentially a guild whose will the government has succumbed to. In a publication titled “100 Years of Medical Robbery” the think tank has this to say about the history of the American Medical Association and its goals:
In the days of its founding AMA was much more open–at its conferences and in its publications–about its real goal: building a government-enforced monopoly for the purpose of dramatically increasing physician incomes. It eventually succeeded, becoming the most formidable labor union on the face of the earth.
To accomplish the twin goals of artificially elevated incomes and worship by patients, AMA formulated a two-pronged strategy for the labor market for physicians. First, use the coercive power of the state to limit the practices of physician competitors such as homeopaths, pharmacists, midwives, nurses, and later, chiropractors. Second, significantly restrict entrance to the profession by restricting the number of approved medical schools in operation and thus the number of students admitted to those approved schools yearly.
The emphasis is my own.
I’ll offer a candid response to this. Through it’s history the AMA appears to have focused largely on improving physician income. Perhaps not as single minded or nefariously as the Ludwig von Mises Institute would have you believe but it remains. And the AMA has had considerable success doing such. The allowance of self goverance that medicine enjoys and the sway it holds over the scope of practice for other providers is incredible. I think there are some real issues of ‘patient safety’ buried in those issues, as the AMA would argue, but it is hard to argue that physician income did not, does not play a role in the AMA’s focus in securing physicians influence over who practices “medicine.”
Organized medicine was responsible for the Flexner Report and continues to hold the greatest sway over the number of physicians this country will (or will not) have by controlling the LCME and ACGME. To argue some conspiracy to suppress the number of medical students (and thus number of future physicians) through these entities is baseless, but it does display how much control organized medicine has wrested for physicians. As does the limiting of the scope of practice of all other medical practitioners. Indeed, that aspect of the AMA’s success (getting state governments to agree to follow their rules on who should be allowed to perform certain procedures or write perscriptions) may be the most marvelous.
It is clear that the ‘thinkers’ and ‘economists’ who criticize the AMA are far removed from the practice of medicine. Some of their rails simply show a lack of understanding of how medicine works. For instance, the article above tries to criticize the AMA’s restriction on who can practice medicine in the name of ‘patient safety’ and ‘quality,’ by saying,
A final challenge to the Lexus standard is the number of accidental deaths occurring in U.S. hospitals every year. Harvard University’s Lucian Leape estimated that there are approximately 120,000 accidental deaths and 1,000,000 injuries in U.S. hospitals every year. To understand what staggering figures these are, imagine a Boeing 777-200 with its maximum of 328 passengers crashing every day for an entire year with no survivors. This would add up to 119,720 deaths, still not as many as are killed through medical error in hospitals every year. UCLA Professor of Medicine Robert Brook, M.D., told the Associated Press, “The bottom line is we have a system that is terribly out of control. It’s really a joke to worry about the occasional plane that goes down when we have thousands of people who are killed in hospitals every year.”
In anycase, the point is there are questionable assertions like this throughout the works of the libertarian thinkers who criticize organized medicine. Despite that, there is some validity to their points. As another Ludwig von Mises paper, “Bring Back The Guild System?” says,
Government regulations on the chiropractic profession, lay midwifery, and on the freedom of nurse practitioners to offer services within their competence, all of which make perfect sense from the point of view of the medical guild that lobbied for them, make no sense at all from the point of view of consumer wishes (as repeatedly expressed in polling data) or from economic considerations. In many cases, such people can provide health services far more cheaply than can licensed physicians (or, in the case of chiropractors, can provide services that licensed physicians do not provide at all), but consumers are prevented from making their own decisions regarding their medical care. Given the logic of the guild structure, no one has the right to be surprised to find that the AMA has put so much effort into undermining its professional opposition.
There is nothing wholly unique about physicians’ efforts towards this. Other professions do the same and also limit their membership through limiting education spots but medicine is certainly one of the most successful at it.
I will accept the blows Milton Friedman lands against the American Medical Association but let me make an argument on why the AMA’s actions are reasonable despite violating the libertarian ideal.
Let us call what the AMA and the rest of organized medicine does a necessary evil. It might not have been through all of its existence granted but today it is. It is because physicians are not playing on a level, free market playing field.
That is the question the thoughtful should be asking; not whether guaranteed access for all can work. Let us be honest, if you goal is improving utilitarian public health measures - life expectancy, infant mortality, time to treatment for diseases, access to care - then a single payer system could work in the United States, provided enough funding. Complaints and nay say against such a system by providers is nonsense and nothing but protection of self interest. There are tradeoffs with such a system, but there are trade offs with any health care system. Look at our current one. If you want to improve what the public would consider ‘health’ then a well funded single payer system would be far superior to our current system, no matter America’s ‘uniqueness’.
But should we do that? The real debate is should the government fund access for those who cannot afford it themselves. Who has such a right?
The Miller Center of Public Affairs tried to do that recently with a panel debate. On the transcript at times the talking heads fall short in defining the debate and staying on course, but it still something worthwhile to look at.
The move towards cost transparency is generally something I support. But there is an argument I will buy that such should be prospective. That’s the line I’m buying with the current lawsuit over Medicare provider data that some consumer groups are waging.
In an unusual statement, the Health and Human Services Department endorsed the objectives of the consumer group that is suing, but said it wanted a higher court to clarify the lower-court rulings.
“We’re caught between court decisions,” said Christina Pearson, a spokeswoman for the department. “There’s conflicting information from different courts, so we’re pushing to get clarity.”
But the government’s legal brief in the case calls for the appeals court to reverse Sullivan’s ruling, leaving the restrictions on the release of data in place.
“I know the government was under a lot of pressure from the AMA in particular, arguing that the government should appeal,” Krughoff said. “Whether that’s the reason the government appealed, I don’t know.”
I’m torn, certainly. It is much easier to speak of the private insured having a ‘right’ to such data than Medicare patients considering what the two groups shoulder in terms of personal costs and responsibility for their health care access.
It is reasonable to imagine that a physician, somewhere out there, participates in Medicare under the understanding that his reimbursement data is shielded from public eyes based on previous court rulings, and would not participate otherwise. Under such a circumstance I think the opening of the Medicare database needs to be solely prospective and not retrospective. That means the data won’t be useful for years and years, I understand that but it is probably the right way to do it.
Several in the medical blogosphere (here and here) have picked up on a front page WSJ story concerning specialist income and shortages.
Probably an overblown story.
But a look at specialist income got me thinking. Is it just me or is diagnostic radiology the specialty most likely to be disappointed over the next couple of decades? When I was writing my previous posts on physician income I started really thinking that radiology may be in for a significant slow down in earnings growth. There are two factors which I think will contribute to disappointing growth in radiologist income:
1) Their rise in income over the past two decades has been precipitous and outpaced the growth in median income of just about every other specialty. And not all of that has been driven by the rise of interventional procedures. Radiology thus, as a specialty, has some of the most to “give back,” if and when physician income growth slows as cost sharing measures.
2) The rise of outsourcing is probably a little overstated but it seems real enough. With rising healthcare costs concerns over international radiologist work (liability issues, etc) may not be enough to prevent the outsourcing trend from speeding up a bit and driving down reimbursement.
This isn’t to make a claim as to the value of radiology or to say that diagnostic radiologists are currently over reimbursed (I don’t think they are). I’m just trying to imagine the future. Radiologists will never be ‘hurting,’ but in my career I think they’ll be doing more work for less dough.
I’m No Radiologist But Something Ain’t Right Here
I have a lot of respect for the ACR and RadPAC’s efforts but diagnostic radiology may not be in a completely defendable position with some of it’s unique aspects as a specialty.
If there’s a bigger single topic discussed in the medical blogosphere than the primary care crisis I’m not sure what it is. It permeates blogs (here and here and here) and the media (here and here and here).
I do believe that the distribution of primary care physicians to specialists in this country is askew but I’ve taken a critical view of some of the claims made by the primary care community. In part there is an argument that the efforts of the organized primary care and the medical blogosphere are merely rhetoric. No one pays attention until there is a ‘crisis’ and the flamboyant and exaggerated claims on the condition of primary care are perhaps merely part of a PR campaign. But in a deeper sense I think that the ‘whining’ coming from primary care is actually contributory to the primary care crisis. I’ve made severalposts to that effect.
I thought what was in order was one summarizing post on the issue, something that might stir up some comments. That’s what I’ve put together here: the four myths of the primary care crisis.
The conclusions I reach are based on what I feel is sound data, but the post is obviously far from comprehensive. If there is data from non-interested parties that I didn’t consider or arguments I’ve ignored then let me know in the comments.
Myth #1:There Is A Worsening Shortage of Primary Care Physicians
I’m just going to flat out say it, the fact that physician bloggers and agenda minded think tanks continue to substitute anecdotal evidence of a shortage as a surrogate for the actual figures is distressing. Take this recently touted article from the WSJ. While I won’t speak to the Massachusetts experience the cited study about a nationwide PCP shortage is flimsy.
One of my biggest pet peeves is that these primary care physician-scientists seem to refuse to characterize the evidence they use in their opinions. I would hope that we can all agree that the HSC Community Tracking Study Physician Survey, cited in the WSJ article, falls short of the best evidence on primary care physician numbers. A 6000 physician sample with nearly less than a 50% response rate. Lovely.
Indeed, the HSC survey is the only original dataset put together by a non-involved entity that I can find that seems to back up a drop in the per capita primary care workforce.
While we have seen a drop in allopathic medical students going into primary care it has more than been offset by IMGs as the GAO says.
From 1995 to 2005 Using AMA and AOA Master Files and HRSA Data
There are probably regional deficiencies in the primary care physician workforce but there are regional shortages for physicians no matter their specialty and it does not speak to a systemic problem facing primary care.
Nor is there good data that demand for primary care will grow with an aging population and cause a shortage. Such predictions by organized primary care are pretty low on the pyramid of evidence. While such a deficit may pan out, trying to predict such (even if you think it is just sooooo obvious a conclusion) is notoriously difficult. Predicting the physician requirements of this nation a decade or more out is essentially impossible. See this IOM report from the mid-nineties on efforts to do such. That’s why the major players over the past decade have flip flopped on whether we need to be graduating fewer or more doctors.
Certainly, even if the above scenario plays out, it would be hard to imagine it as a “crisis.”
I think the best evidence says there is not a general primary care shortage. At least not a new one. As I said, I think we have always needed more primary care physicians in this country but the situation isn’t getting worse. The primary care per capita numbers have been maintained and probably even grown a bit over the decades thanks to an influx of international medical graduates. Let that claim rest in peace.
Myth #2: The RBRVS and RUC Are Responsible For The Primary Care Income Disparity
I’ve posted long and hard on the RBRVS and the AMA’s RUC. I admit that I do not believe that primary care physicians are compensated appropriately and I may even buy that the RUC has not done enough to fix the primary care-specialists income disparity. That being said, the evidence clearly supports that the primary care physician has not done worse versus the specialist since the implementation of the RBRVS.
The RBRVS came into existence in 1992. I think a larger review of income data backs me up but for the sake of this post let me take a couple of examples to highlight the condition of primary care before the RBRVS in 1988 versus today. The data sources are the 1988 Health Care Financing Administration’s PPCIS and the 2007 AMGA Physician Income Survey.
I understand the limitations of comparing these two survey datasets, constructed under two different methodologies by two different groups. For example, below I have to use family medicine income as a surrogate for all of primary care. Even today the major physician income surveys show some wide discrepancies but I do believe that comparing this data gives us at least a general idea that the RBRVS has not screwed the primary care physician. In the end, that is the general point of the myth - the RBRVS and RUC have been bad for primary care. Such doesn’t appear to be the case.
In 1988 all self employed Family Medicine physicians earned a median of $102,500. In 2007 the median Family Medicine physician earned approximately $185,700. That is an increase of 81% in 20 years.
That is better than the orthopedic surgeon (56%), the cardiologist (61%), the anesthesiologist (78%) over the same time frame. There are medical specialties that made off better over that time frame (see radiology) but in general the RBRVS has been progressive for primary care physician income.
Nor, in terms of hours worked, are family practice physicians working more than they did immediately pre-RBRVS.
If you include all primary care physicians the primary care physician earned 65% of what the medical specialists did in 1988 (i.e. the cardiologist, the gastroenterologist, the pulmonologist, etc) and 44% of the average income of all surgical specialists.
No the RBRVS may not have closed the gap in the income disparity completely and/or appropriately but it has made some progress and has not contributed to a worsening of the gap. The income disparity has narrowed since the advent of the RBRVS and the creation of the AMA’s RUC. End of story.
It’s no surprise that I’m not a fan of Paul Krugman. His dismissal of the potential for market forces to help reform health care is chief amongst my disagreements with his positions. In his most recent column, “Voodoo Health Economics,” he’s up to it again. His starting point is this claim,
Elizabeth Edwards has cancer. John McCain has had cancer in the past. Last weekend, Mrs. Edwards bluntly pointed out that neither of them would be able to get insurance under Mr. McCain’s health care plan.
The absoluteness of that claim might be a little far fetched. Both of these individuals have essentially unlimited financial resources and, at least in Mr. McCain’s case, could probably, with enough searching, pass the underwriting process somewhere and get insurance. Even if that insurance excluded cancer as a pre-existing condition and had extremely high patient side costs it would represent something real. The cancer screening, for these individuals, is the important thing. The poor outcomes for the uninsured with cancer are almost entirely attributable to the advanced stage at which cancer is found in the uninsured not in a lack of funding for the actual cancer care.
Mr. Krugman also brings up this age old claim,
[T]he United States has the most privatized system, with the most market competition — and it also has by far the highest health care costs in the world.
It seems to imply a cause and effect in a vacuum without admitting other contributing factors to the high cost of health care in this country.
I’m not disputing that the United States “runs” one of the least effective health care “systems” in the world but there is obviously more contributing to our comparatively high health care costs. Namely that, independent of access to care, the United States has the least healthy population in the western world (i.e. United States patients cost more on average than patients in any other western country).
And, he also praises the Veterans Health Administration. Such was in vogue recently. But I doubt Mr. Krugman has ever spent much time in a VA hospital. As most medical students I will raise my hand that I have. I’ve also had the privilege of hearing and actually speaking with (apparently former) VA Secretary Nicholson. I think I can speak for many, many medical students who have served at many, many VA hospitals in saying this is an incredibly inefficient system.
And I do mean medical students actually do something at the VA. Public health care generally runs easily whether medical students are there or not. Sometimes we even get in the way. I’m not sure that such can be said about some services at VA hospitals. There are many an example where things would’ve taken days longer to get done if I or another medical student hadn’t been there to do grunt work or make phone calls. The complete disregard for expediency, the often times lack of focus on basic patient safety efforts seems like a system wide problem despite some of the praise the VA system has gotten. With the wars in Iraq and Afghanistan dragging on such is finally getting some focus in the media,
VA hospitals are also receiving a surge of new patients after more than five years of combat. At the sprawling James J. Peters VA Medical Center in the Bronx, N.Y., Spec. Roberto Reyes Jr. lies nearly immobile and unable to talk.
[…]
Maria Mendez, his aunt, complained about the hospital staff. “They fight over who’s going to have to give him a bath — in front of him!” she said. Reyes suffered third-degree burns on his leg when a nurse left him in a shower unattended. He was unable to move himself away from the scalding water. His aunt found out only later, when she saw the burns.
Anecdotes of course but there is good evidence that such problems actually affect patient outcomes.
Measuring comparative outcomes in VA patients is difficult. VA patients are more likely to be homeless, to make far less use of care, to make use of care at a later stage of disease versus Medicare patients and just generally are sicker than their counterparts out in Medicare. That said, when trying to control for these there is some evidence that in several key disease states they do worse versus their Medicare counterparts. For example, heart attacks.
Yet Mr. Krugman extends praise over the system,
As I’ve mentioned in past columns, the Veterans Health Administration is one of the few clear American success stories in the struggle to contain health care costs. Since it was reformed during the Clinton years, the V.A. has used the fact that it’s an integrated system — a system that takes long-term responsibility for its clients’ health — to deliver an impressive combination of high-quality care and low costs. It has also taken the lead in the use of information technology, which has both saved money and reduced medical errors.
Sure enough, Mr. McCain wants to privatize and, in effect, dismantle the V.A. Naturally, this destructive agenda comes wrapped in the flag: “America’s veterans have fought for our freedom,” says the McCain Web site. “We should give them freedom to choose to carry their V.A. dollars to a provider that gives them the timely care at high quality and in the best location.”
That’s a recipe for having healthy veterans drop out of the system, undermining its integrated nature and draining away resources.
Draining away resources? What resources? These veterans aren’t (and rightly so) generally paying for their care. It isn’t like an insurance system where having healthy veterans in the pool subsidizes the sick.
Okay, the points above are, in some part, merely semantics but you have to wonder about the soundness of the rest of his arguments when Mr. Krugman makes examples like those above.
This survey of British physicians was published in a British magazine a while back and I only now picked it up. In it a majority of respondants say that some care, apparently especially some operations, should be limited by patients’ age and lifestyles.
Smokers, heavy drinkers, the obese and the elderly should be barred from receiving some operations, according to doctors, with most saying the health service cannot afford to provide free care to everyone.
[…]
About one in 10 hospitals already deny some surgery to obese patients and smokers, with restrictions most common in hospitals battling debt.
Managers defend the policies because of the higher risk of complications on the operating table for unfit patients. But critics believe that patients are being denied care simply to save money.
One in three said that elderly patients should not be given free treatment if it were unlikely to do them good for long. Half thought that smokers should be denied a heart bypass, while a quarter believed that the obese should be denied hip replacements.
Tony Calland, chairman of the BMA’s ethics committee, said it would be “outrageous” to limit care on age grounds. Age Concern called the doctors’ views “disgraceful”.
That’s taking voluntary, transparent rationing to a pretty incredible level. When resources are scarce, as in most of medicine, then lifestyle can play a role in who gets what. I have no problem, along with 94% of British doctors in the survey, in saying an alcoholic who is likely to return to drinking shouldn’t be at the top of the liver transplant list.
Ninety-four per cent said that an alcoholic who refused to stop drinking should not be allowed a liver transplant…
Roger Williams, who carried out the 2002 transplant on the former footballer [George Best,] said doctors could never be sure if an alcoholic would return to drinking, although most would expect a detailed psychological assessment of patients, who would be required to abstain for six months before surgery.
But rationing based on age and some of the other suggestions put up in the survey just elicit a ‘yikes.’ Such transparent, open and flamboyant rationing efforts are inevitable in any limited global budget health care system (i.e. Britain’s socialized NHS).
[Larry] Niven said a good way to help hospitals stem financial losses is to spread rumors in Spanish within the Latino community that emergency rooms are killing patients in order to harvest their organs for transplants.
“The problem [of hospitals going broke] is hugely exaggerated by illegal aliens who aren’t going to pay for anything anyway,” Niven said.
“Do you know how politically incorrect you are?” Pournelle asked.
“I know it may not be possible to use this solution, but it does work,” Niven replied.
I don’t even know how you respond to the stupidity of a comment like this, except just to denounce it as such. Larry Niven simply doesn’t know what he’s talking about…or how to write a novel.
The cost of health care has been and continues to rise dramatically in the United States. But only in the magnitude is the United States alone in the world with such a problem. A New York Times blush points out that,
The United States has long been an unusual study in medical care, with employers assuming much of the cost. Now, though, as the employers say “enough,” calls are deepening for the government to take on more of that role through nationalized health care.
The opposite situation is unfolding in other parts of the world. As long-running national health systems become overburdened, more employers are paying for workers’ supplemental health care costs.
According to the Watson Wyatt survey cited by the NYT piece, India’s employers will spend 30% more this year on health care than they did in 2007. That’s a one year increase. Canadian employers will spend 12% more than last year. Even British employers will spend 8% more than last year.
Granted in some of these countries these are percentage gains on what are relatively small expenses already, but it is still interesting and further circumstantial evidence questioning the sustainability of government run health programs with single budgets.
Tens of thousands of Oregonians queued up quickly for a chance at the state’s latest lottery, but this one is no game.
Officials began drawing names last week for a chance at some rare openings in the state’s healthcare plan.
Announced in February, the lottery drew 91,675 hopefuls in 30 days. The winners will receive a postcard notifying them that they can apply for the Oregon Health Plan.
Budget limitations capped the Oregon Health Plan standard benefit package in mid-2004. Now the plan has room for a few thousand people. The lottery winners will be the first new applicants since the cap was imposed.
Perhaps reflecting some of the obstacles and limitations in/of trying to implant social assistance health programs in the United States, the Oregon program is kind’ve drifting clumsily along. And far from achieving the original goals envisioned for it.
When it was fully funded, it was considered a trailblazing program. In 1996, the benefit package enrolled five times as many people as are enrolled today, and only 10.7% of Oregon’s population lacked insurance, compared with about 16% today.
It was fun, especially on trauma call. But beyond trauma call it was a pretty repetitive service. My home surgical residency program, admittedly merely through faculty report, has the single highest average number of lap choles performed per graduate. I’m not sure that’s really a selling point (although the laparoscopic cholecystectomy is one of the most popular operations in this country), but I do believe it.
On the slowest general surgery service (one to two ORs depending on the day, one fifth year, one second year, two interns) in the hospital (average probably 8-12 cases a week) and with three other students to split up the cases I probably was scrubbed into 12-15 lap choles in six weeks or about two a week. I think a disproportionate number fell to me. While lap choles probably did literally make up the majority of our service, it wasn’t like they represented 90% of the operative load. Even so that seems like there were a lot of choles.
Indeed, I’m pretty sure with my attending on the other side of the table I could perform a lap chole right now with the complication risk about the same as when my junior resident on the service did it.
I will mention one health policy issue which I’ve come to appreciate and it concerns the way we handle trauma. I’m really naive about the issue, but I think as long as we’re throwing around proposals for further government funding of health care that we might also consider the way we fund trauma in this country. It goes beyond EMTALA. We need to seriously consider some kind’ve national trauma insurance pool (I’m sure there are proposals out there) and even consider further mandates to hospitals for Medicare participation (I’m being serious, despite the complications of doing such).
On to medicine. Doctors just make too much money, right? I don’t know. Maybe, because medicine is something people need, rather than want, we think physicians get paid too much. Maybe we do, maybe we don’t. But I think there’s an inherent danger in the very question.
The idea of America has always been, not equal success, but equal opportunity to try and succeed.
[…]
I hope that we remember that. I hope that we don’t decide that someone, read ‘government’ is going to start deciding who makes how much.
The growing public opinion of entitlement to health care is certainly helping to create some ire concerning the piece of growing spending on medical care that physicians take for themselves. That ire is misplaced.
Despite contributing to the rising health care costs, health care providers are far from overpaid.
Let’s take a hypothetical situation involving essentially the highest earning physicians (if not by hourly earnings).
Hey, I Probably Make At Least $300,000 A Year As A Neurosurgeon
If We:
Removed all negotiated schedules with the cabal of payers
Removed all restrictions on who can practice neurosurgery
Removed all debt protections (i.e. the surgeon can balance bill; the surgeon take the house, the car, the first born to collect his fee)
Essentially made it into a situation where neurosurgeons could charge whatever the market would bear (and were able to take any assets to collect their fee)
Do you think there’s any chance neurosurgeons would earn less than the average salaries spelled out here? What is having that spinal fusion or having that tumor out worth? Everything. Even when anyone can do it, how many surgeons would actually arise? Few.
Health care is something you need. And even if we remove the admitted restrictions the fraternity of medicine have in place for admittance, health care will continue to be of relatively limited supply based on the great stakes and the true limit of those actually skilled/qualified in the art of medicine.
Who Do You Want Treating Your Heart Disease?
Why in the world would the public expectation be that because it is something you need it costs less? “Well I need it, therefor I’m entitled to it,” just doesn’t fly. And yet that is what I truly believe is arising as the culture in this country.
Okay, that’s enough of a rant I suppose. Not that I’ve posted anything new here as I’ve made similiar arguments before on this blog.
Also, the people who are so adamantly against throwing a couple bucks of their tax money into the pot to help out their fellow countrymen are really sad excuses for human beings. Really. Subhuman at best.
Certainly, but it ignores the entire point - being an asshole with one’s ‘property’ is a right while no such ‘right’ to health care can be defended with any sincerity.
I don’t agree with the choice not to aid your fellow human being, and it isn’t the choice I have/will make with my life, but it should remains that. A choice.
Medical gift cards? Why limit where they can spend what you’re giving them?
The card is issued by Visa, so it can be used anywhere Visa is accepted for health-related services. They are not sold in stores and need to be purchased online or over the phone for up to $5,000.
“The peak audience we believe though is women 35-50, the famous sandwich generation,” Bellard said. “So, they’ve got parents that have health needs, and they’ve got a spouse that has health needs, and older children going off to college or living on their own that have health needs.”
How does the card impact medical deductions? The person who uses it gets any eligible write-off.
“Be sure to record how much you spent on that card because that is a legitimate medical expense that you can use when you fill out your taxes,” said Jack Gillis of the Consumer Federation of America.
Still if you insist on buying one then here they are.
The Field Poll found 64 percent of California voters inclined to support the universal health insurance plan outlined in the bill, compared with 23 percent opposed.
The Field Poll also found 63 percent of voters in favor of the state raising its cigarette tax to support the medical insurance plan, compared with 33 percent against doing so.
The poll only surveyed support for one of the actual final proposed funding mechanisms. That is a cigarette tax as cited above. If you remember (here’s my previous post on California’s plan) the other funding mechanisms are a 4% tax on hospitals and a pay or play deal for employers.
But with media coverage like this, would anyone be surprised if voters just put those two other little new taxes out of their mind or weren’t even aware of them at all (I mean, the majority don’t even read the plain language explanations on the ballot in full) when they vote?
So despite whatever campaigns the California hospitals or the Chambers of Commerce roll out, I would expect the funding mechanisms to fall into place.
This Is A Stick Up! Give Us Your Money!
And despite claims that the bill faces a challenge in the Senate, the actual ballot initiatives are probably the most likely place for this plan to be defeated. That said, there’s a slight glimmer in the Senate as the bill will not even be taken up in that chamber until the new year.
Despite a last-gasp effort in the Assembly last week, the Legislature is about to finish the “year of health care reform” without passing a health care plan.
While that outcome had become expected, what was surprising to many observers was the person responsible for blocking action before the new year: Don Perata, the Senate leader and a liberal Democrat from Oakland who co-authored the bill.
Perata announced he would not allow the Senate to vote on the Assembly-approved bill - not until he knows more about how the $14 billion-plus measure would affect existing health programs and the state’s overall finances.
[…]
[B]y pushing Senate consideration of the bill into next year, some proponents privately fret that Perata may stall its momentum and kill the measure’s already slim chances of being enacted.
At one point last week, the blunt-spoken Perata said in a TV interview that the health plan was “DOA” - a remark his office quickly said that he didn’t mean literally.
[A] risk of waiting may be that by the time the Senate debates it, presumably sometime next month, the political climate will be much more treacherous. Gov. Arnold Schwarzenegger plans to call the Legislature into a special session to grapple with a projected $14 billion deficit, and Perata himself is stoking doubts about whether the sprawling health care proposal would widen that gap.
That said, because the new funding mechanisms for the plan are being put to a vote by the people, and thus the bill doesn’t need a 2/3rds majority in the rooms to either side of the capitol, the bill will likely squeak out of the Senate.
In the end, even Republicans expect Perata will scare up the votes to pass the bill sometime in January. But they have enjoyed hearing the senator talk their talk.
“I love it,” said Assembly Minority Leader Mike Villines, R-Fresno. “I’d love to see it happen throughout the year.”
The Fields Poll certainly seems to emphasis the political capital California politicians have to implement a plan like this. What’s funny is that, according to the poll, the enthusiasm for the plan is tempered under certain circumstances. It shows the absurdism in the growth of society’s greed expectations of hand outs. The circumstantial evidence for this: the plurality oppose the health care plan if it is funded by a 1% increase in sales tax.
Now true, sales taxes are regressive and place a larger burden on the very population this health care bill is trying to “help.” But if you think the average Californian is thinking that deeply when answering this poll question your faith in humanity is, uh, misplaced. We all know that the “more real” it fells like dollars are being taken out of our pockets the less likely we are to support helping our fellow man. Sure the reality is the costs for the program will be passed onto all in some shape or form, but it’s only when it is obvious enough for them to see it, to feel it’s a reality that they pull their support away.
That speaks wonders to society. It also speaks wonders to the growing expectations of the role of government as a teat to suckle at, as welfare provider. Have no doubt that as income disparity grows we will continue to see increasing clamor from the majority for various forms of wealth redistribution (not to sound like Marx and Engels or anything).
That’s a shame. Just because the majority hawk for such handouts doesn’t make it right.
p.s.
Now, I’ve said it numerous times on this blog, but I’ll repeat: I personally believe I have a moral obligation to help the less fortunate. My continuing efforts throughout my career do and will speak for themselves. I just don’t think the government has any place forcing such an “obligation” on others.
I did my undergrad work in USC's School of Cinema-Television Cinematic Arts. I have a Bachelors of Fine Arts in Writing for Screen & Television. I loved it, but a future of waiting tables and taking meetings with B-List producers was not for me.
This blog is ostensibly to discuss healthcare policy and maybe educate a few of my fellow medical students. But it will stray into current events, politics, and other science topics when they draw my interest
Other odd notes about me:
I've skied half the resorts on this list (Squaw Valley/Lake Tahoe, Snowbird/Park City, Whistler, Taos, Vail)
I "played" lacrosse in high school and through a club level team in college
Nothing on this website is to be taken as medical advice. I am not a physician. Please consult a physician concerning any health related questions.
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Endorsements
"Please be more precise in your practice of medicine than you are in your blogging!"
- Mark Lanier
