Washington Post Columnist
Wednesday, June 10, 2009 11:00 AM
Washington Post business columnist Steven Pearlstein will be online Wednesday, June 10 at 11 a.m. ET to discuss health care reform.
Read today's column: Fixing Health Care Starts With the Doctors.
Annapolis, Md.: Great article. What I always hear from friends who are doctors is that medical school is too expensive. They start their careers with $20,0000 in debt so they have to make lots of money. In order to go to a salaried model (I support this) medical school would have to be much cheaper. That makes me wonder why college tuition has to go up every year at a rate much higher than inflation. Are there any studies where the additional money goes? I don't think teaching methods have changed that much.
Steven Pearlstein: I think we allow doctors to make too much of their debt, but it obviously is something that weighs heavily on them when they just get out of school. In major metropolitan areas, that debt looks pretty small when compared to the lifetime earnings that doctors accumulate in private practice over many years. They more than make up for their investment, as it were. But they use this debt to justify their elevated incomes for the next 30 years -- and make no mistake about it, as McKinsey has found, doctors in the U.S. do make ALOT more than docs elsewhere, on average. My suggestion is that we socialize the cost of medical education , that is have the government pay for it, in exchange for a couple of years of community service. That way, we get the community service and we eliminate the No. 1 reason given by docs to justify getting paid more than docs everywhere else.
Edgewater, Md.: Steven;
I do not disagree with a single thing you say in your column, and I have read Dr. Gawande's article also. I have only 2 comments:
a. One advantage of physicians aggregating into the large groups you describe will be sharing of malpractice risk and therefore, hopefully, a decline in defensive medicine which is helping drive up costs. People have scoffed at this point for ages but every doctor I have ever seen comment on blogs, etc. cites it, and we are the ones practicing it, so it shouldn't be blown off.
b. Please do not lump Kaiser in with the other groups such as Mayo. Unless it has changed since my professional experience with it in the 90's, Kaiser achieves its results at least partially by driving its docs to see more patients in less time, by stonewalling patients, and by taking advantage of EMTALA rules by not providing nighttime specialists for its subscribers' ER care, thus forcing the on-call, non-Kaiser doctor to treat its patients at 3 a.m. In addition, woe betide you if your family has a rare illness. Witness the woman who wrote in to a health care blog recently about her teen daughter with a rare soft tissue sarcoma (highly treatable but fatal if not treated correctly and immediately), who had to have a knockdown, drag-out battle with Kaiser to be referred to one of the few centers with expertise in this area.
People must be aware, there is no FREE LUNCH.
Steven Pearlstein: I didn't mention malpractice in my column today because of space, but one aspect of all these group type practices is that the group pays the malpractice premiums. That's a very important thing, eliminating the defensive medicine. We could do other things, like subject these kinds of disputes to arbitration by a really effective, neutral party, as well as limiting punitive damages and making sure that professional medical societies were no longer allowed to be self-protection societies. But it needs to be an element in changing the way docs practice medicine, no doubt about that. And you'll be glad to know that the president agrees on this point.
As for Kaiser, I've never been a patient, but I think a lot has been learned in the last 20 years by managed care organizations. That doesn't mean that they can't make tradeoffs that involve a member not getting everything he or she wants when she wants it, including a good chatting up -- we need to be open to these kinds of tradeoffs when there is no real medical benefit involved. But I do think they are much more sensitive to the softer side of things, including the way patients feel they are being treated, saying no to every psychological service that is requested, not allowing people to chose a primary physician, etc.
Princeton, N.J.: O.K. Steve, you know we are going to disagree on this. I believe everything you and Dr. Gewande say about medical practice in the U.S. is true. I believe it is the most important reason for our lousy health care system as compared to other countries. BUT I do not think you realize how difficult this is going to be to change. You write, "and then to change the way they work and realign their financial incentives so that this evidence guides their practice," but you give not the faintest idea how to do this. Are there bills in Congress? How do we get Mayo Clinics all over the country? How do we get the physicians in McAllen to change the way they practice?
It is extremely hard to get most doctors to change their minds. They have been taught they can never admit error. I have tried for years to show physicians that tort reform is a red herring. I give them all the statistics which are overwhelming. They never contradict any of my figures. They nod their heads, but then say that every doctor knows that malpractice suits are responsible for the high cost of health care.
My point is that there is enough money wasted by private insurance companies in high overhead, bureaucratic requirements on doctors and in high drug prices for us to give Super Medicare for All (HR676) and it will not cost any more money than we are now spending. You have pointed out that this will be very difficult, but I assure you it will be a piece of cake compared to what you propose. After we get everyone covered, then we can work on your hard problems.
Look, in the past, US auto makers managed to divert outrage about the patently unsafe cars they were building by concentrating interest on drunk driving and speeding. Now, of course, these did contribute to the problem, but now we know that there were other important factors such as unsafe design and improper maintenance. The situation is similar today. The powerful profit making health insurance industry is fighting for its survival. They want to direct attention away from the quick and easy and cheap fix that will give decent health care to everyone, but eliminate their industry like the buggy whip industry. They want us to look at the other important problems which won't hurt them at all. And, unwittingly, you are helping them.
Steven Pearlstein: Len, God love you but this really isn't going to be a useful conversation. Single payer just ain't gonna happen, so let it go. We can make huge improvements without getting there, so let's concentrate on those, shall we.
Moberly, Missouri: We already have government control of health care in this country in several areas. Consider the following list of medical care systems run by federal, state, or local governments:
1. U.S. military hospitals;
2.Public Health Service hospitals;
3.Veterans' Administration hospitals;:
4.State university medical school hospitals;:
5.tax payor supported city and county managed hospitals.:
In general, how do these medical care systems compare with private health care?
Steven Pearlstein: Actually, a lot of them, like the VA, are now better. And they conform to the model I suggested, with salaries docs and good information technology and strong, evidence-basec protocols. This is one of the great myths of the right wing, as recently evidenced by the incredibly stupid comnment from Mitch McConnell yesterday, to the effect that the Democrats want to have organizations on par with the Department of Motor Vehicles running your health care. First of all, that's a slur on all public workers, which is rather curious coming from a man who claims himself to be a leader in government, who in one swipe accuses all public employees of being incompetent boobs (that would include the armed forces, by the way!). But it is also just contrary to all the evidence that we have from the VA hospital system, which is now, for exampled, considered a model for managed, efficient, quality health care. If I were Max Baucus, I'd go to the Senate floor today and demand an apology from McConnell for this libel on the hard working, efficient and competent medical staff at the VA, and watch him try to wriggle out of that one.
Atlanta, Ga.: If the government truly cared about our health care (why do people talk about the uninsured...I don't care about whether or not people have insurance, I care about whether or not they have access to affordable care) - why don't they just open some health clinics up - hire doctors, etc, and see what happens? Let people go there, there could be a way for people to sign up, and based on income, a sliding scale for payment. Do away with 'insurance' for these clinics, and well, let the market decide.
That's my biggest thing - I don't want every single doctor/everyone involved in the health care delivery, to be govt employees. We already have a shortage of doctors, I don't want it to get worse.
Steven Pearlstein: I'm a big believer in such health clinics. They aren't a solution to the problem of the uninsured, but in certain areas of the country, they can be an answer to a failure in the private health market and when appropriate, we should fund them. If everyone has insurance, that shouldn't be a huge outlay, since they would be reimbursed through insurance. But there may be a need in some communities that are underserved to create such facilities. And, again, they are based on a model that involves docs on salary.
Washington, D.C.: A lot of coverage about health care reform seems to focus on the political aspects of who might vote for what. I'd like to see some basic facts. For example, I'd like to know in detail how foreign single-payer systems actually work. Supporters of single-payer plans say everybody could be covered better than they are today for less money. Opponents claim that a single-payer system would result in higher costs, waiting lists and rationing leading to deaths. I'd like to see the Post look in detail at how patients with common illnesses and conditions (and maybe some rare ones) might be treated in, say, Canada, the UK, France, Germany and Japan and report how their systems actually work, including tax outlays. The Congresspersons passing judgment on health care are covered under federal employee plans, which are almost certainly the best in America. When they say they want to protect private insurance, that's their reference point. But for many people private insurance is a world of high premiums, excluded preexisting conditions, big copays and rejected claims. I'd like to see you explain the federal plan to readers who aren't in it. Suppose it was expanded and made available to everyone, as John Kerry suggested in 2004? And if private insurance is mandated, who decides what the premiums and deductibles will be? What would prevent insurers from shafting people who are legally required to buy their products? By contrast, Medicare is an existing national single-payer health plan for pretty much everybody over 65. One organization has been running ads that support "Medicare for Everyone." How would that work? Suppose everybody could buy into Medicare? More facts, please.
Steven Pearlstein: Medicare for Everyone would be a terrible idea, because Medicare for most seniors now follows the fee-for-service model in which care is not managed and everything is left to the patient and the individual doctor in solo practice, which results in lots of bad decisions for patients and for the cost of the overall system. It would really bankrupt the country or ruin the health care system. It's a demonstrably lousy idea. The trick, as I said, is to change the way medical practice is organized and doctors do their work, and that is going to require a lot harder work than simply waiving a magic wand and saying Medicare for All.
Just How Corrupt is Max Baucus & the Senate?: How can a senator from a state with less than 1 million people (who apparently strongly disagree with him themselves) control the healthcare outcomes for more than 350 million people, 50 million of whom (like me) have zero access to medical or dental or any type of health care, much less insurance coverage?
How can there possibly be any excuse for your paper, other corporate media, and especially the democrapt party to allow this well-paid shill for the insurance and pharma-medical industry?
And NOT call it by the corruption that it is?
I am outraged and if the dems allow it, they , like the republicans have already learned, can kiss this and millions of other votes goodbye come 2010.
Really, how in the world can this be allowed to happen as if no one can do anything?
washingtonpost.com: Tax on Health Benefits Weighed: Senator Calls Levy 'Perhaps the Best Way' to Pay for Overhaul (The Post, by Lori Montgomery, June 10)
Steven Pearlstein: What are you talking about?
Annandale, Va.: Just one of the unwashed masses with pitchfork in hand -- There is a rather cavernous divide between those of us with shaky access to the US healthcare system (major of Americans under 65!) and the lucky duckies who have stable access to good insurance. You have been richly blessed in life, I don't begrudge you a thing but you are blind to the reality of the rest of us who live in fear of losing the crap insurance we have or being bankrupted by what our crap insurance won't cover if we have a major illness. We have to literally harass our insurance companies to get what little coverage we have and be wage slaves to our current employers to not lose what little we have.
Please, please Mr. Pearlstein try and understand that most of us know there's no net below as we walk this high wire act. The best stimulus we could have for this broken economy would be to free Americans from the tyranny of your access to humane healthcare being tied to your income and employment.
Steven Pearlstein: Not sure what to say except that this is what health care reform is about. And one thing that will be included is a minimum benefit package to insure that insurance companies cover the important things, and maybe not cover the things that aren't so medically important that all the rest of us should pay for it.
Milwaukee, Wisc.: Steven - Should the cost of medical school and possible public funding towards these costs play a role in health care reform? Given the upfront and related opportunity costs in time and money to become a doctor, can there be enough of a financial incentive factored into health care reform to make the commitment to become a doctor financially viable?
Steven Pearlstein: Yes, as I said before. And by the way, we should stop trying to tuck subsidies for medical education into the Medicare reimubrsement rates of teaching hospitals, which winds up being a boondoggle in their favor. And the reason I know that is true is that if you ever suggest that Medicare pays for medical education directly, and breaks it out as a line item, you will get extraordinary pushback from the New York, California and Massachusetts delegations, which shill for the big teaching hospitals, which know that the current system is a boondoggle.
Wokingham UK: You'll have noticed that our National Health Service managers are predicting a huge deficit for 2011, partly caused (I think) by keeping small, friendly but 'inefficient' local hospitals and units open by grassroots political pressure. Do you think that the distortion of planning by political pressure is inherently greater in state-run than in insurance-based systems, or in reality about the same?
Steven Pearlstein: Yes, that is a problem with a state run system. But nobody -- and let me repeat, nobody -- is proposing that for the U.S. except folks like my friend Len up in Princeton. There are too many hospitals, still, in the US and there is a lot of community pushback when they are closed or their units are closed. But some of it is ridiculous, really. There is no reason why people can't travel an hour to a big hospital to have a baby, for example, in a big modern maternity ward that does lots of deliveries and has enough volume to be able to afford all the latest equipment in case something goes wrong. I mean how many times in your life do you have a baby that you can't drive an hour to have it done, rather than insisting that every community hospital have its own maternity ward. It's just one example of the inefficiency that gets built into the system by people -- that would be you and me -- who insist on things that, in the end, don't have ANY impact on the quality of care. In fact, they have negative impact. The emphasis on being able to chose your own doctor in every instance is another, as if most of us have a clue as to who are the best docs and who aren't. These are the kinds of irrational things we need to try to work out of the system, because they wind up being very costly.
Staten Island, N.Y.: Excellent column as always. In addition, it is well known that a disproportionate share of health care spending goes to the treatment of the chronically ill. Of course many of these illnesses are beyond human control, but our societal failure to address the usual culprits (diet,obesity, smoking, etc.) plays a large role.
How can society address this, beyond more sin taxes?
Steven Pearlstein: Evidence based medicine is the way to address them, because if in fact the cost-benefit of performing a hip replacement surgery on an 88 year old woman with cancer and diabetes is very low, then that should not be an insured service. IF you want that, or you want it for you mom, pay for it yourself -- but don't ask the rest of us to pay for it in higher insurance premiums or Medicare taxes. But first we need the evidence to show that it isn't a good idea.Then, once we have that evidence, the doc has to follow the protocol and explain to the family why it's not a good idea and not merely blame in on the big, bad insurance company for being so heartless--which, by the way, a lot of docs do, so they can look like the good guys. Of course, they'd love to do the surgery in many cases because they'd like the business and the extra income, so they are hopelessly conflicted.
Arlington, Va.: Under any of the three major plans circulating Congress now will illegal immigrants be covered? If not, how do we close the gap of uninsured and underinsured working families?
Steven Pearlstein: I don't think illegal immigrants are going to come out with a lot of coverage from these efforts -- there is just no political will for that. They may get treatment the first time, but they'll also get a deportation notice along with it, as I understand most of the proposals floating around. And Republicans will make a huge deal of it if illegal immigrants are allowed to get subsidized care for years on end, which is why its not gonna happen.
Rochester, Minn.: Dear Steven,
Can you summarize quickly the results of studies regarding cost drivers in health care? How much of an issue is malpractice in driving health care costs, really?
Thanks much for the chats!
Steven Pearlstein: Its a small factor, no where near as significant as doctors think. If you read the New Yorker article, for example, y ou'll be reminded that in the Texas community Atul visits, they have already passed laws restricting malpractice awards, and still it was the most expensive health care setting in the country.
Hyattsville, Md.: Steve,
Federal employees get good health coverage. Why not just expand their coverage to anyone who wants it?
Steven Pearlstein: In general principle, that is exactly what most of the proposals would do.
Washington, D.C.: You need to go be a patient of Kaiser Permanente before you support their model. If you don't have anything wrong with you, they are fine. If you have a condition that requires thought for a diagnosis - forget about it. You will not get appropriate treatment, in fact you may get harmful treatment. The doctors are not allowed to think and they get down right hostile if a patient asks a question. If that is the model of health care in our future, we are doomed.
Steven Pearlstein: I am not a patient, although I have heard such complaints before. I think the Northern California version is considered the good one. Can't speak for the one here.
Lonely Len in Princeton: Here is a question from a Washington Post - ABC poll: "Which would you prefer: the current health insurance system in the United States, in which most people get their health insurance from private employers, but some people have no insurance, OR, a universal health insurance program, in which everyone is covered under a program like Medicare that's run by the government and financed by taxpayers?"
62% favored Medicare for All; 33% were opposed. That's pretty decisive. And this is with the facts suppressed. Other questions in the poll show that the 62% supporting the universal program mostly believe it will cost more when it will cost less. They believe they won't be able to pick their doctor when Medicare allows much more freedom than most private plans. They believe there will be long waiting times when this is a myth. And still they support a universal plan like Medicare for All by 2 to 1.
So you see I have a little company.
Steven Pearlstein: If you lived in Washington rather than Princeton, you'd know that it doesn't matter what the poll says, it ain't gonna happen. And as I have told you many many times, Medicare for all (i.s. fee for service for all) is a terrible, terrible idea, financially, medically, and in every way. The problem is fee for service medicine without any attempt to manage and coordinate care, and now you want to make that the national model. Come on. Why don't you go talk to Uwe Reinhardt at Princeton and have him explain it to you, if you don't want to trust me.
G'town, Md: I grew up in a rural community many years ago, and can remember general practitioners billing on a fee for service basis.
Somehow, the cost of basic medical care didn't break the piggy bank. Plus, back then, doctors would even make house calls.
So much has changed; and it isn't for the better. There is unwarranted stress on all sides. Millions don't even have access to healthcare. Physicians are forced to comply with managed care metrics - physicians withhold and ALOS are the two most intrusive I feel since the quality of patient care may be compromised. Profit and the utilization of re-imbursement tables tend to work their way into decision making at every opportunity.
If I had the wealth to lobby Congress, I would press for (1) Exempt medical providers from lawsuits, (2) Require physicians to bill on a fee for service basis with published fee schedules, and (3) Make it illegal for insurance companies to negotiate with medical providers on patient care, rates and fees.
That would be it.
Insurance firms would go out of business. Physicians would compete for patients - hence, keeping downward pressure on pricing. Plus, physicians would be free to calculate the care and time with each patient as they see fit.
With that, managed care does have its benefits. Germany's Kaiser model is excellent. But operating the healthcare model in a profit maximization context cannot yield good results for society at large.
Steven Pearlstein: Gee, why is that you think non-profit hospitals are essential but then have no problem with doctors determining not only their own fees but how much medical service they are going to sell to every patient. Do you think doctors operate on a non-profit basis?
Clifton, Va.: Federal employees also pay big buck for their health care.
Steven Pearlstein: Indeed, and many of the programs offered by the government are very expensive. But the basic model, of the government soliciting bids from lots of different insurance companies and then offering those, with their various costs and terms, to all comers -- that is the same model of the new "exchanges" that are envisioned in the various proposals on Capitol Hill.
Chicago, Ill.: Hey Steven, what is your rebuttal to Milton Friedman's argument that the reason for rapidly rising healthcare costs is that most people don't pay directly for it and therefore care much less about comparison shopping? As long as we maintain the employer based system or (god forbid) go to "single payer" wont that fact still be true if not more pronounced?
Steven Pearlstein: Its a factor, but buying medical care is not like buying lawn furniture. You don't need much experise to buy lawn furniture -- loook at the price, put your fanny in the seat and you makes your decision. But in medical care, you rely to an extraordinary extent on the advice of the doctors (i.e. the sellers). And its also not an area where you are inclined to be very price sensitive -- is anyone going to go to the Wal-Mart of surgeons if they think their life may depend on it. So this isn't just like any other market and consumer information and consumer choice and transparent pricing isn't going to be the only answer. Conservatives overstate this factor, in my opinion, with their fixation on "consumer driven health care." I agree consumers should have more skin in the game, financially, and I agree pricing should be much more more transparent, even when it is being reinbursed. But it is NOT true that a well-informed consumner will always make the right choice about medical options -- they still need the advice of doctors, who under the current system have a very noticeable conflict of interest.
Princeton, N.J.: anon, MD said that "defensive medicine" is a large expense. This is totally false. Here is a quote from the book "The Medical Malpractice Myth" by Peter Baker about one of the many studies on this issue.
"In connection with tort reform legislation proposed in 2003, the CBO looked at the effect of state tort reform on per patient spending by Medicare for a variety of illnesses as well as the overall per capita health-care spending in each state, Using Kessler and McClellan's methods, they 'found no effect of tort controls on medical spending' and concluded that there would be no cost savings from a reduction in defensive medicine."
Also the total amount paid in malpractice insurance premiums amounts to 0.56% of health care costs.
Steven Pearlstein: Indeed. But doctors don't believe this, no matter what evidence you present them.
Lonely Len : Well, of course, I have talked to Uwe. Why don't you ask him if a single payer system would be better than anything currently proposed?
The point is I do NOT support fee for service. I want to change, but I do not know how and neither do you.
If you do, why can't we use your wonderful idea in a Medicare for All system? In fact, I bet it would be easier under that system tha anything els.
Steven Pearlstein: Well, when people say they like Medicare for All, what they mean is having a system where everything they want they get, they can go to as many doctors as often as they like, and somebody else pays for it -- the current fee for service Medicare model. So while people may say they like that, its not a good alternative, as you acknowledge.
Anonymous: Your column today, and the Gawande article you reference, both underscore the point that we have to get the fat out of the U.S. health care system. But as you and others observe, rationing will never happen, because it seems to be a matter of picking winners and therefore losers.
But it seems to me that the following set of numbers holds the extraordinary promise that there really can be a solution that makes everybody a winner. A slight up-front cost in terms of First, as much as 40 to 50% of the total health care costs an American spends will be in the last few months of their lives. The dying often have all sorts of aggressive and expensive procedures that they do not need, that are not effective, that cause great pain, and cost huge amounts. Study after satudy shows that peoplke who think through what they really want at the end of life, engage the services of Hospice, and fill out Living Wills, live just as long as others, but experience much less pain, and cost a lot less than those who don't.
This seems to me low-hanging fruit, but is largely unharvested. What is your view?
Steven Pearlstein: End of life care is a big part of the overall health care bill, although I think people tend to overestimate how much can be saved by better managing that. There is some saving, even considerable saving. But one of the problems of the end of life analysis is that you don't know when you are making an end of life decision and when you aren't. Unlike the post-hoc researcher, you don't know that a particular course of treatment won't work -- in fact, you often think it will, which is why you pursue it. So you are ignoring all the times that "end of life" type of treatment actually works and therefore isn't categorized as "end of life."
Anyway, there is a lot of money to be squeezed from our system before we have to get into those very difficult moral decisions about denying care to the elderly. Let's pick that low hanging fruit first.
Boston, Mass.: So the 88-year old grandma who wants a new hip should be denied because the "evidence" says so - but if she is lucky enough to have the money, she can get it privately? Or are you saying even then she shouldn't be allowed to have it?
I thought reform was supposed to be about making things fair, not about making things more fair for some than for others?
Steven Pearlstein: No, this is America and if you have the money to "buy" medical services that have a low chance of success or a bad bost-benefit ratio, that should be your right. But please don't ask the rest of us to pay for that in higher premiums. Now if that sounds unfair, so be it -- the purpose of health reform is not to make things perfectly fair in a capitalist society. It is to make sure that essential health care is provided to everyone -- and by essential, I mean medical care that conforms with best practices based on solid medical evidence.
Corvallis, Ore.: Can just expand coverage without controlling cost. Not enough money on the planet to simply "give" everybody what federal employees get.
Steven Pearlstein: Nobody's talking about giving it everyone -- people would have to pay for their insurance, with some subsidy going to those who have such low incomes they can't afford it.
Portsmouth, N.H.: Hi, Steve,
I don't know the numbers on this issue, but I'm guessing they might matter. Have available medical school slots increased over the last thirty years? The population of the country has grown enormously in that time, but it appears that higher education in general has not really caught up with that population increase, which if true, accounts for some of the upward pressure on its pricing. Many more eligible students competing for the same number of slots allows higher ed greater latitude to ridiculously overprice their product. Do you think that's a factor in medical inflation?
Steven Pearlstein: We do have too few of family doctors, OBGYNs, pediatricians and too many surgeons, radiologists, dermatologists, etc. The government needs to get more involved in setting the numbers of slots in each category. Also, this doesn't work the way other markets do. Having too many surgeons doesn't mean the pay of surgeons is depressed -- it means that too much unnecessary surgey is done. Demand rises to meet supply in medicine, which is not true of other markets and is one of the big reasons why we need to change the compensation structure of physicians and get away from fee for service.
Atlanta, Ga.: how qualified and knowledgeable are the presidents advisors on healthcare reform?
and with your knowledge and background,have you been approached by the white house,or have you offered the white house your services on helping with healthcare reform?
i'll hang up and listen(radio joke)
Steven Pearlstein: The president's health care advisers are very, very very knowledgeable. It is a very impressive team.
Boston, MA: Steven, I have never heard of a doctor trying to blame an insurance company for a denied surgery so they can "look like the good guy." The overwhelming majority of doctors are trying to do the right thing by their patients, and are tremendously hindered in that effort by the insurers, private or public.
I'm not sure if a doctor ran over your dog or something, but comments like these make me wonder: "Of course, they'd love to do the surgery in many cases because they'd like the business and the extra income, so they are hopelessly conflicted."
Steven Pearlstein: Maybe you should talk to Atul.
Stockholm, Sweden: The Swedish tax based health care system has some of the best measured outcomes in the world...someone should add this to the list of comparison and benchmarking
Steven Pearlstein: Okay then.
Clifton, Va.: Many of my colleagues and friends who are civil servants don't want our prez messing with our health care. We sacrificed pay and spent years working with crummy bosses so we could have decent health care. its time for those who don't have health care to get an education and take control of their lives and not come begging to the gov't for help.
I want to be able to choose my own doctors and don't want my health care to deteriorate in quality to something that rivals the health care military, retirees, active duty members and their dependents receive. Obama and Congress need to watch their steps. Might be time for open rebellion.
Steven Pearlstein: Nobody is going to mess with your system, or even wants to.
Washington, D.C.: I'm a 30-something female who's never been near the military, and I would LOVE to sign up for VA care. Their outcomes are awesome. If that's what government-run healthcare is like, sign me up. Sign everybody up!
Steven Pearlstein: Sorry, but there's a little pre-requisite that will consume at least three years of your life.
Princeton, N.J.: Steve, France has Medicare for All and it works great. Why didn't you address the part of Washington's questions about other countries?
Steven Pearlstein: France does not have Medicare for all. It has a nationalized system with lots of government controls on doctors pay, hospitals, deciding what treatments will be covered, etc.
Burke, VA: Good column--very clearly articulated. I'd like to know what you think of my theory, which is that prescription drug costs would go down dramatically if pharmaceutical companies were prohibited from direct marketing their products to consumers. This would lower their costs, allowing them to sell the drug for less to those who really need it. They could still provide information on the drug on-line so that consumers can still do research. Am I completely out to lunch on this?
Steven Pearlstein: On the scale of things, a small impact.
Defensive Medicine: 1. The total of all malpractice insurance premiums amounts to 0.56% of health care costs. 2. The CBO has examined the idea of defensive medicine. They found no difference in practice between state with limits on tort settlements and those with no limits. Defensive medicine is a myth.
Steven Pearlstein: Its not a myth, but its impact has been greatly exaggerated.
Washington, D.C.: Physician income, as discussed, is not really the issue. (vertical integration aside) There is plenty of money in the existing system for physicians to be paid well, and so they should. It is their dispensing habits, dispensing of health care and medical assistance without regarding to productivity. New and more expensive technology that yields marginal results over existing methods, and the physician ill rational exuberance to dispense such care that is at the heart of the issue. Most all the data that is evolving and studies being release are pointing in that direction, but few have the courage to say it. Please read Institute of Medicine's Knowing What Works In Health Care.
Steven Pearlstein: All good points. And I have looked at it.
Chantilly, Va.: Let's go right to the bottom line. The U.S. doesn't even rank in the top 20 in life expectancy. Every country ahead of us has some form of national health care plan. Better infant mortality rates too. So congress, get 'er done, no excuse!
Steven Pearlstein: A good way to end our discussion. "See" you all next week, I hope.
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