Oh Henry
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One useless person is a depressing sight. Two useless people are a law firm and three or more useless people constitute a congress. As we watch the Obama administration back away from “change you can believe in,” there is no place where it is greater illustrated than in the question of health care. He was smart enough to appoint a Nobel Prize-winning physicist to deal with energy issues. Why in the world would he pick mere politicians to deal with health care, which is the single largest business and expenditure in the United States? We’ve moved from Tom Daschle – who didn’t know how to pay his income taxes – to a governor from Kansas. What exactly does she bring to the table? I have no idea what makes this person able to comment on health care in the United States.

The principle task of anyone who leads the discussion on health care is that they must LEAD THE DISCUSSION ON HEALTH CARE! They have to talk about issues that are not comfortable or politically correct. Somebody has to be the stalking horse who will get out there and talk about the things we need to discuss. What are those issues? Number one: The shift in the dependency ratio. How many people are sitting in the wagon and how many people are pulling the wagon? The huge shift in this ratio means that this is an aging country and we are no longer going to be able to retire at 67 or 68. The number may have to go up to 72. We are no longer going to be able to supply certain services to everybody through insurance programs. The real question is, who has the courage to carry on the discussion about the limitations of health care. Nobody in Washington minds if you use the “F” word; nobody wants you using the “R” word. Rationing frightens the living daylights out of everyone in this country. If you think we’re held hostage by the National Rifle Association, think again. It’s the American Association of Retired Persons (AARP) that is going to closely monitor any real change in health care.

This is the only country of the 17 western democracies which cannot carry out an intelligent discussion on end-of-life issues. What emergency physician has not watched an 89-year-old with terminal Alzheimer’s brought in for the treatment of their pneumonia? What are we doing? Why have we decided that ministering to dying flesh is better than helping the young?

There is no reasonable way to spend your way out of this situation. The current stimulus package is probably a misnomer and a mistake. To think that we are not going to have pain and suffering while pulling ourselves back into line is a joke. And that pain is going to fall – to a great degree – upon how and what we give out as health care. You can’t avoid it. It’s the largest single expenditure in the United States government. The only way that is will be resolved will be through catastrophic inflation. There are two things everyone should do when they go home tonight. Number one, rethink how health care needs to be given. Number two, teach your children to bow politely to their Chinese masters. If the Chinese are no longer willing to fund the debt, we are, as a country, screwed.

The time for small, itsy bitsy band-aid solutions is over. Someone is going to have to lead. Someone is going to have to make real suggestions. Someone is going to have to ask why the Singaporeans are able to have better health stats for one-quarter the money. Someone will have to ask why the Germans can figure out what therapies they will and will not give for breast cancer and we can’t. This is a politically-driven agenda, not a scientifically-driven agenda. We are encountering forces that are so entrenched it’s beyond belief. To think that there will be respect commanded in the medical community by an ex-governor of Kansas is a joke. We need to bring people to the table who can talk about the history, the worldwide activity, and the future of what’s actually happening in health care. It is almost an affront to tax-paying citizens of the United States (and to our children who will inherit this mess) that we allow someone appointed to that job who, quite frankly, can’t articulate the real issues involved.

If not the governor from Kansas, and if not a former senator who can’t figure out how to pay his taxes, who should sit in the seat as secretary of Health and Human Services? There are plenty with health care policy experience and real ideas who ought to be leading this discussion. I don’t agree with everything Uwe Reinhardt from Princeton has to say, but I respect Uwe Reinhardt as a mind. This is a man who has devoted his life to health care policy. He is, by birth, a German. He understands hard decision-making. And Mr. Reinhardt represents only one of at least a dozen major figures who are well known in the United States, have at least reasonable respect from the American Medical Association, and could at least present a series of discussions which we could all relate to. God save me from this compulsive need to appoint people who can’t get honest jobs to positions where they’ll lead major discussions in this country.

Greg Henry, MD, is the founder and CEO of Medical Practice Risk Assessment, Inc. Dr. Henry is a past president of ACEP and directed an ED for 21 years.
 

Comments   

# Health Care "Problem"Mike M 2009-04-01 22:53
1. The Chinese don't have a choice - they must continue to fund our debt. As the saying goes: If you owe someone $1000, they own you. If you owe them $1,000,000,000, you own them.
2. I propose that Singaporeans have better health stats for less money spent because they also spend less on crack and similar treats.
3. We can't figure out when to say "No" because we were raised on alternate realty TV shows like "Medical Center" where arrival at the hospital alive meant you survived and we are a nation of victims where someone else must be responsible and held accountable for any undesirable consequence that happens. Also, unlike Europe, we are a mobile generation unaccustomed to death in those close to us.
4. Perhaps the most significant problem is that some of our politicians have fooled us into believing that health care is a right. If my health care is a right that is owed to me by some other person or entity, why should I bother to eat right, exercise or refrain from drugs, excess alcohol or tobacco? If it's a right, why shouldn't I run to the doctor for every little sneeze or boo boo?
5. Why should the "we" as a nation decide what is best for "me" the patient? I guess that's the problem when "I" expect "you" to pay for "my" care. My preference is to get "you" and the government out of "my" health care. If I want the right to health care, it should be my responsibility. The hard question is not what care "we" as a nation cannot afford. The hard question that we have shifted away from is: "What do we do about people who don't have insurance (for whatever reason}:-?" For far too long, instead of insisting that people be responsible for themselves, we have taken the politically correct avenue and avoided the hard answer.
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# Robert Bitterman 2009-04-04 05:21
Greg,
How true, how well said, and how unfortunately your logic and truth will be ignored by politicians who simply don't understand the service they are attempting to manage.
Bob
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# The 'R" word is 'RIGHTS', not 'rationing'.Michael Garrett, M.D. 2009-04-06 20:56
The discussion regarding health care policy must be brought back to basics. Dr Henry's "number one" issue is the "dependency ratio," and he appears in this essay to advocate rationing of health care to Americans. How sad.

The basic issue in this debate is whether health care is a right. It is not. A right, as our founders understood, is a freedom of action, NOT a right to goods and services. Health care is a complex combination of goods and services provided by real people (US!) with actual rights. If we treat it as a right, then we have to provide it for everyone, which means violating the actual rights of everyone involved. The taxpayer's right to his property, the providers'(that 's us, guys) right to freely practice as they see fit, and the patient's right to decide what care they choose.

The problems of rationing with it's excruciating dilemmas of who to sacrifice, what to cover/not cover, the dependency ratio, etc all are solved by recognizing that health care is not a right. And it clearly allows us not to get caught up in squabbles about which bureaucrat (or intellectual) should head an agency which by it's nature violates rights and should not even exist.

If we return to a free market in medicine, each individual can decide what coverage he wants, what treatment he's willing to pay for, et cetera. And we won't have any federal boards deciding what medicines or treatments we can prescribe, or when we're too old to be worth saving.
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# MDERDFW 2009-04-06 21:43
The problem with not viewing healthcare as a "right" is that by doing so, you abandon the segment of society who needs it the very most: the very old, the very young, the destitute. If you're going to argue "healthcare is not a right" I hope you're prepared to take care of patients with epiglottitis again, since immunizations are not a "right" and not to be subsidized by our government when need be. You can see the slippery slope this can become.

Third world countries do not view health care as a right, and if we take that stance, how exactly would it reflect on our nation? I wouldn't call it progress and I wouldn't call it enlightened. I'd call it a sad step in the wrong direction.

Our healthcare expenditures have grown simultaneously with our waistlines in this country. I recognize the aging population and I fear that generation will hold us hostage one day as they retire in droves. But one can't ignore the obesity epidemic, one can't ignore how unhealthy our society has become, one can't help but ponder how many BILLIONS we would save tomorrow if people were healthier in the U.S. today
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# Praise Reinhardt's German Decisiveness?anonymous 2009-04-07 06:20
Dr. Henry's interesting essay unfortunately seems to attribute some of Uwe Reinhardt's qualifications to his birth in Germany. He is a man who "understands hard decision-making ." Spare me this praise of legendary German decisiveness. Some of my ancestors fled Europe in time to survive the Nazi's, some didn't, and the decisions Germany made in the 1930's led to unmitigated catastrophe for all of Europe a few years later. Mr. Reinhardt's qualifications certainly can be praised without invoking that legendary German character.
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# Right on GregMichael Halasy, PA-C, MPAS 2009-04-10 22:48
One of the better commentaries I've read, as a member of the Mayo Clinic Health Policy Center, big changes are coming. We need to be part of the discussion. And, decidely, some parts of that discussion, such as rationing of care, and decreased reimbursements AND benefits, MUST be part of that discussion. 6.7 % is not sustainable.
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# Nebulous solutionsJohn Frey 2009-04-11 18:09
Healthcare isn't a right. No one has the right to another's labor. Because if they do, it is called Slavery. And that is illegal.
Healthcare isn't a right anymore than owning an ipod is. It is a consumer product. A benefit that people pay for. It is traded in a marketplace already highly regulated by the govt so it makes sense that the solution would be a political one. Should everyone get ipods or a free place to live because it is not fair that some have and some don't?
Can we talk about the real issue here - the inability of the govt to regulate the healthcare market effectively? Where is the evidence that they can do it better than the free market? Or is this just a fantasy based on hope?
I understand if some want a king or a faceless socialist bureacracy to post dictates in the village square. Some in this country aren't americans. Some are americans and don't like america. And many aren't comfortable with freedom.
In America, rights are given by our creator and it is the govt's role to have the humility to stay out of the way. If men can give it, men can take it away.
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# The end of the autonomous physician? Part 1Robert A. Jasso 2009-04-12 10:00
I am pleased to have the opportunity to present my concerns to you. Have you ever been drawn into a fight that you did not start, but once in, you realized that the fight was worth your effort? The more you fought, the more you realized that you needed to win? I answered a cry for help and in my research I discovered a scenario that if allowed to continue unimpeded would eventually lead to the destruction of one of Americas finest achievements. This achievement in my estimate is our current model and practice of medicine in the U.S.

The emphasized attention by the administration to change our model from an indemnified healthcare system to a socialized system of healthcare, if implemented, will degrade the quality of care. The majority of the citizens have no interest in this degradation. Sen. Clinton’s attempt to introduce socialized health care under her husband’s administration while done in stealth did reveal a strong objection to this proposition.

With the current system, I have built the greatest trust with my health professionals. If I did not have this level of trust, I would freely find a professional with which I did. This is my current prerogative and privilege. I could do this without any delay. I do not have evidence that a socialized health care system would deliver this same quality. Current socialized health care cannot match this expediency. Their delays and limitations are not acceptable.

So who’s interest is it to transform our system into a socialized system of health care beside Sen. Clinton and President Obama and why? Uninsured citizens and undocumented non-residents, not really, but yes to medical care in any form. You can all see the pattern. Most all want medical care coverage, but is this feasible, and the quality of care.

The obvious, when all are entitled (have rights) to a limited resource, the end result is an equal portion (ration). The type of proportion (covered services), along with the qualifications (age limits, co-morbs, and genetic profile, etc.), reimbursement and interval are all dictated in the rules, regulations, and treatment protocol. In my estimate, what is at stake is the clear attempt to for domination over the only true autonomous profession, the physician. Why? The motivations could vary widely. Regrettably, the need for power for the sake of power itself is also part of this equation

We can only estimate the success of this paradigm shift with results from other nations and special environments domestically that emulate social order. The results do not warrant the intrusion and change. Herein lays the immediate danger, with Gov. Sebelius the nominee for confirmation as the Secretary of the Department of Health and Human Services, her documented outcome with socialized medicine are accumulating gross evidence of being. Her model and executive responsibility contain all the elements, and attributes to draw correlation with which we can extract her predictability as the chief as nominee for HHS Secretary. Due to its low public visibility, coloration due to the Hawthorne effect is limited. The model contains elements of socialized medicine; limited resource, rationing, governance, oversight protocol, 100% population coverage, treatment protocol, and quality of care that are all attributes of socialized medicine. Her model is the Kansas Department of Correction system of health care. All I can say, if you are unfortunate to cause yourself entry into this system of socialized medicine under Gov. Sebelius, don’t get sick. To get sick may change your 24 month sentence into the Death Penalty.
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# The end of the autonomous physician? Part 2Robert A. Jasso 2009-04-12 10:02
Furthermore, try to fight her inhumanity and you may find that she has close allies in the federal courts that see no need to recuse. Judges name look similar to the governors? https://ecf.ksd.uscourts.gov/cgi-bin/show_public_doc?2003cv3451-111 . Conflict of interest rules does not extend to the Governor Sebelius, she appears above the law. A quick web search of the many instances of medically documented court proceedings for instances of torture, pain, and suffering under her socialized medicine system demonstrate the poor quality of care (Google: CORRECT CARE SOLUTIONS complaints). It also demonstrates her ability to not be subject to oversight on the grounds of technicalities. As I write, I am beginning to understand the motivation and reasoning by Gov. Sebelius to transfer certain inmates to certain correctional facilities within certain Federal Jurisdiction, clever. A statistical study may prove a high correlation with the transfer of inmates who have filled suite for medical care into particular Federal Jurisdiction Districts due to the high probability for dismissal by certain judges. This if demonstrated, does offer direct evidence of intent and collaboration. For more detail see: www.iscientiausa.com She does not deserve the honor of HHS, it is a mockery and dangerous.

My friends, I may not be the first to bear you bad news, but I do believe you must take a stand. You have earned you place in society by talent, hard work, and dedication. This along with a love to serve mankind has enabled you the ability to practice you profession in an autonomous fashion. I want to thank you for your service. I also want to indicate that you have my support and I will join the fight, but this fight must be led by you. I have confidence that your dedication and intellect will enable you to win the battle. But let us be clear, the opposition is motivated and with a one party controlling majority in both houses and the Office of the President on there side, they are a clear and present danger to our freedom in our medical system. Remember, it is better to fight; win or die on your feet in the name of freedom, than it is to die on your knees in tyranny. Resolve to fight!

Sincerely,

Robert A. Jasso, MHSA
University of Kansas
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# MDLevine 2009-04-15 23:48
The New York Times and Washington Post should publish this piece! The American public doesn't understand healthcare issues. One item that Dr. Henry didn't mention is that our President, Senators and Congressmen have the best healthcare in the world. They will never have to be bound by the practices of Medicare.
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# Health Care rightK M.D. 2009-04-16 15:38
The problem with taking the position that health care is NOT a right is that you are ignoring a few realities. Due to technology, advancements (whether for the good or bad) we have created a system where very few people can afford not only to pay for their own care, but to pay for the insurance that will provide the care. The discussion of "Is Health Care a Right" is a bit moot, as the system we have demands we find a solution. If we are an intelligent and moral people, we must find a solution.

Secondly, I became a patient a few years ago. NOT impressed. As a physician I previously believed that people in the system did the best they could, which was good. Now I see clearly how many people enter the hospital due to medication errors, etc. In my own family: sister killed by med error, father coded due to medical error, mother got a heart cath by accident?? and without family knowledge, on another occasion spent a week in the hospital (should have been an afternoon) because the hosptialist didn't have time to discharge her (didn't want to do paperwork and punted every shift to the next guy), and best friend had entire colon removed due to procedural accident (I doubt seriously her doctor loses sleep over her lifelong condition that she handles bravely). I would be permanently paralyzed if I have followed the insane instructions I was given by some overworked and rude doctors. My eyes are opened and I see what people have been complaining about. We have to shift. Let's just make the wisest moves possible. I LOVE Ewe Reinhardt. Great selection.
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# Jerald Reisman, MD 2009-04-16 23:02
As usual, Dr. Henry articulates the problem well. I would add that it is time that this country comes to terms with the fact that we cannot afford everything that everyone wants or feels entitled to. I find it incredible to see demented 80 year old nursing home patients on dialysis. They also have feeding tubes never mind treating there pneumonia. Can we afford to do face transplants? Should expensive medical procedures be rationed by an ethics committee.I find that patients coming into the ED use to demand CT's for everything now they want MRI's. I want to tell patients they can have any test they want but they have to write out a check for $1000. If the test is positive they get their money back and if it is negative, we keep the money. When you pay nothing for all you demand, why not demand everything. "Health care is a right in this country, is food not?" Why can't you walk into a grocery store if you are hungry and take whatever you want. Someone needs to make better sense of our health care system.
Dr. R.
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# emergency physicianPatrick Connell, MD, FACEP 2009-04-17 09:03
I largely agree with Dr. Henry. My personal solution is not for everyone. I voted with my feet, and I now practice for the most part in Central America. The needs are great, the resources are few, the gratitude is enormous, and the lawyers lurking are non-existent. And the pay sucks.

After 30 years of clinical emergency medicine practice, I still enjoy the practice of this honorable profession. Yes, I enjoy it. And I think I am getting better at it. Now I can apply my experience, my instincts, and my compassion to treating people who have not yet acquired a sense of entitlement. In Honduras, we refer to this country up north as "The Entitled States of America."

If we as a profession do not find a unified voice with which to stand up to the newly empowered Beltway Bandits who are trying to "reform" our health care system, the outcome will be a weak porridge of poorly conceived "solutions" which will neither serve our patients nor the profession well.

What if we as a profession were to acclaim our support for evidence based universal health care in exchange for abolition of the tort system in the health arena? What if we make this non-negotiable? We walk unless we get it.

There is not simply an elephant in the room. There is a herd of carnivores: the health insurance vultures, the pharmaceutical pirhanas, the lawyer hyenas, and the oft cowardly lions of our profession. The carcass at which we are all tearing is beginning to stink!

If we could put aside physician wallet issues and come forth as advocates of best practices in patient care.....? If we could take "re-imbursement " out of our lexicon for a bit and stand united for our patients.....? Doesn't seem likely, does it?

Yes, the issues involved are terribly complex. And the vested interest groups are powerful, territorial, and poised to tear each other apart if need be to protect their turf. Why shouldn't we take the high ground? That is our best option to preserve this time-honored but increasingly tarnished profession.



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# Physician AssistantPeter W Elvin 2009-04-17 15:10
The solution is simple. Demand an end to the two tier, separate, and elite HealthCare Coverage for members of the Legislative, Executive, & Judicial Branches of Gov't, and all Federal Employees; and the rest of the populace. Decree an end to their separate payment system; and role them into the M'Care/M'Caid system the rest of us use.
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# The "R" WordMatthew Vreeland 2009-04-19 22:01
In many ways, we are afraid to speak the most important "R" word. RESPONSIBILITY. We have a system now where the patient, at the heart of the system, has no responsibility. They do not have to pay. If they fail to take their expensive medicines that we give them for their disease, they can come to the hospital for someone else to care for them. Diabetes, congestive heart failure. Don't arrange for care for your back pain? Come to the hospital. They'll give you pain medications. Too busy for your dialysis run today? Come in to the ED tonight to get admitted. They'll discharge you in the morning. Don't followup with the Medicaid assigned doctor because you don't like him/her? Come to the ED. Don't have money for a dentist? Don't worry. The ED will help. Unhappy that the Amoxicillin you got earlier today at Urgent Care has not helped your sore throat? Call EMS to come to the ED. Have your mom follow in the car, so she can drive you home since you'll be seen quickly after arriving by ambulance. Don't worry about bringing your medication list to the hospital, they call around and figure it out for you.

Medical Providers also fail to fill their responsibilitie s. Too busy to see a patient of yours that has a post-op problem. Send them to the ED. They'll check and make sure it's nothing serious. Need to get that CT done today, but don't have the time to get the insurance company's pre-authorizati on? Send the patient to the ED.

Any solution MUST contain elements of returning responsibility to patients for their actions and inactions.
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# ED physiciansullivan 2009-04-23 17:48
Greg is correct. If you send someone into McDonalds and tell them they can have anything they want at no cost to them, they will grab everything on the menu, take a bite and throw the rest away in the trash. This is where our healthcare system is headed. We also need to allow physicians to practice medicine using clinical judgement, not always expensive tests, to make treatment decisions; and free them from fear of legal reprisals for not having "tested enough." Malpractice mediation panels, not a "jury of our peers", should make reasonable decisions of culpabity and restitution to the victims. Attorneys should be paid for their time, not by the award, and their fees should be capped just as with physicians. What do you think are the chances of such changes occurring? are
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# Dr. Henry-the Man Who Cried WolfJohn Janousek 2009-04-28 21:47
Great article, you are crying wolf but you are right,and you are no Chicken Little. According to the trustees of Medicare themselves,it will become financially insolvent in 2019.I also wrote a blog, with references, explaining that Medicare was a failing business, and one reader wrote, "A country is measured by how it treats its children, its women, its elderly and the ill. Do not try to suggest to me there is not enough money for this!"
We need to somehow explain to our citizens that we cannot continue getting everything done paid for by the government - near impossible in the current legislative environment. C'est la vie, no, c'est la guerre!
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# RightsDwight Burdick 2009-05-06 09:05
I am ashamed to be a Fellow of some of those responding.
For those who believe access to health care is not a right, I assume they also believe access to services provided by teachers in education and access to services of policemen providing protection from crime are privileges rather than rights.
I for one want no part of your elitist world of privilege.
If you truly believe it is your right to stand at the door of your ED and ask for payment as a condition of your service, you picked the wrong profession, Doctor.
I took an oath to my fellow man. If all I receive for my service (no cash, no "Thank you.", not even a smile) is the personal satisfaction of doing the right thing for my brother suffering there in my ED on a cold hard Gurney, my reward is handsome indeed!
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# Are you the Dwight Burdick from Saudi Arabia who has the blog?Dr. P 2009-05-06 18:54
Google has a blog by a Dwight Burdick. Is that you? I don't want to confuse you with someone else.
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# YesDwight Burdick 2009-05-08 10:23
Dr. P - Yes, it's me.
To the rest - Sorry to use the comment section for my personal response.
My email is d_burdick@hotmail.com
Dwight
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# Public Healthcare Public CostJim Hullverson 2009-08-14 14:37
The thoughtful article and comments nonetheless improperly collapse "health care"into a rights/rationin g dichotomy. Sixty years of Public immunizations against polio, measles, tetanus, diptheria, whooping cough,and more recently against influenza, and perhaps future public inoculations against HPV and herpes as approaches to prevent cervical cancers due to previous viral infections are Public Health care phenomena, publicly funded, yielding some private profit, especially to drug manufacturers. Public sewer systems to prevent plague, and public drinking water treated with flouride and chlorine are societal "best interests" accomplished healthy persons one by one, and along with mandatory inoculations override individual religious "freedoms" that Jehovah's witness or Christian Science practitioners might prefer. Public schools and libraries to educate are aspects of public health care in the "best" interest of society in general, and its individual members in particular. Public streets maintained to high standards reduce collision injuries, and the collective expense of caring for collision cripples and disabled. OSHA helps reduce workplace disability and the "cost"of such disability on the individual worker, and the society at large. Limitations on air,land and water pollution are public health subjects, publicly funded to prevent private excess. NIH and CDC are dedicated health care institutions,pu blicly funded, as is the Dept. of Health, Education, and Welfare - an integrated trilogy of topics. Beyond the dedicated Health institutions, all sorts of grants to innumerable health care entities are funded by public monies, and medical and undergraduate schools are funded in whole by public monies directly and in part by project research grants,in the "best interests" of American public health, and a disproportionat e benefit for those ready willing and able to undertake medical professions, whose education is subsidized - in whole or in part - by such public funding. Amidst this universe of publicly funded "public health", individual choice of diet is preserved, at personal expense. Medicare and Medicaid are publicly funded health: Is healthcare provided under Medicare and Medicaid inferior to non-publicly funded healthcare?
Our "sin" taxes on tobacco and alcohol are much less than in European countries and Canada, (except wine in France. Why? because of the influence of the manufacturers at electing public officials who best promote the corporate bottom line, and the great polluters have enjoyed the same power.
And then we turn to healthcare provided to all members of national government and bureaucracy and the military: Public! Congressmen and women get treatment comparable to any private health insurance, and President Reagan didn't have any complaints after treating for gunshot at Georgetown ER, nor did his family lament his treatment for Alzheimers in California... which was all paid for by tax dollars. GEICO - GOV'T EMPLOYEES INSURANCE CO. is now owned by ... Berkshire Hathaway/Warren Buffet - who bought that hybrid Gov't/private insurer and extended its reach to much larger private participation in private auto insurance, with the clever help of a Gecko lizard with a British accent! In the end, "Universal" or single payer health care is not such a radical departure from these other "best interest" public health care phenomena, publicly funded, and the health care provided in those countries that provide universal health care seems to be as good as in America, but at much less cost, especially as a % of GNP. In the current "town hall" meetings, the harangue fails to consider these dimensions of "public health". Enough for now. JR Hullverson
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