August, 2009

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                        BY  SY SCHECHTMAN              


    Back in 1993, as now in 2009,   we began to  face  the growing   medical health meltdown in the escalating cost  of   providing  for  health care. In  the Clinton years of  the mid  nineties  there was already  much talk of  a radical change  in health care delivery, similar to those  already  in place most European  countries.  Back then there was already growing realization that  health  care costs were exceeding the  general price inflation by 2.5 percent a year.  That medical price inflation has continued  up  till now. As President Obama has currently stated:  “Make  no mistake about it: the cost of  our health care is a threat to our economy.  It’s an escalating burden on our families and businesses.  It’s a ticking time bomb.  And it is unsustainable for the United States of America.”

          Yet as of now our current president is not  committing the same blunder that assured the  ultimate defeat  of Hilary Rodham (!) Clinton’s  first  medical go round  with new all inclusive  medical  horizons.   Empowered by her husband,   then fledgling President Bill Clinton  at the beginning of    his first term,  as the new  leader in the search for comprehensive  health care she impaneled a large prestigious group of academic authorities, but no “hands on” physicians,  scientists or well known political people.    They met in camera  for months    and produced an almost 1500 page  document  which few studied in  its full complexity.    Coupled with a very skillful TV  campaign  by “Harry” and “Louise”emphasizing  its  negative  or rather dubious implications for both their fiscal and physical health this plan was soundly thrashed  in  Congress and in the l994 mid term elections  the Democrats lost control of  both houses of Congress  and Bill Clinton’s presidency seemed  in dire straits.

          This time President Obama is proceding  much more cautiously, even though  stressing the urgent need for  swift action.  Now all the legislative  details  are, ostensibly, out  in the open,  wending their way through both the Senate and the House of  Representatives  as we watch expectantly.    And on the sidelines, industry, labor and the general public are involved  and reacting to the evolving legislative struggle.   A democratic birth process and   struggle of joy and  sorrow  but not ,we hope,  an ultimate miscarriage of  economic  rationality or sound medical  care.    We are already  stirred and stressed  by cost projections of a trillion dollars  over the next ten years  to   expand health care to all the nation.    And this over and above the looming current recession  incurred deficits  of almost a trillion dollars in stimulus money  to jump start our stagnant  economy.   Most of  us remember the time when you  put together   “a million dollars here and there and soon you were talking about  real money”.    Then we realized that   with persistent if insidious inflation and  so called “bracket creep”  it  took  “at least 16 million to live like a millionaire”!   So now we throw around billions instead of millions.    But now trillions?!    And less than a century ago, before  World War One,   our  country  was  a creditor nation, and the dollar became the universal currency of the world after World War Two,  after Britain lost its hegemony  as the “world’s  banker”.    Now  the United States is the largest single debtor nation in the world, seemingly  dependant on the largesse of  China,  who now hold almost two trillion dollars of our bonds.  But we still are the most the most powerful in many crucial respects---certainly  in unbridled  military  power.

          But  this is not a plea for isolationism,  but merely to “make haste slowly”.   And  harvest  more of our national assets more successfully.    One of which is more involvement  of the our loyal citizens and health care recipients  in the  financing  of our  health care commitments. There has been a not so splendid silence  on all fronts  about the efficacy of the simple  term and practice of  “co pay”.    The time honored political “third rail”   of politics  has been, up till now,  social security.   But,  now, obviously,  the this  looming medical entitlement  has to be another almost sacrosanct, untouchable concept.   But it needs help from its putative recipients if the final fiscal jolt will not be too electrifying---a  lethal “third rail” effect . As the several House and Senate   bills to finance our glorious(?) new medical  entitlement wend their way through various involved committees  the air is filled with tax abatements, subsidies, exemptions,  new insurance exchanges to trade differing health plans,  and a competing  government plan to restrain the possibly overpriced private insurance purveyors.   All this must be balanced  and  compromised.   But surely somewhere in this vast sea of monetary repayment  plans a significant  sum of money can be raised  by gradually escalating co-- payments from many of the patients receiving  the needed care. Most lower income people, of course,  would be exempt.   Most people in the  work force  would still covered by mandated employer based plans,  but the concept of direct out of pocket patient involvement   financially can be an inhibiting  and restraining  factor  as the patient has to consider his share of the cost,  minimal as it may be.   Optional or “frivolous” procedures would  thus be mitigated, and  review boards could easily  assess the validity of  such procedures.     These  co-pays  would only apply to higher level incomes, of course.   This incentive to scrutinize  the cost because of  personal involvement to some extent is still a vital aspect of  our hopefully still nascent  free enterprise system.  And it  is   cause for some wonderment why  our loyal minority party opposition—the Republicans---  do not urge any bill that encourages individual  participation  even if it might require  some cost.  It is the complete opposite of the dreaded  “socialism”--- that bugaboo of increasing government control   hoisted by  clueless Republicans  who do not have much positive ammunition on their side.    Only the  accumulating massive debt!!   Which unfortunately  might be a sufficient overload  to abort this  effort,  as in the Clinton era,  even though we do have  Obama’s splendid  speechifying rhetoric  to keep it alive as all the small print details now seem to be  dimming the enthusiasm quite a bit. 

                   Much has also been made of  salaried  and not fee for service physicians.   Clinics such as the Mayo in Rochester, Minnesota  and the Cleveland  Clinic   in Ohio have impressive quality performance at lower than  average cost per patient than the national average.   A  group approach for each patient is deemed to be the goal;  better  health for the individual that is more than the sum of individual  procedures,  which may increase  the cost and line the pocket of the  physician more than  wise,  watchful care of the individual  with the a successful outcome  with the less financial  outflow.   However  much more research into this delivery approach has to be done before its more universal feasibility can be assessed.

          Not much, however,  has been made of tort reform  and  so called  defensive and excessive medicine  to avoid malpractice suits.   The sacred right to sue in this country seems still inviolate and an essential part  of the pursuit of happiness.   After all,  we have the most  litigious society in the world, and more lawyers in this country  than in all the rest of the world combined, and a lot of Congress men and women are lawyers,  and contribute heavily to the Democratic party.

          Ultimately we still have the best system in the world to  resolve this very vital matter,  with  the absolute certainty of getting the best system that we deserve.   We are really trying and not just going through the motions!!  And if we need more  work and improvement   another elected Congress will be around  to improve on the good foundation being accomplished.   Remember that good old maxim of  Jaw! Jaw! and only verbal War! War!  and we can   live almost happily ever after.   Also that good old Latin  proverb  Festina Lente applies. --- Make haste slowly!!   Maybe only a sizable portion of the uninsured can now be covered,    and perhaps we must wait hopefully for our seriously wounded  economic system to be fully  reinvigorated an be able to avoid  the twin hobgoblins of inflation and deflation and thus be able to succor and sustain   a resurgent healthier nation!