The HealthCare Debate is Misdirected

by admin on 01/26/2017 7:13 AM

For Healthcare to be truly patient oriented and directed it has to be entrepreneurial
Government directed Healthcare can never be truly patient friendly

How Did We Get Here?

The US Healthcare debate has been “what should or can the government do to solve the healthcare crises since the New Deal in the 1933 and following. Efforts to impose on a free society have always failed. There were efforts during the New Deal but they were always thwarted. The American Medical Association (AMA) at that time was composed mostly of private physicians in a business entrepreneurial structure. Each physician was a private enterprise. He had to provide a valuable medical service for those that needed his service and then paid him for those services. If he didn’t provide  medical care in a professional pleasing manner, his patients would seek another physician. When the patients were pleased with his basic services he could provide more services by adding immunization, a laboratory to do basic blood counts (CBC), urinalysis (UA), blood sugars (FBS) to improved his service for diabetics. In each case he had to explain why vaccines or a blood count or urine check were important and then if the patient agreed and accepted the additional costs, proceed with these additional services.

The Cost of Care

When I grew up in the 1940s, my family paid one dollar for an office call. That could double if we needed a “shot.” There were several poor families in town, and our physician treated them without charging.  When I was in my Junior Year of medical school doing my Preceptorship in 1960 in Norton Kansas, the family doctors were charging two dollars for an office call. Again, I observed when known poor families came in, the charges were written off. No one was denied care. They said their fees had not been raised in more than ten years. If a “shot” was required, it was three dollars extra. They confided to me that in perhaps half the cases, a penicillin shot may not have been appropriate, but they had decided the extra charge was more effective in decreasing the demand for injections than trying to convince the store keepers and farmers. The cost of a throat culture was several times the cost of the shot which they would immediately decline. They knew the excessive time to spend teaching patients that they didn’t need it for their sore throats, was not cost effective.  If they didn’t give the requested injection, they would just go to the GP across town who would always give them what they requested. They knew this would be at odds with what I was taught in Medical School. To which they responded that perhaps half of the sore throats were caused by Streptococcus Pyogenes which could cause kidney or heart disease later in life.  (Years later it became apparent that this indiscriminant use of penicillin injections eliminated the vast number of patients who years later would develop glomerulonephritis or rheumatic heart disease (RHD) with heart valve damages requiring mitral valve or aortic valve replacement,  which are major late sequela of streptococcus (Strep) infections.) The incidence of kidney failure or RHD requiring surgery did plummet dramatically decades later.

As much of complicated medical and surgery care move to the hospitals, the cost of care skyrocketed.  Hospitals were run as businesses. They did not have a personal relationship with the patients admitted by their physicians. Hence, the charges of poor patients could not be dismissed by their physicians. This created a challenge for care of the needy. The private physicians were suspicious of government intrusion into their practice.

The poor you have always with you . . .

But when the disciples saw it, they were angry and said, “Why this waste? For this ointment could have been sold for a large sum, and the money given to the poor.” But Jesus, aware of this, said to them, “Why do you trouble the woman? She has performed a good service for me. For you always have the poor with you, but you will not always have me. By pouring this ointment on my body she has prepared me for burial. . .” Matthew 26:11; Mark 14:7

Since there will never cease to be some in need on the earth, I therefore command you, “Open your hand to the poor and needy neighbor in your land.” Deuteronomy 15:11

Was that a Divine command for mankind individually or for the government? For the first 150 years of the American Experience it was a personal, community and church commitment. As America became more secular and even agnostic, there was a strong ascendency to produce heaven on earth since there was no real heaven. Then the goal was to make our earthly sojourn as pleasant, kind and free of pain and stress as possible.  But that is not Biblical either. It was recognized that after “opening your hand to the poor needy neighbor” there will never cease to be some in need on the earth. Hence, there will never be a heaven on earth. Not even the government can satisfy all human need. Human greed will always exceed human need. That has been well demonstrated in the last 100 years of the American experiment. The greater the benefits to the poor and needy, the greater is the outcry for increasing benefits.

Are there alternatives?

For instance, take Social Security Retirement benefits which were implemented to those over 65 when life expectancy was 62 years. But the 65-year life expectance was reach by mid-20th century.  At the present time, life expectancy is nearly 80-years. What is the possibility that the retirement age will be extended to 75-years which would be similar to the retirement criteria when SS was implemented? By all financial criteria, it should be extended at least to age 72 as an economic reality. Could a president be elected who even hinted at that possibility? Could any Congressman or Senator be elected who would suggest that as a possibility? Thus, reform is a lethal concept. Any office seeker would never reach his office if he dared to utter the word “reform Social Security.” Thus, Social Security Reform, or Medicare Reform, or Medicaid Reform, or any entitlement correction will never occur. We have seen that amply demonstrated in Greece which decided by popular vote that they would rather have the entire country go bankrupt and cease to exist rather than succumb to any entitlement reduction to survive a few years longer in earthly comfort. They cannot comprehend that for their children and grandchildren to have any partial or reduced benefits to retirement or health care, they themselves must also receive reduced benefits.

Private Insurance: Blue Cross Blue Shield

During the 1920s, individual hospitals began offering services to individuals on a pre-paid basis, eventually leading to the development of Blue Cross organizations in the 1930s. The first employer-sponsored hospitalization plan was created by teachers in Dallas, Texas in 1929. The first plan guaranteed teachers 21 days of hospital care for $6 a year, was later extended to other employee groups in Dallas, and then nationally.[4

Blue Cross and Blue Shield developed separately, with Blue Cross plans providing coverage for hospital services and Blue Shield covering physicians’ services.[3]

Blue Cross was founded in 1929 and became the Blue Cross Association in 1960. Blue Shield emerged in 1939 and the Blue Shield Association was created in 1948. The two organizations merged in 1982.

Blue Shield was developed by employers in lumber and mining camps of the Pacific Northwest to provide medical care by paying monthly fees to medical service bureaus composed of groups of physicians.[5][6] In 1939, the first official Blue Shield plan was founded in California. In 1948, the symbol was informally adopted by nine plans called the Associated Medical Care Plan, and was later renamed the National Association of Blue Shield Plans.

The American Hospital Association (AHA) adopted the Blue Cross symbol in 1939 as the emblem for plans meeting certain standards. In 1960, the AHA commission was superseded by the Blue Cross Association. Blue Cross severed its ties with the AHA in 1972.

Blue Cross Blue Shield Association (BCBSA) is a federation of 36 separate United States health insurance organizations and companies, providing health insurance to more than 106[2] million Americans.[2

In the 1960s the US government chose to partner with Blue Cross and Blue Shield companies to administer Medicare.[6]

In 1982, Blue Shield merged with The Blue Cross Association to form the Blue Cross and Blue Shield Association (BCBS).[7]

Managed Care Medicine; the first major step to control physicians.

But who would take care of the poor? The indigent? This was not an issue until well into the 20th century. Citizens of the 21st Century cannot imagine a world without health insurance.  Our younger colleagues can’t comprehend that we took care of the poor without any government program? Citizens of UK cannot comprehend living without their National Health Service (NHS). After six years there is hardly anyone that can remember private health care. There is not a physician alive who is now working the government rather than their patients who has ever experienced non-government health care.  There is not a physician in the UK that can even imagine a world of private health care when their entire lives they have been at war with the NHS? Many no longer consider this a war; since they have always thought health care was an adversarial endeavor.

Many of our younger colleagues in the United States cannot conceive of seeing a their patient, doing a complete medical history and physical exam, that there ever was a time when they could write a requisition or a prescription or ask for a consultation and have the patient proceed immediately to the pharmacy or the lab or to a consultant directly without their staff spending hours, days, weeks or even months to get a treatment authorization request (TAR) before their patient could proceed?

Government Medicine: The First Step

The first Federal medical payments for recipients of welfare were authorized in the 1950 public assistance amendments. This law provided Federal matching funds for a limited program of State medical payments to vendors (providers of health care) for people who were receiving cash welfare payments.

This medical vendor payment program was followed in 1960 by the enactment of the Kerr-Mills legislation authorizing Medical Assistance to the Aged (MAA), which provided Federal funding to States to cover medical costs for the indigent elderly (Public Law 86-778).  This legislation was really the template for Medicaid 5 years later.

Wilbur J. Cohen (then Assistant Secretary for Legislation in the Department of Health, Education and Welfare) (HEW) said that the idea of a Medicaid Program began to develop in his mind in 1942, when Rhode Island attempted to tap public assistance funds for vendor payments for medical care. Vendor payments in the 1950 amendments were the first Federal legislative action in this area. In 1954, Cohen worked with Nelson A. Rockefeller (then Undersecretary of HEW in the Eisenhower Administration) to develop a Medicaid type proposal for the needy (Cohen, 1985). Cohen (1985) was able to get a provision included in the Social Security Amendments of 1956 for a separate medical assistance funding match and an averaging formula helpful to State administrators. The Federal-State matching formula was subsequently liberalized in both 1956 and 1958. By 1960, four-fifths of the States had availed themselves of the medical vendor payment option and these vendor payments had grown from an estimated $81 million to $5141 million (Social Security Bulletin, 1950). Although still far from meeting the need, these vendor payments for medical care nourished a growth industry within the States and created an appetite for more.

Between 1945 and 1960, few other health care initiatives succeeded. The legislative success in the 1950s was one of the keys to the evolution from vendor payments to Kerr-Mills to modern day Medicaid, and continued a tradition of incremental change.

An important negative feature of the law was that Kerr-Mills integrated medical assistance for the poor even more firmly and pervasively with public assistance. With this step, medical assistance was burdened with the social stigma and political disadvantages associated with a welfare program.

Government Medicine: Total Controlled

This is how private based personalize health care became co-opted by the government with continued incremental expansion with no end in sight with no significant dialogue by our professional representatives as they gain power in the government superstructure and enjoy their new importance. The AMA has become more like their British counterpart, the BMA which writes the contracts for the UK physicians. We are no longer members of the world’s honored profession. The meetings of our Medical Societies, our specialty societies no longer meet on MedicalTuesday. They have been usurped by inane union type meetings where we are told how long our appointments are, how many patients we need to see per hour, what penalties we will suffer if “members” have to wait more than 15 minutes, what drugs we are allowed to order, what laboratory tests we are allowed to order, what x-rays we are allowed to order, which procedures we are allowed to do, which consultants our patients are allowed to see.


Wake up doctors. We are now Union People. We are no longer an honored profession. Why did we allow this to happen? Will the present administration in DC give us another chance?

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