Our Medical System – What I Believe is Possible

doctor-stethoscopeby Tia Will

With the proposal and subsequent approval of the ACA, concerns have been expressed about the destruction of our free market system of medical care. I would like to address this from the point of view of a front line medical practitioner with 30 years of experience.

What we have had in the United States for as long as I have been in medicine has not been a “free market.” I don’t know if a true free market system would have been better or not. This is a moot point since it simply did not exist. A “free market” did not exist for health care workers, and most importantly, it did not exist for patients.

What I would like to present are what I see as the deviations from a “free market” in the health care delivery in this country prior to the ACA and then what I envision more effective and less costly health care system might look like.

I have worked within the Kaiser system for 27 years and have a view of how pre-paid health care can be achieved in a more efficient and cost effective manner, with better patient outcomes, and without interference from a profit-driven third party – the insurance industry.

First,how did our fee-for-service model of health care delivery differ from a free market?

Let’s start with where the impact matters most on the patient.

For the majority of people, the “free market” started and ended with their employer’s choice of insurance company. Every decision about the individual’s health care from that point on was driven not by a free market, but rather by what the insurance company had decided they would cover. While it is true that doctors could still perform the optimal procedure or prescribe the optimal medicine, they would get no compensation unless the procedure was preapproved. And who actually made the decision? Not a medical care provider and the patient in collaboration, but rather an office worker armed with a company-provided protocol that was determined not on the basis of what was the best for the patient, but rather what was best for the financial well-being of the insurance company.

In this system, the patient was limited in another way. Unlike a free market where you typically know the exact price of an item before making the decision to buy,

this rarely occurs in fee-for-service medicine especially when it comes to hospital care.

In fee-for-service medicine one has to dig very hard to actually get numbers in advance, and even when provided, they are always estimates, not guaranteed final costs.

Now lets suppose the patient has been persistent and finally arrived at an estimate of cost. It’s not like they can walk across the street from Kaiser to Sutter to see if they can get a better deal for their biopsy or ultrasound or MRI. Unless they are independently wealthy, they are stuck with the services and agreed-upon-fees provided by the insurance offered by their employer. The only “freedom” that the patient has in this case is to quit his job and hope that another employer will offer insurance options more favorable to him. However, this option is fraught with risk since the new employer will be free to change their insurance offerings next year. Add to this the “freedom” of the insurance company to refuse to insure on the basis of pre-existing conditions, and the freedom to cancel on the basis of technicalities on an initial application once a high cost diagnosis is made, you certainly have “freedom” for the insurance company, but virtually none for the patient.

Another deviation from the free market for the patient is the inability to know the motivation for a doctor’s recommendation. In the fee-for-service world, health care providers have a financial incentive to advise more procedures. The more procedures performed, the more times they see the patient, the more they can bill within the constraints of what the insurance company will compensate. Unlike a free market as it applies to the purchase of an article of clothing or a dinner out, the patient rarely has the luxury of truly being able to assess objectively what is the best for them based on their budget and individual tastes. They must rely on the doctor to make the best recommendation for them.

Unlike the free market customer seeking a new dress or a night on the town, the patient is frequently in pain, frightened, confused, exhausted, and only wants to feel better. This limits their ability to make the best decision for themselves. While the doctor in fee-for-service medicine may indeed recommend the best course for the patient, they may also have incentives to order additional tests or procedures that are in the doctor’s– but not the patient’s – best interest. These incentives may include fear of lawsuit for a missed diagnosis or just simply what is in their own financial best interest. Often expensive tests or procedures are recommended to the patient “just to be on the safe side,” when the provider knows very well that the findings of the expensive test statistically approach zero benefit for this particular patient.

American “free market” medicine has also imposed artificial constraints on other parts of health care delivery. The “market” for doctors and to a lesser degree other health care professionals has been artificially manipulated for as long as I have been in medicine. The number of training slots in both medical school and residency programs has been held down to maintain a high level of compensation. The rationale provided has been that this is necessary to maintain the high quality of skills and knowledge needed by physicians. My opinion is that this is neither the primary cause nor the outcome. At the time I was in training, a typical workweek was frequently 90+ hours at less than minimum wage. Although this has been adjusted to less than 80 hours weekly, at slightly higher compensation, it engenders a mindset focused on paying back student loans and achieving the lifestyle to which some feel entitled, given the amount of time, effort and money they have invested in their career. Ultimately, it is the patient that pays for this antiquated and not “market driven” system without realizing that they are subsidizing a profession that is being manipulated for profit.

Obamacare is only a small step in the right direction, I believe the most cost-effective and equitable system would be single party payer administered through a Kaiser-like model of care delivery.

Based on my experience, here are some real-world examples of how a pre-paid system actually works more efficiently.

1. Elimination of fee-for-service provides the following benefits:

No incentive to order more or more expensive tests or procedures.

  •  Income provided on the basis of salary for all workers, including doctors, eliminates the temptation of a “more is better mind set.” Financial incentives are based on providing more efficient and better patient care.
  • Overall cost savings. Prepaid preventive care lowers cost by preventing high cost illnesses from occurring and allowing for less expensive early interventions.

A common example from my practice: Obese women have an increased risk of developing precancerous conditions of the uterus which present as heavy bleeding. The best and most cost-effective practice would be to encourage and ensure that women with obesity have access to programs effective to help with weight reduction. Within Kaiser and other integrated systems of care like Group Health Cooperative in Seattle,this can be done through appointments, classes, with telephone or on line consultations, most of which are fully covered. Next best practice if she has progressed from increased risk to actual symptoms of abnormal bleeding would include a same day office biopsy. Once cancer is excluded, the next best practice would be either an oral hormonal agent or even better, the Mirena IUD which can be placed at the same appointment. Only if ineffective would one go on to surgical management up to and including the most expensive option, a hysterectomy, which includes the most risk of expensive and dangerous complications as well as the highest cost.

How does this same scenario play out in the fee-for-service, “free market” model?

The recommendation for weight reduction may be made, however weight reduction services are rarely available without additional cost. A visit to a nutritionist, or exercise physiologist or other support critical to success in this very difficult area will involve referrals for which the patient will often have to pay out of pocket. She may not be able to do this, or may not be able to take time off work to go to appointments even if covered.

In the fee-for-service world, she will often have hysterectomy recommended as the first option, not because other less costly options are not available, but because that is the most highly compensated procedure for the doctor. But first, the insurance company, not the doctor, is going to decide that they will approve the hysterectomy only after the doctor has done an endometrial biopsy which should have been done at the first appointment. So now the patient must come back for that procedure as a separate appointment thus costing more. Next will be an ultrasound to determine the size of the uterus and to exclude the possibility of fibroids, both determinations which can often be made on the initial office exam without the need for ultrasound. This test will be ordered on yet another visit dictated by the insurance company with additional time and monetary cost. The patient will likely now proceed to hysterectomy without benefit of having tried any safer, less expensive options first.

2. What are the advantages of a collaborative, integrated model of care for the individual patient ?

Within the Kaiser model, I enjoy access to real time consultation with a specialist in virtually every medical specialty. My patients have access to specialty care limited only by the time needed to process and convey test results to me. This is a two way street. A specialist who identifies the need for routine care such as a clinical breast exam can refer the patient for a same day appointment with me.

For instance, a patient presents with no menstrual periods although they had previously been regular.Part of the evaluation is a blood test that can suggest the presence of a benign brain tumor usually medically managed. The patient had her blood test drawn in our on-site lab immediately after our appointment. The results were available within 24 hours and indicated the need for an MRI, which is completed within two days. I call the results to an endocrinologist who sees and treats her the next day.

In fee-for-service medicine the patient would have an initial appointment with a co-pay. The labs would be ordered and the patient would have to have a separate appointment with additional co-pay for the lab draw. The labs would be drawn and the results conveyed to the doctor. There was commonly a lag time associated if the doctor was not using an integrated electronic medical record, which posts results as they are completed. The doctor would then request an MRI using a contracted radiology service, with further delay and possibly more cost depending on the insurance plan selected by her employer. The results of the MRI would be conveyed to the doctor with more time passed. The doctor would then decide on an endocrinologist and would place a consult that would be triaged by the consultant’s office. Additional time wasted and money spent for no improvement in care is the cost of competitive fee-for-service medicine. These are amongst the savings offered by a collaborative, integrated, preventive model of health care delivery.

3. Some have suggested that a preventive, collaborative, integrated model of health care delivery would prevent innovation in health care.

My experience suggests this is not the case. Here are two examples.

Kaiser physicians have been leaders in innovation in the practice of medicine. One example locally is a specialist in gynecological oncology. This specialist is a world renowned researcher instrumental in rewriting the nationally and internationally approved recommendations which have allowed cervical cancer screening to be performed every three years rather than annually. This change has decreased cost both to the patient and to the health care system while improving early diagnosis and treatment of precancerous conditions of the cervix. He did not do this for financial gain. He receives the exact same compensation from Kaiser (and with no outside financial compensation) for every hour he works whether he is seeing patients in the office, taking care of them by phone or online, operating, doing research, or teaching. What is his motivation for innovation in this setting ?

His motivation is the improvement of health care for women.

What about innovation in the provision of health care services? I believe Kaiser has also been a major leader and innovator. This is largely achieved through the efforts of administrators and directors at all levels in the Kaiser system all of whom are also front line providers working with the front line doctors not directly involved in management. Our departments are responsible for constant innovation to improve services. The highly efficient consultation system I described above has only been in place for three years and is under constant revision to fine tune it.

Recently, forecasters underestimated the number of new patients that would sign up for services through Covered California, the state’s new health care exchange. This resulted in a deficit of appointments. In fee-for-service medicine this would have resulted in longer and longer delays for those initial appointments. This has occurred to a lesser degree in our system as department managers were given the directive, but also the freedom to seek and promote efficiencies within our departments to maintain patient access. Our salaries are not dependent upon this. We will get the same compensation whether we are working on this during normal working hours, or whether we are performing any other function of our job including surgery. Kaiser physicians frequently work after hours without compensation to plan and implement these initiatives.

So why do we do this knowing that we will not be getting paid overtime? For most of us, it is because we are committed to the improvement of patient care. While I am aware that this also occurs in private companies, we have the advantage of economies of scale and collaboration rather than competition as our model. If one region or office develops a better model, we do not hide it for competitive advantage, we share it so that all of our patients benefit from the change. Kaiser and other integrated health care systems do this to improve patient care and, admittedly, to prove the superiority of our model of care. Innovation can and does occur without additional economic incentive.

I can imagine a future health care system in which no doctor in the country (not just in Kaiser) works alone in competition with others but rather works collaboratively with all doctors to provide the best possible care for every patient. I can imagine patients benefiting from the best evidence-driven care possible regardless of physician, lab, hospital or pharmaceutical compensation, but only dependent upon what best meets their individual need. I can imagine a system in which research about any aspect of medicine is freely shared to promote further innovation and best practices, not kept as “trade secrets” for individual profit.

I can imagine such a system. I know it can be done because it exists in the microcosm that is Kaiser and similar systems, which while not perfect, are leaders in moving toward this model of care. It has not yet been adopted on a broader scale largely because patients outside of the system and the public in general do not know it is possible. It has also not been adopted because of the fears of the stakeholders in the current system that their incomes, maintained through artificially imposed constraints, not the “free market”, will be threatened.

As just one individual, one doctor who could have earned much more money in private practice especially in the early days of my career when obstetrics/gynecology was still a male dominated specialty, I did not and would not have chosen to have my practice outside of Kaiser. Private wealth is far from the only reason that people go into medicine. Many of my colleagues and I have established and maintained our careers within Kaiser because we believe that this is the best model of care for patients, and the best model of care for our country.

I would love to see a system like this established within my lifetime. I do not believe it will be, but I know that it will not if someone does not envision and act on what they know can be achieved.

About The Author

Tia is a graduate of UCDMC and long time resident of Davis who raised her two now adult children here. She is a local obstetrician gynecologist with special interests in preventive medicine and public health and safety. All articles and posts written by Tia are reflective only of her own opinions and are in no way a reflection of the opinions of her partners or her employer.

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  1. SODA

    Two comments Tia, and I share your view of single payer….
    As a health care professional I reviewed the hospital bill carefully when I had my son. The only medication was an oral laxative and it was exhorbitantly priced! I argued its necessity and so only took 1-2. To your point, it was priced so high to cover other costs I am sure.
    Now we are Kaiser members, initially as individuals since we were self employed and now under Medicare. The wonderful thing about Kaiser (that others are catching up with) is its use of electronic communication; Email your pracitiioner and often not need an appointment: beneifits both the patient who pays a high copay and Kaiser. Electronic records of hospitalizations and other vists are available to all within the system for seamless care. My two minor complaints are:
    that access to specialiss is controlled, e.g., dermatologists much more than in fee for service whereby one could just make an appointment and not go through primary, etc.
    AND it is difficult to change primary physicians if they are not taking new patients.
    Thanks Tia for this and other articles. Sounds like you are transitioning into a retirment career of journalism 🙂

  2. Tia Will

    Hi Soda

    I am really happy to see that others are making rapid progress in the area of the electronic record. We now have access to the system “Care Everywhere” which as soon as the patient gives permission, allows us to see records from the UCD and Sutter systems. This is invaluable in trying to figure out what has already been done and what the next steps in a patient’s care should be.

    I agree with you about Dermatology services. The reason has been our inability to hire up to meet the demand.
    One way that we have attempted to address this problem is to train internists with a special interest in Derm to function as Dermatology Fellows much as is done after residency when an individual is planning, but no yet fully sub specialized.

    I also agree regarding changing physicians when a primary care providers panel is full. I have no idea how to solve this problem since when you have a very popular physician, they will always be full once they have a mature practice. I think that this is true regardless of the type or size or practice. We have not managed to make a dent in this issue the whole time i have been with Kaiser, not for want of trying ; ).

  3. TrueBlueDevil

    Good article, I’m not very knowledgeable about Kaiser. A few items.

    1. Are there any prominent publications / authors who have written about the pros and cons of your system that you can recommend?

    2. If it is this good, has any other company, group, or state copied the model?

    3. I agree, a lack of up-front pricing in HC causes lots of problems for the consumer.

    4. You skipped over how states limit the number of HC providers, thereby stifling the free market. If I wanted a bare-bones catastrophic plan in many states, I couldn’t get that s the do-gooders have restricted by choices and mandated when is covered.

    5. I agree about the restriction on doctors. I knew many bright, hard-working students at UCD who were ground up in “the curve”, and felt like med school was impossible if they didn’t have a 3.7 or 3.5 GPA. They were typically in the top 1% or 2% of their high school class, diligent, hard-working, and I believe many would have made good doctors.

    This has to apply 5-fold to the vet school, as we only have one grad school for a state of 40 million people?? (A friend recently took ‘Fido’ in for his shots in a nice suburb, and the vet recommended $1,200 in shots and tests for a healthy animal! Needless to say, my friend found another vet.)

    1. Tia Will


      Great questions. Thanks for taking the time to consider.

      1. I don’t know the answer. I can get you started with an article from the NYT but it is a bit of a puff piece.
      What I will do when at work isto find out if there have been any scholarly, or at least neutral comparisons of
      the Kaiser system with others…..I’ll get back with you on that one.

      2. There are a number of systems that are using the same model such as the Mayo, and Group Health Cooperative in Seattle
      who have independently come to the same conclusion that this pre paid, collaborative, integrated, preventive care model is the
      best way to provide care to large numbers of patients. In our area Sutter is moving with similar steps. I am not sure of the
      UCD and Mercy Systems and where they stand.

      4. I did not intend to skip over the issue of deliberate limitation of health care providers. I did mention one aspect of this in the
      limitation of the number of training slots. Of course, there are many ways to limit providers. Some are governmental and/or political such as limiting the ability of health care workers to provide certain services that are legal and have safely been provided for many years in clinical settings by saying that now they can only be provided in hospitals or that providers have to have admitting privileges. Some are blatantly and obviously designed to intimidate people from attempting to establish a practice in what the established providers consider “their territory”. Before jointing Kaiser I had considered joining a solo practitioner in Montana because of my then husband’s career. I had a very threatening conversation with a member of the only other group in town whose message was quite clear. He and his partner did not want the competition of a woman gynecologist. I asked a nurse at the hospital who had witnessed our encounter what that was all about. She said that while the nurses would love to have a woman providing care and knew that many of the patients would too, she felt I should “be careful” in accepting this offer because I would in her words “always have to watch my back.” In terms of health care, this is the really nasty side of fee-for-service that the public just doesn’t see.

    2. D.D.

      My labrador needed oral surgery. (Tooth extraction with special anesthesia for an older dog). A vet in the El Macero area charged almost twice as much as Aggie Vet in Dixon. An Arizona vet charged even less. Same procedure.

        1. Tia Will


          “In this case, the free market worked. ”

          Thanks for the smile. I have always found it ironic that the vet can tell me exactly what my cat or dogs procedure will cost, but not so the doctors I have taken my children to when traveling.

    3. D.D.

      My friend did not have good enough grades to get into Davis Vet School, her first choice of occupation. She joked that she was accepted into med school instead. Today she really is an M.D. but she wanted to be a vet! She does love her M.D. job and has much gratitude for her life.

      1. TrueBlueDevil

        I always heard that joke as an undergrad.

        Don’t you think another vet school in California would be helpful? Or should the UCD Vet program double in size? We are now a state of 40 million, and growing!

        1. D.D.

          I’m convinced that another vet school in CA would be wonderful, and the care of our pets would not suffer. Just not convinced that the vet schools have to charge so much for education. Many vets charge a lot for their fees after graduating because they are trying to pay off their student loans, or open their new business. After paid off, they rarely lower their prices!

      2. Tia Will

        D.D. and TBD

        “My friend did not have good enough grades to get into Davis Vet School, her first choice of occupation. She joked that she was accepted into med school instead. Today she really is an M.D. but she wanted to be a vet! She does love her M.D. job and has much gratitude for her life.”

        On reflection, I see this as another illustration of how the lack of a “free market” impacts both human and animal health care. The artificial maintenance of a low number of slots in both veterinary medicine and in human medicine drives us to fewer choices of whom to patronize and encourages prices to rise. So much for the beneficial effects of the “free market”.

        What I think that you over look sometimes TBD is that the free market that you are so devoted to did not exist in medicine. While the free market may work very well when considering whether you want pizza or hamburgers for dinner, or whether you want to purchase your clothing at Target or Nordstroms, it simply has not been allowed to function in medicine because of the actions of the private interest groups involved. Until everyone is willing to admit that the “free market” was not the operative agent in medicine, we will continue to have this pointless argument about the benefits of a mythical system over those of an admittedly flawed attempt to mitigate some of the major deficiencies of the reality of health care as it existed in the real world.

        1. Matt Williams

          [The free market] simply has not been allowed to function in medicine because of the actions of the private interest groups involved. Until everyone is willing to admit that the “free market” was not the operative agent in medicine, we will continue to have this pointless argument about the benefits of a mythical system over those of an admittedly flawed attempt to mitigate some of the major deficiencies of the reality of health care as it existed in the real world.

          I agree with you Tia there has not been a free market operating in healthcare since the beginning of the 1950s. Getting to a single payor system will get us the closest to a free market in over 65 years. Health care providers will not have to practice all the shenanigans that they currently do in order to determine whether they will get paid for providing health care to a patient … and how much they will get paid.

          By making the insurance marketplace “less free” we will be making the healthcare marketplace significantly more free.

          1. Matt Williams

            TBD, in a single payor system you will be able to go almost anywhere to get your care because all healthcare providers will be paid for by the single insurance alternative. The exception to that will be the “closed” plans like Kaiser who will contract with the single payor to accept a bulk capitation payment from the payor and accept the fiscal risk of holistically providing all the care to a member for that capitation payment. Such a capitated health system would then be able to retain within their system any difference that exists between the revenues and the costs.

            Is it possible for you to wrap your mind around such a separation of (A) the delivery of insurance coverage and (B) the delivery of healthcare services? To torture your buying a car metaphor, going out and “buying” insurance is the same as going out and “buying” a car loan. Going out and choosing what car you want delivered to you from what car dealer, once you have the car loan in place to pay for the car, is like going out and choosing what healthcare services you want delivered to you from what healthcare proviser, once you have the insurance in place to pay for the healthcare services.

          2. TrueBlueDevil

            Matt, so if the single payor – Uncle Sam – decides to pay $500 for a procedure, but the doctor in Davis decides he needs $800, what happens?

            What happens if no doctor will do the test for $500? Do the doctor’s get thrown in jail?

            And if all doctors get paid $500 for said procedure, where is the incentive to innovate with something cheaper, or better?

            Will single payor still allow private medical practices, and independent insurance companies?

          3. Matt Williams

            Matt, so if the single payor – Uncle Sam – decides to pay $500 for a procedure, but the doctor in Davis decides he needs $800, what happens?

            What happens if no doctor will do the test for $500? Do the doctor’s get thrown in jail?

            TBD, the same thing would happen that happens in the current system if Blue Cross decides to pay $500 for a procedure, but the providers decide they need $800. The mutually decide to work together or go their separate ways. If they decide to go their separate ways, then the provider doesn’t offer that service to its/his/her patients. Not all providers offer all services.

          4. Matt Williams

            Will single payor still allow private medical practices, and independent insurance companies?

            Medical practices are not payors, so their existance is unaffected by the existence of only a single payor. Independent insurance companies are payors, so the actuarial insurance portion of their existance would be eliminated by the existence of only a single payor, but the claims processing portion of their existence would not be eliminated. The payor would contract with local third parties to perform the claims processing functions.

          5. wdf1

            TBD: And if all doctors get paid $500 for said procedure, where is the incentive to innovate with something cheaper, or better?

            You assume that money is the principle (or only) motivator behind innovation. I think that is a limited perspective.

  4. TrueBlueDevil

    The Republicans also have a health care plan: The Patient Choice, Affordability, Responsibility, and Empowerment (CARE) Act

    Dr. Tom Coburn, a Congressman who is fighting cancer and had one of his oncologists rejected by the Affordable Care Act, is one of the sponsors.


    “The Patient CARE Act provides a legislative roadmap to fully repeal the President’s health care law, known as Obamacare, and replace the law with common-sense measures that would:

    Establish sustainable, patient-centered reforms:
    -Adopt common-sense consumer protections;
    -Create a new protection to help Americans with pre-existing conditions;
    -Empower small business and individuals with purchasing power;
    -Empower states with more tools to help provide coverage while reducing costs; and
    -Expand and strengthen consumer directed health care.

    Modernize Medicaid to provide better coverage and care to patients:
    -Transition to capped allotment to provide states with predictable funding and flexibility; and
    -Reauthorize Health Opportunity Accounts to empower Medicaid patients.

    Reduce unnecessary defensive medicine practices and rein in frivolous lawsuits.
    -Medical Malpractice reforms.

    Increase health care price transparency to empower consumers and patients.
    -Requiring basic health care transparency to inform and empower patients.

    Reduce distortions in the tax code that drive up health care costs:
    -Capping the exclusion of an employee’s employer-provided health coverage.


    SUMMARY of the plan, 8 pages


    ACA vs Patient CARE Act Comparison


    1. Don Shor

      I have read the plan. It completely fails on pre-existing conditions, so it’s a non-starter from my viewpoint. Also, it would not pass the Tea Party base of the Republican Party, and Democrats have zero reason to support it as a ‘repeal and replace’ option. So it’s going absolutely nowhere. If there are good aspects of it, they can become part of ACA legislative revisions that might occur in, say, 2017. But the base and a majority of the Republican Party does not favor any ‘replace’ legislation. All they want is ‘repeal’. And since 57% of Americans either support the ACA (40%) or want something more liberal like single-payer (17%), this plan by Coburn is pointless.

      1. TrueBlueDevil

        Obamacare is already facing new scrutiny by the courts over state vs federal issues.

        Obama will continue to put off onerous sections of Obamacare until after the next election, and then the next presidential election. Rates will continue to rise as younger people haven’t signed up for the program as anticipated, but more sick / older people did sign up for the program, a double whammy.

        1. Barack Palin

          “Obama will continue to put off onerous sections of Obamacare until after the next election,”

          Exactly, whoever becomes the next president is in for a huge problem. If the ACA was so great why does Obama keep delaying key parts of its enactment?

          1. Tia Will


            I don’t think that anyone, including Obama is saying that the ACA is so “great” that it would not need revision. As a matter of fact, I have heard him say that he knew revisions would be necessary. What I don’t understand is why Republicans, having lost on every attempt to repeal, will not simply try to help to improve the points that need it. I am quite sure ( although I need to read the actual bill) that there are parts of the CARE plan that might make a positive contribution. So why not do the obvious and attempt to pick the best parts of both plans and move forward ?

          2. D.D.

            I agree with Tia. Republicans need to work with our President and try to improve and accomplish, rather than critique & impeach. Just give the guy a chance? Please? It’s not too late to cross the aisle & get something accomplished.

          3. TrueBlueDevil

            I believe the Dems froze the GOP out of discussions.

            And if the ACA was so great, why did Congress, their staff, and the President get a waiver?

            Why the midnight votes?

            Why the 22 Executive actions to alter the passed legislation, that probably violate the Constitution?

            The standing thinking before the ACA was that any major legislation needed 70 votes to be sustainable, like Social Security and Medicare. The ACA violated that common-sense approach, hence the disdain and problems.

            Democrats had 30 years to prepare this legislation, and this is what we have.

          4. Don Shor

            I believe the Dems froze the GOP out of discussions.

            I’d say you weren’t paying attention at the time. More than a year of congressional hearings. Single payer off the table from the start. Expansion of Medicare off the table. Hundreds of Republican amendments accepted. Months of negotiations, led by Sen. Max Baucus, to try to get Republican votes. Dozens of hearings in the Senate Finance Committee, chaired by Baucus and Republican Sen. Grassley. “Gang of Six” negotiations, 3 Dem, 3 Rep senators, went on for weeks. Blocking it all? Publicly stated, and enforced, policy by Sen. Minority Leader Mitch McConnell to block the president’s agenda across the board, and in particular to block any health care measure.
            Yes, Obama eventually gave up on trying to get Republican votes. He was still trying to get Olympia Snowe and a couple of others, right up to the very end. But McConnell held firm.
            Blaming Obama for complete Republican intransigence is just plain ridiculous.

          5. TrueBlueDevil

            This link gives a good summary of our HC industry / laws. I was unaware of this, but it adds light: “The United States Congress passed the Emergency Medical Treatment and Active Labor Act (EMTALA) in 1986. EMTALA requires hospitals and ambulance services to provide care to anyone needing emergency treatment regardless of citizenship, legal status or ability to pay.”

            Other nuggets:

            “On July 8, 2009, Barack Obama met with hospital lobbyists and struck a deal with the hospital industry to remove the public option in exchange for the industry’s support of the bill, while also reducing costs for hospitals under the plan.[41] …”

            “Less than one year after Obamacare was signed into law, 111 unions, companies, and organizations had received approval for Waiver of the Annual Limits Requirements of the PHS Act Section 2711.[152][153][154][155] By December 7, 2010, the list of unions, companies, and insurers who have used the HHS waiver as an escape to avoid the costly, destructive consequences of Obamacare for their members and employees grew from 111 to 222.[156][153] More than 50 unions have already received waivers.[157] Moreover, three Service Employees International Union (SEIU) local chapters, including the Chicago chapter, whose political action committee spent $27 million supporting Barack Obama in the 2008 presidential election, have received waivers from a provision in the Obamacare law.[158]”

            “There have already been deaths attributed to doctors exercising newly-granted authority from these extra-judicial decision making bodies. A young girl, in liberal California of all places, was told that her liver transplant was not “worth it,” because she wouldn’t live long enough to justify the value of the organ. Though public outcry forced the doctors to change their minds after ten days, but those ten days were enough to kill an innocent child. Another woman, a nurse in Texas, was denied treatment for her breast cancer, purportedly because she was in middle age and was not worth the “investment.” [161]…”

            “According to a monthly poll from the Kaiser Family Foundation, as reported by The Hill on October 28, 2011, 51 percent of respondents had an unfavorable view while only 34 percent had a favorable impression of Obamacare.[166]”


          6. TrueBlueDevil

            Gallup says the approval rating of the ACA is holding at 39-40%, and holding strong, and concludes that people have their opinions set.

            They continually update their polling.

          7. Matt Williams

            When you drill down into the Gallup data, what percentage of those who “disapprove” hold that opinion because they believe ObamaCare does not go far enough in achieving a single payor solution?

          8. wdf1

            Maybe the more informative poll question to ask is “should we abolish the ACA and go back to what we had before?”

  5. D.D.

    “In the fee-for-service world, she will often have hysterectomy recommended as the first option, not because other less costly options are not available, but because that is the most highly compensated procedure for the doctor.”

    I witnessed the same in w.c. claims-sometimes back surgery was immediately prescribed, other times psychological therapy, weight loss, aerobic walking, tens units, massage, chiropractic were prescribed for the exact same back injury.

  6. Tia Will


    When you do a good faith look at examples of deaths caused by delays in treatment
    prune to inability to pay for care prior to the perceived qualification for ER care, combined with delays
    In care caused by doctors waiting for insurance companies to approve a needed treatment, added to care denied by insurance companies because a patient had made a trivial misstatement on initial application, I think you would find that they number of deaths related to failure of the fee for service, free market, employer based model would far exceed those which have occurred under the ACA. As a matter of fact, I can probably match you anecdote for anecdote just on the basis of my own
    time in medicine. No Google search needed.

  7. Jeff Boone

    Thanks for the article Tia. It is well written.

    What we have had in the United States for as long as I have been in medicine has not been a “free market.”

    True, and that is a big reason that costs have been increasing much faster than the rate of inflation. By integrating more free market aspects, we would reduce costs. And Kaiser, the system you laud, would likely not exist without the level of market freedom that has existed. The Kaiser model was developed specifically to win the competitive game of higher-quality, lower-cost healthcare. Because companies and individuals have some freedom to select a healthcare insurance and/or care provider, Kaiser was motivated to develop its model. If people were not free to choose… say in a single-payer, government-run, service-allocated, system like you advocate, companies and individuals would not have any choice, and so there would not exist the motivation for developing a new model to compete. I know you have a vision of all these uncompetitive happy people collaborating together in harmony to make the world a better place, but I think you don’t understand human nature very well.

    In fee-for-service medicine one has to dig very hard to actually get numbers in advance, and even when provided, they are always estimates, not guaranteed final costs.

    Don’t be silly. This can be fixed. Take your car to the shop. They don’t know what is wrong. At least they give you an estimate for the diagnosis work. And then they eventually give you an estimate for the final repair. The medical industry is just resisting this because it is easier to just bill the customer as much as possible. But it could be done… full disclosure of every procedure and supply and drug that a customer has to pay for. Every other industry does it. There is no good reason that the medical industry does not except resistance. How much does that MRI cost? Give everyone high deductible HSA account insurance, and open and clear pricing, and they will absolutely go to the lower cost provider.

    In the fee-for-service world, health care providers have a financial incentive to advise more procedures.

    In the medical malpractice world, health care advisors have a financial incentive to advise more procedures. And will all due respect, I am not very happy with this inference that the employees of your profession are so prone to ordering procedures just for the money. If this is as big of a problem as you make it out to be, then we have other problems that must be dealt with. I think few doctors order more procedures than are needed… especially if and when the patient is paying for it out of his/her own pocket. In fact, with my high deductible HSA plan, that is exactly what happens with my doctor. He helps me make value decisions on care options. Recently one of my family members needed a colonoscopy. Davis Sutter was $10k and Sac was $3k, but we collaborated on which choice we needed to make… not which choice was less expensive.

    American “free market” medicine has also imposed artificial constraints on other parts of health care delivery. The “market” for doctors and to a lesser degree other health care professionals has been artificially manipulated for as long as I have been in medicine.

    I think you are near my age. I remember healthcare costs being a big political debate over 3 decades ago. And then the rise of the HMO. And the HMO controlled the rise in costs for a time. The point here is that you should not blame the insurance companies. The reason we have too high medical costs is that the healthcare providers have failed to control costs… failed to do what Kaiser has done and create new models of efficiency and affordability. And the reason they have failed is that government meddled too much in the healthcare industry, and trial lawyers raped and pillaged with frivolous malpractice suits.

    The bottom line here is that Democrats ignored collaborating with Republicans on this junk legislation. All the arguments that existed about his legislation being junk are coming true. It is a mess. And the few people that have secured coverage compared against the cost and the impacts to those that have lost coverage… and to the damage to the job market… and the pending damage… all added together make it one giant mistake.

    And now the complaint from the left is that the GOP does not HELP fix it and make it better.

    God I really hate that. Stick your finger in a person’s eye while ignoring his warnings. Then go make your unilateral decision and later see all of the warnings come true. Then cry and complain that the person you dismissed, ignored, poked and harmed is not coming to your rescue to fix the mess you caused. That is the behavior children.

    And you wonder why folks like me see a county in decline.

    Democrats own this lock stock and barrel. The transformation of the country from majority producer to majority moocher might mean that Democrats will not suffer the full deserved consequences for the mess that they created. But then the mess isn’t done. And so we will just wait it out.

    1. Don Shor

      The bottom line here is that Democrats ignored collaborating with Republicans on this junk legislation.

      As I posted to TBD earlier:

      I’d say you weren’t paying attention at the time. More than a year of congressional hearings. Single payer off the table from the start. Expansion of Medicare off the table. Hundreds of Republican amendments accepted. Months of negotiations, led by Sen. Max Baucus, to try to get Republican votes. Dozens of hearings in the Senate Finance Committee, chaired by Baucus and Republican Sen. Grassley. “Gang of Six” negotiations, 3 Dem, 3 Rep senators, went on for weeks. Blocking it all? Publicly stated, and enforced, policy by Sen. Minority Leader Mitch McConnell to block the president’s agenda across the board, and in particular to block any health care measure.
      Yes, Obama eventually gave up on trying to get Republican votes. He was still trying to get Olympia Snowe and a couple of others, right up to the very end. But McConnell held firm.
      Blaming Obama for complete Republican intransigence is just plain ridiculous.


      Democrats own this lock stock and barrel.

      Ok. 40% of the country is satisfied with the ACA, 17% wants something more liberal like single payer. You guys are just wandering in the political wilderness, arguing among yourselves.

          1. wdf1

            You can refer to Don’s link reference above and find where independents track. As you might expect, they fall between Dems and Reps.

        1. TrueBlueDevil

          This survey mainly asked about the good stuff.

          Do you like ice cream? Do you like cake? Do you like chocolate?

          Where are the questions about …

          “Do you want to lose your doctor b/c of the ACA”?
          “Do you want to lose your current policy due to ACA?”
          “Do you want the government going after you if you make negative comments about Obamacare in online forums?”
          “Do you approve of new medical device taxes?’
          “Do you approve of $500 Billion in Medicare cuts?”
          “Do you approve of an independent body being able to deny you medical care (rationing)?”
          “Should American citizens be required to pay higher taxes to provide health care to illegal immigrants?”

          1. Tia Will


            Well the phrasing of the questions really does matter doesn’t it ? So let’s take your list and basically apply it to what we had before the ACA.

            1. Do you know that you can lose your doctor any time your employer decides not to offer the insurance he is contracted with ?
            2. Do you know that your employer could change insurance every year if they wanted to?
            3. Do you want the Republicans dictating what health care services you can access ?
            4. Do you approve of not knowing how much a medical device will cost you ?
            5. Are you aware that an independent body is currently able to deny your medical care by refusing to reimburse your doctor. It’s called your insurance company. Are you aware that the current system does ration care…..it rations by ability to pay. No insurance or refusal of your company to pay and its out of your pocket….no money, no treatment. Do you like that ?
            6. “Should American citizens….” Not relevant to the current article. I think this question pertains to the “Snowpiercer” piece.

          2. Matt Williams

            Tia and TBD, I would add the following to Tia’s list:

            7. Do you know that the very first question every patient gets asked when they call a doctor or hospital for an appointment is “What insurance coverage do you have?”
            8. Do you know that the only place in the healthcare delivery system that is required to treat a patient with no insurance is a Hospital Emergency Room. No doctor is so required. No Hospital Admissions Office is so required. No Hospital Outpatient clinic or facility is so required.

    2. TrueBlueDevil

      There are a lot of major signals that this thing is going poorly, not the least of which is that Obama himself rarely refers to it anymore – his singular achievement. When Nancy Pelosi said “You have to vote for it to see what’s in it”, that was another gigantic clue.

      As a senator, Obama said his end game was single payer. He then had to run away from that. Now major impacts are continually delayed until after the next election. Why the game playing, if it is so great? That includes using 10 years of revenue (new taxes) but only 6 years of new services (costs) to keep the projected cost down.

      Cases of rationing will start to emerge, like the 12-year-old girl here that was going to be denied a liver transplant.

      The advantage of HSA is that we will be motivated to conserve and use our funds wisely.

      John Stossel often refers to optometrists as a sector with free market at play, increasing quality and innovation, and prices falling. Doctors who even answer email!

      I think an underlying motivation here is that many liberals think they are more compassionate than conservatives, more enlightened, which I don’t agree with. I’ve joked with liberal friends that they have a problem with basic math. I think many conservatives realize the complexity of life, and that no one person or group is smart enough to make hundreds or thousands of decisions yearly, weekly, or daily, like the free market. I heard a story on the radio about how a pencil is made – pretty simple product, eh? The products’ chemicals, processes, and such that go into making a basic pencil are amazing. I could never have dreamed of that, yet we do it efficiently, effectively, and cheaply. So if a pencil is that involved, how many factors more complex is the medical industry? But Obama, and Hillary, and Harry Reid think they can figure it out? Please.

      1. Tia Will


        “When Nancy Pelosi said “You have to vote for it to see what’s in it”, that was another gigantic clue.”

        The only thing that this oft repeated quote was a major clue about was that Nancy Pelosi had made a stupid comment. Kind of like President Bush appearing in front of the Mission Accomplished banner. Politicians of all stripes say and do stupid things. They are human.

      2. Tia Will


        “no one person or group is smart enough to make hundreds or thousands of decisions yearly, weekly, or daily, like the free market”

        What you are not noticing in this analysis is that the “free market” is an intellectual construct, not an actual being. It is the aggregate of all of the decisions made by millions of human beings one decision at a time.
        So what you are saying is that the aggregate of decisions is necessarily better than individual decisions.
        Kind of an oxymoron from my point of view.

        On another note, you are acting as though a “free market” actually existed for medical care.
        One major theme of my article was that medical care has not been governed by a “free market” going back to well before the 1930’s when Kaiser was started. Even Frankly stated his agreement with this.

        So if you claim a “free market” is better, then we should see the plan for one and consider its merits.
        No one, not the Republicans, not the Democrats, not the insurance industry or the pharmaceutical industry or the medical professions has put forth a plan that even approaches a “free market”. So given that this is the case, you are defending something that has not existed in our lifetimes as the best option. You might be right, but what we had previously was not a free market.

        1. Matt Williams

          Tia, the key to producing a free market in the delivery of health care is to decouple the healthcare delivery marketplace from the insurance marketplace.

          TBD doesn’t appear to understand that the non-free aspects of the insurance marketplace are a massive anchor that drags the “freeness” of the heathcare marketplace down to the level of the lowest common denominator.

        2. TrueBlueDevil

          Please see my reply below. The best way to prove which model would work best would be to have an open competition between the Free Market, Kaiser Model, and Single Payer.

          The proof is in the pudding!

          Same goes for “education reform”. Common Core is a half-baked experiment foisted on our children. Contrast this with business, which will often “pilot” a new program or car to make sure that it is effective; same thing for an Alpha or Beta release in software, and lab usability testing / stress tests. Ironically, if we are to believe the new graduation rates at LAUSD over the past 8-10 years, that would mean that No Child Left Behind worked!

          1. Tia Will


            In one way, you could see Kaiser as a “pilot program” such as you are suggesting.
            A problem with your suggestion (which is a good one) of a direct comparison
            of the three models that you have suggested is that two of them, the free market and single party payer do not exist in our country

          2. TrueBlueDevil

            Which is why I say bring it on!!! Competition! Party!

            Fire up the systems and see what system(s) actually prevail in the real world.

            I am reminded of all of the “innovations” we have had in education for decades. There was an inner city teacher who was tired of this, so she went to a private prep school that had been a top performer for eons, and simply copied everything they did. She stood on the doorstep, greeting every child by name… had her inner city, largely black students reading the classics… this would be unheard of! Her students excelled, and she came to take the worst students, and they achieved wonderfully! That was a great story. (I think she recently passed away.)

        3. TrueBlueDevil

          Tia, the Free Market is as real as the air you breath. Individuals on their own, and collectively, make decisions, good, bad, horrible, wonderful. It is truly the invisible hand of the free market, along with creative destruction. Poor products or services can’t stand the test of time, whereas the free market forces adaptation, innovation, efficiency. It can be tough, it can be brutal and unfair, but it’s the best that we have.

          Yes, aggregate dynamic, evolving, motivated decisions by millions of consumers are monumentally better than – the individual decisions of 10 politically appointed bureaucrats who by definition are not dynamic or evolving. And their primary motivation is to keep their power, influence, paycheck, and perks intact … not make something cheaper, faster, or better. And even if that was their mortivation, the don’t know how. It’s impossible.

          1. Tia Will


            I simply do not believe that a tough brutal system is the “best we have or the best we can do”. I believe that human beings have the ability to look at our world, analyze where things can be improved and make changes accordingly.
            I refuse to believe that unfair, tough, and brutal ( your words, not mine) are the best we can do. That is not the world I want to leave for my children.

    3. D.D.

      “I am not very happy with this inference that the employees of your profession are so prone to ordering procedures just for the money.”

      I have processed thousands of medical claims and I can confidently state that this does occur more often than we’d like to imagine. (I used to be a witness at the workers comp appeals board to discuss the CA Fee Schedule, IC9 coding ,over-billing and unnecessary procedures.)

    4. Tia Will

      Hi Frankly

      Thanks for taking the time to read and consider. Naturally we have some differences of opinion, but we should not have differences of fact.
      1. You have stated without supporting that Kaiser would not exist without the free market and that the Kaiser model was designed to “win the competitive game.” This is inaccurate. The Kaiser model was developed in the late 1930’s to provide pre paid, cost effective health care to a very limited group of industrial workers and was not even opened to the public until 1945. In the beginning, it was not about free choice of health care.
      2. If there were a single party payer, companies would not have to choose since the link between patient and employer would not exist. There would only be two decision makers, the patient and the doctor. The patient would have more, not less choice on two levels. First they could go to see any doctor they wanted ( who was accepting new patients as SODA pointed out) since doctors would be paid by the government not within the network they were limited to ( an artificial limitation of all the current plans including Kaiser). Thus the patient would have not only the free choice of provider, but also the free choice of treatment without the intervention of the insurance company. In fee for service, people think they have more freedom because they do not see behind the scenes to see how their treatment options are really decided.
      3. I don’t have a “vision” of people working collaboratively together. I operate daily in such a system. Of course there is competition. It just isn’t about the money. It iso about who gets the award for making the largest contribution or who gets to move up in the administration if that is where their motivation lies. I believe that what I understand about human motivation is that it is not exclusively about money.
      4. Nothing silly about my comment. I didn’t say that providing costs up front couldn’t be fixed. I said it hasn’t been. This is because it favors the insurance companies. It isn’t the government that has kept this from happening, it is the insurance industry.
      You correctly noted that “every other industry”…. It is my belief that we would not be where we are now if the private insurance industry had not consistently acted to its own perceived benefit to the exclusion of the patient.
      5. You are quoting me one example of what occurred between one doctor and you and extrapolating that to form your belief about what happens across the board. I can guarantee you that there are doctors who do exactly what I wrote. I have trained with, gone to conferences with, and ultimately worked with many doctors who have left fee for service to work with Kaiser. Unless they are lying, I can guarantee that all motivations are not pure, and some are not even realized by the doctor who may honestly believe that he is making the best choice while it has been proven that our choices are swayed by ads and drug and equipment reps when there is any “token gift” even a pen left behind to “remind” us of a particular product or service. It can be subtle, but undue influence is there.
      6. Hmmm…..about whom to blame. I blame the insurance companies for their part. I blame the medical groups and societies for their part. Both have had distinct roles in developing the mess as it existed before Obamacare. Obama is only to blame for whatever mess does and may exist after the ACA. It is my belief that if he is allowed to make changes as necessary as all new systems must do ( can you name a major system that has not undergone many, many changes to improve it ?) and if those with differing ideas would help to alter the plan rather than “repeal and replace” then we would have a system that would be better than what we had previously. It would not be what either you or I want, but better than the reality that existed. From my point of view, Obamacare would not have even been dreamed of if the health care profession and insurance industry had been working consistently in good faith to always put the patient first. That obviously had not happened. So yes, lets both be willing to place the blame where it really belongs.
      7. The bottom line for me is obviously not partisan as it is for you. The bottom line for me is that neither the Republicans nor the Democrats were willing to put all options on the table. The Republicans were not the first group to be “shut out ” of the talks.
      Those who favored single party payer were excluded long before the Republicans who were “shut out” only after many, many attempts to work together as Don has pointed out.
      8. As for the “country in decline”, I see a country in decline when it stands by an entire industry ( or two or three if you want to put in the pharmaceutical industry that I did not touch on) that leverages people’s health care and lives for its own profit. Plenty of fingers to point around on that one.
      9. Democrats own this lock stock and barrel
      As I stated, Democrats own the ACA entirely. The reason the ACA came to be is because of the inertia and greed that allowed the previous mess ( I know you don’t see it that way because you had insurance….many didn’t) to persist in the first place. That is much more widely owned and much bigger than the ACA.

    1. Don Shor

      Oh for God’s sake!!! This is completely ridiculous! You are not reading what we post.
      Try this:
      40% support Obamacare.
      17% support something more liberal, such as single payer.
      Please add those up. That makes 57% who either support Obamacare or want something more liberal. 57%. Ok?
      What you are clearly not understanding is that a percentage of those who “oppose” it do so because they want something more liberal. Like single-payer.
      There is not majority support for “repeal and replace.” The Republicans do not hold a position that is supported by a majority of Americans.
      Really: do you understand this?

      1. Don Shor

        From the CNN poll:
        14. (IF OPPOSE) Do you oppose that legislation because you think its approach toward health care is too liberal, or because you think it is not liberal enough?
        Favor: 40%
        Oppose, too liberal: 38%
        Oppose, not liberal enough: 17%

        1. TrueBlueDevil

          I dunno, a recent poll said if the last Presidential election were held today, something like 70% would vote for Romney! I believe the poll was by CNN, not Fox News. That shows you how unhappy people are, and it will only get worse.

  8. TrueBlueDevil

    Obama Democrats Lose Their Big Bet on Health Exchanges

    Beyond the recent legal setback to the ACA, there was another ruling I wasn’t aware of.

    “On the legal front, it has generally escaped notice that in its NFIB v. Sebelius decision upholding Obamacare, the Supreme Court also invalidated its Medicaid provisions — and by a 7-2 vote that is unlikely to be overturned by one or two new Democratic-appointed justices.

    “Obamacare provided that states must accept new Medicaid provisions requiring higher spending or lose all their federal Medicaid money altogether. Not valid, said the justices. Congress can’t take command of state governments by threatening to cut them off if they don’t spend more.”


  9. Topcat

    Tia wrote “I believe the most cost-effective and equitable system would be single party payer administered through a Kaiser-like model of care delivery.”

    I tend to agree with this direction. I think it’s important to completely eliminate the involvement of employers in paying for employee’s healthcare. This has led to all sorts of economic distortions and wasted societal resources.

    In our patchwork healthcare system we already have some segments that employ the single payer model. These include Medicare, VA Health benefits, and the Indian Health Service. It’s interesting that we never hear Republicans or the Tea Party calling for repeal of any of these services.

    Unfortunately, there are powerful political forces that will fight any moves towards an efficient single payer system for those in society who are not already covered by these systems.

    1. Matt Williams

      Topcat, I agree with the first part of Tia’s statement, but am not willing to go as far as the second part. For many people a Kaiser-like model of care delivery is the ideal, but for others the “academic medicine” model is the ideal. My sense is that the free market created by the decoupling of insurance from care delivery through the creation of a single payer system will support both the Kaiser model and other models as well.

      1. Tia Will


        I agree with your statement that one key in enabling the establishment of a true “free market would be to de couple health care from insurance. However, this still does not address the issue that will often put the patient at such a disadvantage that no true freedom within the market place as to invalidate that word ” free”.
        If the patient is in pain, or afraid, or perceives that their functioning or their life is at risk, they are no longer capable of deciding logically what course of action is in their best interest. A “free” choice is far beyond their grasp.

        1. Don Shor

          I keep thinking of the two most expensive medical situations we encountered. Two emergencies in which we were directed to a hospital, once with an ankle broken in three places, the other a pediatric emergency. We didn’t get on the phone to compare fees. The hospital was chosen by proximity (ankle) or by our pediatrician. We had no idea what procedures would be performed, and we weren’t in a position to ask. We had no idea afterwards how much it was going to cost. But in both cases, as we left we had to sign a guarantee that we would pay the bill — whatever it was.
          So when your infant goes into pediatric emergency, including IC, for four days and three nights, are you going to shop around? No.
          The bill for the ankle was $17,000.

          1. Jeff Boone

            What percentage of medical procedures are emergency compared to scheduled throughout a life?

            Of course you don’t have time to comparison shop when there is an emergency. But comparison shopping all the other times will cause the providers to have to be more competitive and this will help drive down the cost of procedures when there is an emergency.

            Really Don, you would not want to shop for the least expensive MRI in your area? Seems lazy to me.

          1. Tia Will


            “What percentage of medical procedures are emergency compared to scheduled throughout a life?”

            100% if you have no insurance and do not have enough money to pay out of pocket and do not qualify for government payment through Medicaid/Medicare.

          2. Matt Williams

            I was going to say the exact same thing.

            That is the downside of TBD’s “free marketplace.” But it doesn’t stop with the simple fact that a substantial portion of the members of that marketplace are denied access to care. It goes much further, because when the diseases/conditions of the people with no insurance naturally get worse due to the marketplace denial of care to them, they arrive at the emergency room with advanced stages of their illness which are significantly (sometimes massively) more expensive to treat, and the healthcare provider has to treat them for free, and write off the cost of that treatment as a dead loss on their accounting ledger.

            The written off “free” care isn’t free though. When the provider decides whether his/her/its prices should be $500 or $800 (using TBD’s prior example) those writeoff costs drive the price upward … away from TBD’s $500 and closer to TBD’s $800. Then the insurance companies have two choices. They can stick by their principles and refuse to pay the $800, paying no more than $500, or give in and pay the $800. If they refuse to pay more and the providers then decise to stop offering the service, then the patients in the free market no longer have access to that service … and the quality of care delivered by the healthcare system declines.

            Alternatively the insurance company can decide to pay the $800 to the providers so that the service will continue to be available to their policy holders, but the insurance company won’t simply “eat” the additional $300. They will pass it on to their policy holders in the form of an insurance premium price increase.

    2. TrueBlueDevil

      Arrogance drives a lot of these decisions, the status quo, ignorance.

      How simple is this? Have 2 states (1 urban, 1 rural) implement a Free Market system; have a second set of states implement a Kaiser-type system; and have a 3rd set of states implement a single-payer system.

      After 6 or 8 years, look at all the data for various illnesses, survival rates, costs, outcomes, quality of service, innovations, and client satisfaction. Let’s see how they all stack up!

      Topcat, the reason why the GOP probably doesn’t want to dump any of these is that once you give someone something, taking it away makes you look like the bad guy … even if you are watching out for the other 290 Million Americans. Just like when we finally get down to talking about deficit reduction, no one wants to name names … once you name this group or that group, they’ll line you up to paint you as satan. (Speaking of, I think liberal icon Saul Alinsky thanked Satan in his famous book Rules for Radicals.)

      1. Matt Williams

        You are confusing insurance with healthcare. You need to separate the two. As long as the current healthcare insurance system continues to exist, there can not be, and will not be, a free market for healthcare services.

        1. Frankly

          Because of the necessity and the high potential cost for treatments and the potential impact on a family, I think we need insurance to level risk across a larger group.

          Insurance is not the problem. The problem is hyper-inflationary cost from healthcare providers. The root cause of that problem is:

          – Too little competition and too few free market incentives.
          – Too many costly government regulations.
          – Too many trial lawyers with too much freedom to extort money from the system.
          – Too much union labor in the healthcare field.
          – Too few individual incentives to become a good value consumer of healthcare services.

          1. Tia Will


            I agree that risk should be leveled across a larger group. I just believe that that “larger group” should be our entire population. Hard to get risk more broadly than that.

          2. Don Shor

            Yes, that is precisely why those with pre-existing conditions should be spread out into the largest risk group (i.e., everybody) rather than segregated off into special high-cost under-funded risk groups. I find it surprising that Frankly would say this after all of his previous comments.

          3. TrueBlueDevil

            Frankly, that’s a good list. Add too few medical schools: double the number, produce more doctors and nurse practioners and alternative delivery systems, and drive costs down. Direct the millions of illegal immigrants who use the ER as their docrtor’s office somewhere else less costly. And maybe tax money trtasnfers to Mexico and Central America 15% to help pay these costs if they don’t provide proof of legal residence.

            Set up my test, guage the three systems as they compete, and see what the results are. But arrogance and power will instead rukle the day.

            Yes, many changes would have to be made to attempt to test a truer Free Market system. Published pricing – online – could be a huge boon to the HC market.

          4. Matt Williams

            Frankly, insurance is absolutely the lions share of the problem. When I came into the healthcare field in 1981 the administrative costs for healthcare providers was 8% of total expenditures. Now that administrative component is between 20% and 25%. That incremental 12 cents to 17 cents being bled off from every dollar is the result of the spaghetti code of the myriads of insurance carrier requirements. Medicare has its set of requirements, Medi-Cal has its set of requirements, each different Blue Cross plan for each different state in the US has its set of requirements, each different Blue Shield plan for each different state in the US has its set of requirements, each individual commercial insurance company (there are thousands) has its own set of requirements, each different HMO like Kaiser has its own requirements. All those requirements result in clerks and financial analysts and utilization review specialists and risk managers and supervisors and managers for all those incremental employees.

            — All those disparate individual requirements are massive barriers to competition because what is competitive under one set of requirements is not competitive under another set, and the sets exist simultaneously.

            — The same thing applies to market incentives. Unless a preponderance of the payors honor the incentives then the incentives fall on fallow ground, because so few patients actually pay for their healthcare directly … only indirectly.

            – Government regulations pale in comparison to payor requirements.

            – Too many trial lawyers with too much freedom to extort money from the system. Compared to the 12 cents to 17 cents of incremental administrative overhead, the legal “extortion” is a penny or two.

            – The incremental cost of union labor is a marginal contribution to the inflated costs.

            – Too few individual incentives to become a good value consumer of healthcare services. The current highly fractured insurance realities of the healthcare market eliminates the direct fiscal relationship between patient and provider.

            In a single payor insurance environment virtually all of that 12 cents to 17 cents of “blood” will stop being removed from each dollar spent in the healthcare marketplace.

  10. Frankly

    I think an underlying motivation here is that many liberals think they are more compassionate than conservatives, more enlightened, which I don’t agree with.

    Jonathon Haidt explains it the best.


    Read The Righteous Mind: Why Good People Are Divided by Politics and Religion. It makes a very strong argument for differences in our moral mind being at the center of our politics and political differences. My take away is that without enough of conservatives morality we will experience social and economic decline, but without liberal morality we will become too restricted, harsh and authoritarian.

    Seems to me that we need each other and need to balance our moral preferences. The problem we see today is an out of balance condition that is largely perpetrated and promulgated by a liberal press and media. Without so much liberal bias in our press and media, we would have better balance, IMO.

    1. Matt Williams

      Come on Frankly. There is just as much radical conservative bias in the press as there is radical liberal bias. What we have is lots of representation at the poles and very little in between.

      1. Frankly

        I disagree completely Matt. Most people get their news from main sources that are highly liberal biased. Until and unless that changes, you cannot win the argument that we have anything close to balance.

        1. Matt Williams

          We will have to agree to disagree. In today’s electronic media world the viewer hours of conservative biased news are very much the equal of liberal biased news. I personally can’t think of a single liberal bilased talk radio news program. On the rare occasion when I am surfing the radio dial, I run into conservative talk radio a myriad of times … and it doesn’t matter what hour of the day it is. They are going 24-7 the same way CNN and FoxNews are.

          1. TrueBlueDevil

            But Matt,. Martha and Mayme in Sacramento aren’t listening to talk radio or reading the drudgereport.

            ABC, NBC, CBS, PBS, CNN, and MSLSD are all very liberal. The New York Times – which feeds many local daily papers – had over 20 articles on the abysmal Air America, yet games to system to keep conservative books out of their top-10 list. Or they get there, but there book isn’t reviewed.

            Obama 2016 was the 2nd highest grossing independent movie ever, yet wasn’t nominated for an Academy Award.

            On top of this, the New York Times, The LA Times, the San Francisco Chronicle, the Oakland Tribune, the Sacramento Bee, etc., are all liberal.

            For years the conservatives could only wait for Williams F Buckley or the National Review. Now we have talk radio, and Fox News; but the liberal side has added Stephen Colbert, Jon Stewart, and all of the late night joke readers.

          1. Matt Williams

            What I see on Local News is really not news, it is gossip, with a bit of weather, traffic and sports thrown in.

            A good unbiased source of real news is All Things Considered on NPR.

        2. Tia Will


          I could be very wrong but I think your reference to the “academic model” May be a misunderstanding of what Kaiser does in the “academic realm”,
          1) many if not most Kaiser docs in this area serve as volunteer faculty at UCD.
          2) We parter with both medical schools, UCD and Drexel currently, Stanford and Loma Linda and residency programs, previously in my experience in teaching their students.
          3) We have many researchers ( multiply published ) within the Kaiser system. The gentleman who I referenced with regard to cervical cancer screening was just one example .
          4) We have expertise levels in many areas equal to if not superior to that found at UCD

          I know I sound like I work in PR, but I assure I do not. I just have been around a long time and have had the chance to observe the evolution of Kaiser first hand since 1981.

          1. Matt Williams

            Tia, I don’t disagree with you characterization of Kaiser as an academically robust health system. The issue is much more one of perception. Many consumers look at a medical center like UCDMC with the belief that its primary mission is research and the development of cutting edge therapies within a tertiary care model, and those same consumers look at Kaiser as a deliverer of preventative and therapeudic medicine therapies within a primary care model.

            As they say, perception is reality.

    2. TrueBlueDevil

      But Frankly, isn’t it funny that Liberals want to ban smoking, ban smoking in public, ban plastic bags, add extra sin taxes like the recent soda taxes, etc. That’s restrictive! But then they want to legalize pot, which we now know causes harm to the teenage brain in three different areas, and then we have to pay the social costs?

      1. Frankly

        There is irony there that is indicative of some cognitive dissonance.

        My thinking on this is that liberals are largely baby boomers. And baby boomers grew up smoking weed and so they can’t accept any argument that it harms because then they would have to accept that they, in fact, might have been harmed.

        And weed is weed… just a plant growing in your yard man… just some botanical herb that has medicinal qualities.

        But junk food harms people only so the corrupt business man can stuff his pockets with more cash.

        It will be interesting to see how liberal views on pot change over time as the business man takes over more and more of the marijuana industry.

        1. Tia Will


          Absolutely no cognitive dissonance here.
          I favor the legalization of marijuana but not because it is harmless.
          You and others have posted that you do not believe that we should regulate or “ban” cigarettes which have been demonstrated far more deadly than marijuana.

          What I believe that we should do is to de criminalize individual drug use, and treat all mind altering drugs in the same way.
          1) medical advise against their use using no scare tactics but demonstrated fact.
          2) no driving impaired for anyone. A mind altering drug be ir alcohol or marijuana or cocaine or sedatives or opiates has no place in the body of a person behind the wheel
          I would further extend this to tobacco as smoking and driving equals distracted driving just as does texting or applying your make up while driving. If our goal is health and safety as opposed to pushing our idealogic agenda, all should be treated equally.

          1. TrueBlueDevil

            Tia, you are aware of the studes that show that marijuana can reduce the IQ of teenagers by up to 10%? This apears to have been validated by the recent study which shows that cannibus harms the brain in 3 different areas … even casual use.

            Given these facts, would you restrict cannibus use to 25 (when the brain is done develolping) or 21 (like booze)?

            Are you also aware that accidents while drivers are under the infleunce of weed are up 300%?

          2. Don Shor

            Are you also aware that accidents while drivers are under the infleunce of weed are up 300%?

            Actually, I think it’s fatalities, not accidents. And there is a basic problem: there is currently no accurate test for current use of marijuana comparable to the tests that can be administered to drivers for alcohol. THC can be tested in a person for several days after consumption. So it isn’t possible to say that a positive test indicates impairment, which you can say with alcohol. You need a field impairment test like a field sobriety test.

        2. D.D.

          Maybe business women will take it over, like some of the sustainable fishing villages in Mexico. Maybe UCD graduates will make a fortune on the cannabis industry & put in a few nice coffee houses/bakeries in downtown Davis. We can always hope. The future’s so bright I gotta wear shades.

      2. Tia Will


        “isn’t it funny that Liberals want to ban smoking, ban smoking in public”

        Yes it is true that I want to ban smoking in public places. Not because I want to control the choices of the adult smoker, but because I want to protect those who do not smoke from the well known hazards of cigarettes which are far, far greater than the hazards of marijuana over a lifetime. In this, I would think we would have complete agreement. I am sure that neither of us believe that it is a good idea for children to start smoking. Some facts we know:
        1. Most people who smoke start before age 17
        2. Most people who smoke are those who have been intimately exposed, usually in their families or close
        3. Fewer people start smoking in areas where is is not “the norm” as demonstrated by people smoking
        in public places

        What I would like to see is all mind altering drugs ( including tobacco with its “stress reduction” aka addictive properties) treated the same. All legal with age restriction, all counseled against in the schools, in doctors offices and through public health education, all regulated for quantity and quality of components,
        all prohibited when driving or operating any kind of dangerous equipment. I would think that this approach would have great bipartisan appeal since it removes the subjectivity, would provide revenue in the form of sales taxes as opposed to being an endless drain on our economy in terms of law enforcement, judicial proceedings, expenses related both directly and indirectly to incarceration to say nothing of the devastation of the lives of the families of those incarcerated.

    3. Tia Will


      “Seems to me that we need each other and need to balance our moral preferences. The problem we see today is an out of balance condition that is largely perpetrated and promulgated by a liberal press and media. Without so much liberal bias in our press and media, we would have better balance, IMO.”

      So I was with you through the first sentence. And then I had to laugh ( yes, out loud) because I see the situation exactly as you see it, only out of balance on the conservative side.

      1. Frankly

        But Tia – Sorry, but you are wrong about this. If we really had conservative bias in the main press and media, you would not be so polite in saying so. That is one way I know you are wrong. There are other ways too.

        1. Tia Will


          No, I simply don’t often comment on what is presented by what I consider to be the conservative press and media any more than I pretend that J. Stewart is presenting the “news”. I see the right media exactly the way that you see the left and I give no more credibility to your “rightness or wrongness ” than you give to mine. I guess that this is where we agree to disagree.

          1. Frankly

            Ok, here is the test. Imagine Fox News derivatives are on ABC, CBS, NBC, CNN and NPR.

            Like I say, you would not be so polite and calm about your point that there was too much conservative bias in the press and media.

          2. Matt Williams

            When you say “derivatives” what do you mean? That’s not a term I have used since Calculus.

  11. Don Shor

    The public does not support single-payer. That is a small minority on the left.
    The public does not want to repeal the ACA. That is a small minority on the right.
    The public does not support repeal-and-replace.

    Most want to keep the ACA in place and pass legislation to fix or improve it.

    There is no Republican alternative that would be supported by conservatives while also being acceptable to the public as a whole. Every Republican alternative put forth recently would fail to gain support within the base of the Republican Party, much less among Democrats and independents.

    The legal challenges to the ACA are being settled, one by one. There have been impacts, especially to the Medicaid expansion. That may need followup legislation and funding to get the very poor covered in states where the governors refused it. The issue of state vs federal exchanges can be resolved. The employer exemptions for religious issues may require expansion of government financing, but not to a degree that affects the overall cost significantly.

    The dire predictions of conservatives have not come true. It is likely there will be slight rate increases in 2015 due to the demographics of enrollment. There will be more enrollment in 2015 as the individual fine increases. There will likely be more insurers entering the exchange market in 2015 and 2016, which could help reduce costs due to competition.

    The ACA was always compromise legislation. It moved the Democratic Party away from the single-payer model promoted by Edward Kennedy and others for years. It accepts that our insurance and our health care are largely provided privately, with significant public-sector components (VA, Medicare, etc.). It establishes a basic minimum standard of coverage to sell through the public exchanges; those regulations and exchanges are the government’s role.

    The Progressive Caucus nearly balked in summer 2009, threatening to withhold support because of the concessions made by Senator Baucus. They fell in line ultimately because they realized that this was the only health care legislation that was likely to pass. In the end, the centrist ‘blue dog’ Democrats held all the cards when it came to the shape of the final legislation.

    It was never going to be possible to ‘compromise’ or negotiate with those who oppose a federal role in health care. But it is simply not true to suggest that efforts were not made to include Republicans in the discussions. The process in 2009 was arduous and extensive. But it is important to note that the Republican Party position on health coverage has changed over the last seven years, from broad support for universal health coverage and an individual mandate, to a position of opposition to any federal role in health care. Look at the proposals from George W. Bush, then John McCain, and then Mitt Romney and see the progression of GOP policy. Read at Cato Institute what has become the basis of Republican policy on the issue. On health care, the Democrats have moved toward the center, while Republicans have moved to the right.

    1. Frankly

      Don is basically explaining the general plan that the left had all along. Lie and push an agenda roughshod over the desires of the majority and over the absolute rejection by the other side. Then use the liberal media propaganda machine to create a new narrative through biased polling and more lies to make the case that a majority now just wants the mess to be fixed instead of repealed.

      And this is how we keep piling on mess after mess after mess.

      Obamacare needs to be repealed ASAP, so real and sustainable healthcare reform can be implemented in its place.

      1. Don Shor

        The majority supports most of the components of the ACA. The majority does not want it repealed. This is not a new narrative, Frankly. Pew and Kaiser are not “biased polling.” You simply want to believe that Americans are more conservative than they really are, and that if they aren’t — well, it must be because of the media.
        You’re wrong. The polls show you are wrong. Obamacare won’t be repealed. That would be a disaster for millions of Americans. It can be modified at some point in the future. But it won’t be repealed, and it shouldn’t be. That isn’t what the public wants. Repeal would require a 60-vote GOP majority in the Senate and a Republican in the White House, and even then it would be very politically risky.
        I’m not lying. Stop saying things like that.

          1. Don Shor

            From the survey methodology:

            32% described themselves as Democrats, 24% described themselves as Republicans, and 44% described themselves as Independents or members of another party

            Overall party affiliation from a Gallup survey of 18,000 people in 2013:

            Forty-two percent of Americans, on average, identified as political independents in 2013, the highest Gallup has measured since it began conducting interviews by telephone 25 years ago. Meanwhile, Republican identification fell to 25%, the lowest over that time span. At 31%, Democratic identification is unchanged from the last four years but down from 36% in 2008….
            Americans’ increasing shift to independent status has come more at the expense of the Republican Party than the Democratic Party. Republican identification peaked at 34% in 2004, the year George W. Bush won a second term in office….
            Democratic identification has also declined in recent years, falling five points from its recent high of 36% in 2008, the year President Barack Obama was elected.

          2. TrueBlueDevil

            The Left has successfully tar and feathered the GOP – the party of Lincoln and MLK – with the slander “racist” enough that many identify themselves as Independent to avoid angst. Proof of this seems to be the fiscally conservative nature of Independents.

          3. Don Shor

            Actually, when pollsters ask followup questions of people who label themselves ‘independent’ they find that they usually lean toward one party or the other, and it’s about even or fairly proportional to the affiliations of the major parties. Cook Report: http://cookpolitical.com/story/6608

  12. Tia Will


    Surely you are not implying that either Lincoln or MLK would even recognize the Republican party of today ? And from my point of view, no one has had to “tar and feather” the current Republican Party as anything. They have done that thoroughly by their own words and actions…..no outside help needed.

  13. Tia Will


    “And if all doctor’s get paid $500 for said procedure, where is the incentive to innovate with something cheaper, or better ? ”

    Perhaps I did not emphasize this enough in my article. I will have to use Kaiser again since it is the model with which I am the most familiar. All motivation is not financial. We can make more money if we want to. But that is done collaboratively, not competitively. Within my specialty, there are doctors who want to make more money and those who want more time off. This is done by trading shifts which can be done for either time or money whichever the individual doctor is seeking.

    Many innovations to improve direct patient care are made within Kaiser not for money, but simply to improve patient care which is what motivated many of us to choose medicine as our career in the first place. Some examples :
    1. The gyn oncologist that I mentioned who published the data that led to the improvement in cervical cancer screening that
    made it possible to screen every three years instead of annually with improved outcomes. He received only his salary, hour
    for hour ( and national recognition) for his contribution.
    2. The Breast Cancer Screening clinic was formed 16 years ago by a group of 7 docs and NPs to improve access to care for
    women with breast cancer. It was the first such center in the region. Before it opened, the wait time from cancer discovery to
    surgical treatment was about 2 months ( similar to on the outside at that time). Within a couple of months of opening, we
    had dropped the wait time to two weeks. This year, in collaboration with radiology and surgery, we typically have the initial
    physical exam, all necessary radiology evaluation, biopsy, results , surgical
    consultation and initial treatment within a working week if the patient is willing to move that fast.
    None of us got paid one cent more for this innovation. We are devoted to its continued improvement because that is what
    we came to medicine to do.
    3. Our phone consultation system was the creation of one doc who had the thought ” wouldn’t it be great if we didn’t have to
    wait to send a patient to a specialist, but could speak to the specialist while we are in the room with the patient in real time.
    His idea and efforts to implement it led to its adoption by all specialties. This has saved countless trips for countless patients
    to a specialists office with additional copays all for advice that could be obtained over the phone. What is saved is time and
    discomfort for the patient, less lost work hours for employers. There is no loss to either the referring or the consulting docs
    since they are paid the same amount consulting on the phone or operating. He received a lot of personal thanks, but no
    additional money for this innovation.
    4. The ER docs came up with a system in which the ER doc is the initial evaluator rather than a triage nurse. This process has cut
    the patients waiting time dramatically with improvement in the overall quality of care. Again, no extra money, but a great
    deal of satisfaction for improving the functioning of one’s team to provide better patient care.
    5. We have within our department a doc whose passion is patient safety. His work led to interdepartmental collaboration between ob/gyn / anesthesiology/ internists / nursing and the blood bank to design what is called a “massive transfusion protocol” since maternal death from hemorrhage is still a major risk on Labor and Delivery and the Post Partum units. His and his teams success has led to greatly improved patient care and just within this year has saved three patient lives of which I am personally aware ( We have a very high risk delivery service in Roseville). Once again although you are probably tired of hearing me say it by now, he received no additional money, but endless gratitude from the other members of our department whose patients are now happily living their lives with their newborns due to his willingness to innovate without financial gain beyond his
    usual salary.

    I suspect that many of us ( and certainly the women gynecologists) could have made much more money in the fee for service model. We have chosen not to for a variety of reasons, none of which was simply how much money we could make.

    One major flaw I see in the postings of those who are uncritical of the “free market” is the persistent belief that money is the only motivator of human behavior. This is simply not true, and it is particularly not true of those who prefer a collaborative over a competitive model of care delivery. I know that a collaborative model in which the goal is not to make as much money as possible, but rather to provide the best care possible can work. I don’t have to have another pilot. I have worked within such a pilot for the past 30 years. If all doctors were assured an adequate income, had the ability to make more money by working more hours, and were focused on advancing medicine both in the realms of science and care delivery, think how much further along we might be in terms of knowledge and implementation rather than each group jealously guarding its “secrets” in order to profit from them. I believe that in the realm of medicine, collaboration with sharing of ideas will trump competition in providing better and less expensive care every time.

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