Here is a little YouTube clip of a Michael Moore like exposé of the Canadian healthcare system. Based on conversations with my colleagues and just being in the profession, I can tell you that this is an all too common situation. Many, many people in Canada needing rapid specialized care head south of the border and – horror of horrors – pay for it. This video makes the case that liberal Democrats in this country are trying to turn the U.S. healthcare system into a mirror of the Canadian one. I suspect that there are more than just liberal Democrats working to make it a reality. It will require help from the voters, who, unfortunately, are often driven by demagoguery. They will be told it’s free, and who wouldn’t want free anything, especially free health care. Problem is it’s not free. It has to be paid for. Instead of insurance and self-pay, the healthcare system will be funded by taxes. And instead of the taxes simply going to straight into healthcare, there will be a giant layer of bureaucracy that has to be funded before a penny gets to the actual hands-on, patient-treatment part of the system.
Once health care is ‘free’ it becomes an entitlement. Think about it. If you got anything free, then suddenly had to start paying for it, you would feel ill used. Here is an interview with a young woman who has apparently moved from Canada to the United States and has been confronted with paying for her health care. She is the definition of entitlement. You can almost see the sense of entitlement oozing from her every pore. She just can’t come to grip with the idea that she has to pay for medical treatment.
She has a slight grasp on the idea that the Canadian healthcare system is funded with taxes and even realizes the long-term problems existing within that system. But, her sense of entitlement is so great that she can’t get past it. She pretends that the problems don’t exist. She simply wants the free health care that she feels is her due. This is the mind set that will get us to nationalized medicine and the mindset that will never let it go.
This sense of entitlement is the real problem. We can’t ever give this system a try here just to see how it works because if we do, we will create millions of copies of the young woman in the interview who will never want to go back to the old way in which payment is required. Once this woman gets older and is confronted by health problems more serious than a sore throat that she can’t get treated in a timely fashion, she will discover the problems with ‘free’ health care, but it will be too late. And if there is no U.S. system such as there is today, where will she turn. Like the guy in the first video with the brain tumor, she will be dead before her turn for treatment comes around.
I find it really annoying when people gripe about paying $30 to have a doctor look in their mouth and treat them for a sore throat. They equate the time spent in the diagnostic process as the only expense involved. They don’t realize that the doctor has to pay rent on the office, has to pay for front office people and nurses, has to pay for malpractice insurance, has to pay for all kinds of insurance, for that matter, has to pay for the paper on the exam tables, has to pay for the tongue depressors, has to pay for the little disposable covers for the otoscope (the thing used to look in ears, which I’m sure was used along with the tongue depressor), has to pay to have the office cleaned, has to pay to keep his medical license current, etc. Plus the doctor had to pay to put in the long hours of medical education to able to look in the patient’s throat and make an intelligent diagnosis to be able to properly treat. All of this is amortized in the office fee; the doctor doesn’t simply trouser the $30. Ignorant people simply see the 10 minutes it takes for the exam and equate that with the cost.
I just took a friend to get his car fixed. The mechanic (who also happens to own the shop and is a friend of mine) showed us how he works. He took a plug-in device, inserted it into a plug underneath the dash, turned on the little computer attached to the other end, and got a code on the screen. He took that code, put it in his computer, and got a read out of the problem. It was a faulty oxygen sensor in the left bank of sensors. More specifically it was a sensor that read the amount of oxygen in the left exhaust outlet and used that reading to regulate the fuel mixture going into the engine. He ordered the part, installed it, and gave my friend a bill for $158. My friend didn’t bat an eye.
I’m sure that Canadians have the same thing happen to them routinely, and they pay without thinking about it. But if suddenly car repairs were free and paid for by the government, how long do you think it would take them to react with outrage if they got a bill for fixing their cars? And how long do you think they would have to wait to get their cars fixed?
I hope that everyone thinks long and hard about all the repercussions of a vote to change the system we have now in the United States. The U.S. healthcare system reminds me of Winston Churchill’s remark about our form of government:

It has been said that democracy is the worst form of government except all the others that have been tried.

But Mr. Churchill made another comment about democracy that is sadly all too true:

The best argument against democracy is a five-minute conversation with the average voter.

Unfortunately, there are a lot of average voters out there. Most won’t remember the passport fiasco and apply the lessons there of government control in an emergency situation.


  1. Hrm. So, with the current system of insurance, I pay a biweekly fee (and since I work for the government, taxpayers, including self, pays a biweekly fee for me). That fee goes to an insurance company. They have all kinds of overhead and bureaucracy. Ask anyone who had to get a major surgery approved by their less than platinum HMO. Then, when I get a sore throat, I go to the doc, pay my $10 (This is a hell of a sore throat if I’m going to the doc). My Doc gets my $10. He also gets some, presumably larger amount of money from my insurance company (I presume it’s larger because my cost for insurance, the portion I pay, is considerably larger than $10, and I pay it every other week, regardless of whether I’m seeing the doc or not). If the doc does anything extra, like take some blood that I ask him to take and run some tests, I get another bill.
    Now, I can pay premiums or I can pay taxes. I can have government overhead or I can have a private company’s overhead. I’m not even looking at being uninsured, but I can just pay $100 for my sore throat as they happen. I can have government inefficiency or I can have the lowest bidder (if I’m a real American, not some rich person who can afford whatever health care they want).
    Personally, I’m for a two-tiered system. I like to use a car analogy. Everyone gets, through taxes, the health care version of a honda civic. It’s basic. It will get you to where you’re going. It would not be confused with a Mercedes G-class (the big boxy SUVs). That’s the other tier. If you want everything, use the existing market, which would switch to selling add ons to the basic catastrophic and child/elder care package. So, you can buy your Lexus, your Ferrari, your M-Class, or whatever you want. But no matter what happens to you, you always have your basic, government supplied system to fall back on.
    Basically, expand medicaid to everyone, while cutting back the coverage a little. Give people an incentive to get good jobs with health insurance or at least enough salary to afford some add ons, keep the market, but expand the safety net.
    I know you’re a died in the wool “Let them figure it out” guy, Mike, but I don’t like living in a society where the less fortunate citizens of a very rich country get next to nothing. It’s bad policy and it’s bad for the macro economy.
    Hi Max–
    We’ve already got a two-tiered system.  It’s called Medicare.  Ask someone who’s stuck in it and can’t afford to go non-Medicare how he or she likes it.
    We also cover the less fortunate people.  They go to emergency rooms all over the country where they have to be seen for non-emergency matters.  Since virtually all hospitals take Medicare, they have to dance to the Fed’s tune, which is a melody telling them they have to see indigents.  And don’t think for a minute that indigents don’t know this.
    As to your comment:

    I can have government overhead or I can have a private company’s overhead.

    You somehow seem to equate these.  You’ve got to be kidding, right?  Give me private company’s overhead anytime.  Go back and read all the posts on the passport nightmare.
    Most ‘poor’ people have cars, cell phones, TVs, cable–all of which they want and freely pay for.   And they pay to replace or repair these items as needed.  Most could ditch their cell phones, TVs, cable bills and have more than enough to pay for health insurance.  But they don’t want to.  They want you and me to pay for it and feel righteously indignant if we don’t want to pay for it.  That’s what I’m talking about as a sense of entitlement.

  2. Hi, Dr. Eades,
    Thanks for putting the costs of health care into some sort of rational perspective, especially with the reference to the auto mechanic.
    Here’s another look at the problems with socialized medicine (which I just happened to have read before your latest posting), only this time from the European (specifically French) model:
    I think that there are some real problems with the American system and that it is probably more expensive than it should be, but I also think those problems are created by the level of socialized medicine (e.g., Medicare) we already have. We certainly don’t need to socialize American medical care even more.
    Again, thanks for your blog. Your blog is part of my daily blog reading list.

  3. I would have no problem with paying for routine office visits. In fact, I have done so in the past to get around the cumbersome process of getting a referal from my primary care physician to see my ENT. The ENT’s office manager couldn’t get her head around it, though, and kept asking me why I was paying up front rather than using my insurance. I, for one, wouldn’t mind going to a system where we pay for routine care out of our own pockets and reserve insurance for more catastrophic needs. As is, I’m quite certain that even with insurance he has, hubby and I will most likely be in financial straits should he ever have a liver transplant.
    The big difference that I can see that might make people resistant to going back to paying out of pocket for basic healthcare is that there is so much more to it these days. Back then, people saw the doctor pretty much only when they were sick and weren’t constantly marching in all year long for all sorts of routine “preventive” tests with various offices/doctors. That would add up very quickly.
    Oh, by the way, there is one area of health care where we have to pay out of our pockets and up front if we want to utilize it, and that’s at our vet’s office. As you can imagine, it’s not cheap. And with six cats to care for, he’s practically rolling out the red carpet for us every time we come up his walk.

  4. The majority of us Canadians are aware that our medical care isn’t free but paid for by our taxes. We’re also painfully aware of the ridiculous wait-times and other problems. This is why generally, we don’t have a problem paying for certain procedures so we don’t have to wait.
    However…when I was 16, I got in a terrible car accident and was hospitalized for over 2 weeks. I needed x-rays, physio, pain medication etc., plus canes and such for home use when I was discharged. Taxes covered all of this. My mum, single at the time and earning less than poverty level (working at a school with behavioural problem kids), would not have been able to pay for my care otherwise…or would still be paying it off now.
    It’s not a perfect system, but it’s one I’m damn thankful for.
    Hi Tracy–
    You would have gotten the same care here (probably better) in any hospital emergency room.  You would have been admitted and treated and discharged.  Your mother would’ve gotten a bill.  She wouldn’t have been able to pay it, and the hospital would have written it off.  That’s one scenario.  The more likely is that your mother would have had health insurance if she were working for a school, and once again your care would have been virtually free.  Instead of being underwritten by the taxpayers, it would have been underwritten by other people paying insurance premiums. The whole situation would have been handled for less because insurance overhead isn’t nearly as wasteful as government overhead.


  5. $30 for a doctor’s office visit? where? Not in any US state I know of.
    One thing I’ve always been curious about. In my private company, every single year we have to figure out how to provide better products and services, on less money. And given that intention, and because that’s what we are paid for, it happens. Even if the differences are pretty tiny some years.
    I never hear doctors, or HMOs, or any “sickness care” provider, talk about providing more with less money, like my private-sector company does. Some HMOs talk about “cost cutting” but that’s not the same as a culture of ever-better service per dollar.
    Instead it seems that “oh! it’s for medicine! nothing but the best!” or something, is the underlying theme.
    I’m about to go off the grid for insurance myself. I’d rather spend that 2400 a year on food and gym fees.
    Hi Connie–
    I think she was talking about the $30 as being her co-pay.
    A constant complaint of doctors all over the country is that they are working harder than ever and making less money.  They are taking early retirement and leaving the profession in droves.  Many are getting rid of receptionists and nurses and booking their own appointments and doing all their own nursing work to keep overhead down. 
    I think it would reduce costs considerably if medicine were a pay as you go kind of profession, much like the auto mechanic.  Or at the very least, pay as you go and get your own insurance reimbursement.
    If I’m a doctor in practice and I see a patient with a history of bad headaches, I have a couple of choices.  I can tell the patient that he’s probably got a migraine, give him a shot for the immediate pain, give him a prescription for medications to hold future migraines at bay.  I would tell him that if he didn’t get better or if his headaches kept recurring, we would need to investigate further.  Or, I could send him for a $1500 MRI just to make sure he doesn’t have a brain tumor.  When patients have to pay out of pocket, they all opt for conservative treatment.  When someone else is paying, they always want the Rolls Royce.  I can’t tell you how many times I’ve recommended patients to wait and watch only to be told: Doc, I’ve got great insurance.  Let’s go ahead and do (fill in the blank with whatever expensive test is available).
    In medicine the tincture of time treats many conditions.  I’m not talking about forgetting about a potentially serious problem or pretending it doesn’t exist, but waiting a few days to see what happens.  Most conditions get better and don’t require the high dollar testing.  In fact, most high dollar testing gives negative results.

  6. Well, in my opinion the problem with health care isn’t the $30.00 co-pay, it is the fact you cannot get health insurance if you’ve ever had a pre-existing condition or are over 25 years of age and you need to provide your own insurance policy or if you do manage to get health insurance the policy costs $1000 a month or more.
    I had to give up having my own small business simply because I couldn’t find any affordable health insurance.
    So, lets say I somehow manage to pay my own costs myself and avoid the whole insurance thing… I end up paying far, far more than the insurance companies do. I would probably pay at least double or triple what would otherwise be charged because I’m not part of any negotiated rate structure.
    We’ve got to choose which set of problems we want I guess.
    Hi Nancy–
    You can get health insurance with a pre-existing condition, you just have to pay through the nose for it. Or have your pre-existing condition excluded.

    It is a real problem, but I don’t think that the government taking over health care is the best solution for the greatest number of people. 
    I wish I could offer you a solution, but I can’t.  I do understand your predicament.

  7. Folks; this is a wonderful post as it is a glaring example of the sense of entitlement exhibited on daily basis by all too many Americans (especially the far-left). The virtues of a free market extend far beyond what always meets the eye in the short-term. I will, myself, be entering med-school in a year or so. Those who advocate socialized healthcare need to ask themselves a very simple, but poignant question: when was the last time you were favorably impressed with the quality of service and expedience of a bureaucracy?… That’s what I thought… NEVER. “Free” healthcare is anything but. THERE AIN’T NO SUCH THING AS A FREE LUNCH! Irrespective of the good or service provision; it must be paid for! Dr. Mike makes it abundantly clear in this post that EVERYTHING, right down to the cotton balls in the jar have to be accounted for (in any system!). Let the market dictate the price of healthcare (supply and demand). Hillary Clinton and George W. Bush do NOT have the ability to effectively set the prices of production. Additionally, I don’t want anyone telling me when I can/cannot receive anything (let alone urgent health care). The American system sucks; but it sure beats the heck out of whatever’s in 2nd place. I’m not politico or economist, but socialized policy is ineffective, PERIOD. It has been demonstrated as such repeatedly. We as individuals are entitled to nothing. It must be earned. The free market will always prove to be more efficient and wholly less expensive than government subsidy. So, for the sake of all of us, do not succumb to emotional interests by voting for “public” health care. You WILL regret it. Thank you for putting up with my little rant. I appreciate your patience.
    Drew Iman
    Hi Drew–
    Feel free to rant any time.  Most everyone else does.
    Good luck in med school.  It’s a long, hard haul.

  8. As a P.S. The U.S. healthcare system does not actually suck. It’s a wonderfully efficient system. What I meant is that private health insurance is ostensibly expensive, but given the overhead incurred alternatively (as without coverage), it’s well worth it. I just needed to elucidate so I didn’t come off as an ingrate.

  9. Wait times vary from region to region. Nobody I know has ever had a wait time more than a month for surgery of any type. That includes my grandmothers double mastectomy. Some areas do have problems, mostly due to bureaucratic boondoggles and underfunding. I’m in Alberta, where we do pay a monthly premium.

  10. You can get health insurance with a pre-existing condition, you just have to pay through the nose for it. Or have your pre-existing condition excluded.

    Sorry, Dr. Eades, but that’s not universally true. My wife is basically uninsurable outside of large, group coverage or a state’s high risk pool (as if that’s really insurance). How do I know? I’ve tried. The insurance companies wouldn’t even quote me a price, much less allow me to exclude the condition. And yes, I spoke to quite a few large, reputable companies.
    And you know what’s really ridiculous about it? Her health care is basically a fixed cost that can be proven over a 14 year history for this condition. The cost? About $25/month. Granted, it could mean complications if she had some trauma and slightly higher expenses for surgery, but the insurance companies are out money whether she has the condition or not in that scenario.
    How would socialized medicine be better? My wife and I could make a decision about where we want to work (or not work) without health insurance always entering the discussion. Do I want socialized medicine? No. But in the absence of any other reforms, I would consider it.
    Still interested to see your thoughts on how to fix some the problems…
    Hi Hap–
    There is no doubt that socialized medicine would be better for some people – your wife, perhaps.  But is it the best thing for the rest?  That’s the question.  And as far as I’m concerned, the answer is a resounding NO.

  11. The best measurement of a country’s health system is the death rate. The lower, the better.
    The US is slightly better than average (8.37) at 8.26/1000/year. Canada is 7.86; Australia is 7.56; Cuba is 7.14. All have government run health systems. Of course the United Kingdom is at 10.05 and France at 8.55; both with government run systems.
    The only conclusion that I can draw is that European governments don’t know how to run a heath care system.

  12. Another good post Dr Mike.
    A democratic society/government has to focus on what is best for the majority. That doesn’t preclude individuals from focusing on what is best for themselves within the framework of democracy. I think the entitlement to life, liberty, and the pursuit of happiness (I love that part) pretty much covers it.
    As do I.

  13. Dr. Eades, I don’t understand why you think private medical administration is more “efficient” than government. It’s a well-known fact that 30% of medical costs in the U.S. go to administration (especially the expensive war between insurance companies trying not to pay and MDs trying to get them to pay) and insurance company profits. That’s one reason why medical spending per capita is almost twice in the US what it is in any other country.
    I think that both the US and Canada would benefit most from a two-tier system, where the bottom tier looks like Canada’s present system (including the long waits and other incentives to choose conservative care), and the upper tier offers care as good as an individual is willing to pay for (with the caveat that the rich are not exempt from paying for the bottom tier, whether they use it or not). The key to making this system work is to eliminate most of the administrative costs and profits that now consume 30 cents of every US medical dollar, and spend that money on care instead. The single-payer, not-for-profit, everybody-is-covered (in the bottom tier) system accomplishes this.
    Hi Jonathan–
    You don’t know why I think private administration is more efficient than government…  You obviously haven’t been reading this blog for very long.  I’ve made my position pretty clear on what I think about waste, incompetence and inefficiency in the government’s running of anything.  Take the recent passport fiasco and apply it to medicine.
    You wrote that “it’s a well known fact that 30% of medical costs in the U.S. go to administration and insurance company profits.”  It’s not well known to me.  Where is your documentation?  I simply don’t believe that is true.  If it were, everyone would be buying healthcare stocks and prices would be through the roof; as it is, healthcare stocks kind of suck.
    You’re always going to have profits because no one works for free.  I don’t know what you do for a living, but I doubt that you work just for the hell of it.  Profits go to the people who take the risk and provide the capital.  Insurance company stocks are held in the pension funds that provide retirement benefits for teachers, auto workers, construction workers and a host of other people that depend on them.
    If we have a two tiered system it wouldn’t take long for the politicians (John lives-in-a-20,000-square-foot-house Edwards springs to mind) to start harping on the fact that there are two American healthcare systems: one for the rich and one for the poor.  From there it’s a short step to a one-tiered government run system from which there is no recovery.

  14. Here is what confuses me: Here in the U.S. we hear these horror stories of how Canadians can’t get the right care, have to wait a very long time for care, etc. And maybe I’m imagining it, but these stories often seem to come from sources in medicine and/or insurance.
    I had a conversation last week with some co-workers from Canada who said they never had to wait for any type of treatment and were a bit baffled by these horror stories. They speculated that perhaps, if true, the people who had such problems lived out in the boonies where specialist and labs were few and far between? They could think of no one they knew who had had similar problems.
    So my question is whether there is any place we can see actual statistics of the average wait for various procedures in different parts of Canada and/or in European countries with socialized medicine. One man’s story, while terrible, doesn’t really tell me much about how well the entire system.
    Hi Pam–
    I’m not a Canadian so I don’t have an answer.  What I do know is that the papers are full of reports of Canadian crossing the border to get what we consider fairly routine care because they don’t want to wait there.  I doubt that all these stories originate from medical or insurance sources.

  15. The death rate is NOT
    the best measurement of a country’s health system. To quote the Wikipedia
    ….the crude death rate as defined above and applied to a whole population of people can give a misleading impression. For example, the number of deaths per 1000 people can be higher for developed nations than in less-developed countries, despite standards of health being better in developed countries. This is because developed countries have relatively more older people, who are more likely to die in a given year, so that the overall mortality rate can be higher even if the mortality rate at any given age is lower. A more complete picture of mortality is given by a life table which summarises mortality separately at each age. A life table is necessary to give a good estimate of life expectancy.
    Cuba has a lower death rate because it has a younger population. Western European countries have an older population than we do. It all comes down to demographics.

  16. I don’t know that I agree that the best measurement of a country’s health care system is the death rate. I’d think that the average age of the population would have a HUGE effect on that (Probably explaining the discrepancies in Europe.) You’d have to normalize it for ‘baby booms’ and population spikes, etc. I don’t think there’s even a universal description of a birth rate. It’s one of the reasons infant mortality statistics are so controversial.
    What about average lifespan? If you have to pick one statistic, I’d think that would be far better, even though IMHO that would only have a tenuous relationship to the healthcare system.

  17. I don’t have a problem paying a doctor for treatment. What I’m currently having a problem with is he looks at me and says “You just eat too much”! He doesn’t listen to what I eat. I don’t need rubber stamp treatment. Result, I don’t think I’ll be going to him. Plus he practically insisted I go on a statin. (TC235 HDL 75 LDL 150 TRI 68) um, right… (no, I’m not taking one and flat told him no.)
    Sounds like a change might be in order. 

  18. So the U.S. health “system” -if you want to call it that- is only “good for” some people. Not people who happen to be sick- Like Hap’s wife.
    There is something wrong with that?
    The fact is that not everything runs better as a money focused enterprise. I do not want my medical care to depend on the profit margin of a business run by greedy CEOs and stockholders. (I’m not sure you can even consider the insurance industry to be a business. I have other names for it.)
    All other western civilized countries have some system of socialized medicine. I believe they all also have private systems in tandem. How is this a bad thing for us?
    Hi maureen–
    If it were a perfect world it might not be bad, but it’s far from a perfect world.
    The “greedy” stockholders for most corporations are pension funds that underwrite the retirement plans for “greedy” teachers, construction workers, auto workers, small businessmen, electricians, plumbers, etc.
    All of the “greedy” stockholders risk their money in the hope of a good return when they invest in these companies.  Many lose a substantial part of their investment, so it’s not a risk free deal.  I invested in a medical technology company about 8 years ago, and the stock I bought is now worth almost a quarter of what I paid for it.  I guess that makes me a “greedy” stockholder.  I provided capital for the company in the hope of making a good return on my investment; the investment went south and I’m left holding the bag hoping that someday the company will turn a profit and the stock will soar.  That’s why people invest.

  19. I’m sorry, Mike, I can’t follow you on this one. The American health care system is so broken, that it probably can’t be fixed. There is no reason to assume that health care should ever be conducted for profit. The only way a for-profit insurance company can make money is to deny treatment, and many doctors are outraged over this fact. The for-profit health care industry employs many people whose principle job is to look for ways to deny paying for treatment.
    The irony here is that the most efficient and cost-effective health care systems in the US are the Veteran’s Administration and Medicare, both non-profit, government run programs. There is evidence that the Bush administration has tried to squelch information of this kind from reaching the public. Because of their anti- government ideology, they didn’t want people to know that government was doing something right. In fact, the for-profit health insurance companies pay about 30% of their money for administration, while Medicare and the VA pay about 3%.
    There are even reasons why rock-ribbed Republicans should oppose the current health care system. Employer-based health insurance is a costly tax on American businesses of all sizes and prevents American businesses from being globally competitive. Single payer health insurance would go a long way in preventing the outsourcing of the America’s ability to create wealth.
    In my own experience, being self-employed, health care is expensive and inadequate. Would I be willing to pay three thousand dollars a year more in taxes so I wouldn’t have to pay ten thousand dollars in health insurance premiums which don’t cover me anyway? You bet I would!
    Currently, I am suffering from three excruciating pain episodes a day caused by a ruptured thoracic disc, which prevent me from working full-time, and have drastically cut into my income. I need an expensive operation that I can’t afford and which insurance refuses to cover. The only way to control my pain is through massive doses of Percocet and other drugs which I’m sure will ruin my health in other ways. I am doomed to suffer through this Hell while still paying ten thousand dollars a year until my disorder is no longer deemed pre-existing. Is my only recourse an expensive and costly law-suit to challenge the insurance companies’ pretexts for denying coverage?
    I am less bothered by the Canadian woman’s sense of entitlement than I am by Americans’ blithe acceptance of the questionable idea that health care should be a for-profit industry. I will vote for the first candidate who utters the words: single payer.
    All the best,
    Chuck Berezin
    Hi Chuck–
    I empathize with you over your health problems, and I hope you get them solved. But I disagree with almost everything else you wrote.
    The law of unexpected consequences will rear its ugly head if we go to a socialized medical system. Everyone makes the assumption that if the government pays for health care that everything will stay the same, that you will be able to go to the same doctor you’ve always gone to, but that it just won’t cost anything. And that American medical technology will continue to outpace that everywhere else. I’m here to tell you that it won’t.
    Why not? Because brains follow money. Medical school is long and difficult. And postgraduate medical training makes medical school look like a cake walk. One has to pay for medical school, and one gets paid a pittance for postgraduate training. Most interns and residents moonlight at local emergency rooms to make ends meet. I worked at a half dozen emergency rooms – some requiring a two hour drive to get there – on many of the nights I wasn’t on call during my residency. It was brutal.
    Why did I sign up for this when I was making a perfectly good living as an engineer? Because – at that time – doctors made a better than good living, and I calculated that considering the engineering income I lost by going to medical school and doing my postgraduate training I would still come out ahead over the long haul. Now, money aside, it takes a certain type of person who wants to go to medical school – many don’t irrespective of what kind of income they might earn. One has to enjoy it.
    I really wanted to become a doctor, but I hadn’t figured that out until I was out of engineering school. If there weren’t the income differential that there was at that time, I would never have made the switch. Who would go through the hell that is medical training for 8 years (after an undergraduate degree) to make the same income one could make coming right out of 4 years of college? Very few.
    In years gone by, medicine was the one field where a smart person from a low-income background could absolutely be assured of making an upper middle class income. For that reason, most smart people who came from non-moneyed families applied to medical school. And the competition was intense. The year I started medical school there were thousands of applicants for a few hundred spots in every medical school. Those who couldn’t get in to U.S. medical schools were going to Mexico or the Caribbean to go med school. No one ever went to Mexico to go to law school or to engineering school. Why not? Because the income potential didn’t justify it.
    What I’m taking a long time to say is that if doctor’s incomes are cut, very few smart people will become doctors. You may have a doctor that you don’t have to pay for, but you may end up getting what you pay for. All the smart people will have gone into law or business where they can earn much higher incomes. It’s already happening. Our oldest son is a lawyer and a bunch of his classmates from high school are doctors. He got an undergraduate degree and spent three years in law school; they got undergraduate degrees and spent 8 or more years in medical school and residency. Our son earns substantially more than any of them. This wouldn’t have been the case in the medical generation just before mine.

    My father got transfered to Detroit, Michigan while I was in college. My mother, who is an R.N., went to work in one of the first HMO style health systems in the country. There were a number of clinics that she rotated through, and not a single one of them had an American-educated physician. The doctors were all from third world countries and third world medical schools. They were the only doctors then who would work for HMO wages. Most docs in the UK that work for the NHS now are foreign medical graduates, not U.K. trained.
    Some foreign medical grads are great – others aren’t. The standards of foreign medical schools are not the same as the standards of U.S. medical schools. If we go to a system in which doctors incomes are substantially reduced, we will have the same situation. I’m not in practice right now, so I don’t have a dog in this fight. I’ll do okay no matter what because I’ve got the medical knowledge to take care of myself or at least to know who to put my own and my family’s health into the hands of. Others won’t be so lucky.
    As to your comment about the VA and Medicare being the cat’s meow… You obviously haven’t spent the time dealing with either one as I have or you would never have made the comment. The VA and Medicare are like the Arkansas Razorback football team: they look good on paper. The reality is much different.
    P.S. What if it’s John McCain who utters the words: single payer?  Or Rudy Giuliani?  Just curious. 

  20. Greetings,
    IMHO, many great points have been made here.
    I find myself torn. I do not think that the lady in the clip showed a sense of entitlement. I didn’t see that at all. She explained very well that she understands that she pays through her taxes.
    I see valuable points on both sides. There are many that I agree with on the capitalist side with regards to bureaucracy, innovative technology, money as motivator to enter the field, etc.
    Due to my work with insurance companies, though, and the horrible things that they do in pursuit of profit and denying claims (which, sadly, I am a part of in a small way), I feel great resentment toward them. All of the things that they do and the supporting industries just to help them achieve denials (of which I work in) disgusts me.
    That disgust weighs heavily on my opinion of which way to go. At this juncture, as previously stated, I don’t have an answer. I am very pleased that such a great discussion is going on here, though.
    Keep up the great posts!
    Hi RRX–
    First, a disclosure: I don’t own any insurance company stocks, and I know no one and have no family members employed by the insurance industry.  I have no reason to champion the insurance industry.  In fact, I’ve probably been abused by them as much as anyone else has.
    But, as I see it, there is an ongoing battle between insurers and the insured.  People paying for insurance try to get the best deal they can.  As a consequence they often reduce their coverage to what they feel are the most likely adverse events that may befall them in an effort to get premiums lower.  Then, when something happens that isn’t covered by their policy as written, they try to figure a way to claim it.  When they are successful, they cheat the insurance company because the insurance company pays for something they haven’t received premiums to protect against.  It’s a constant battle between people trying to get what they don’t deserve and the insurance companies trying to keep from paying what they should pay.
    I’ve been asked countless times to write prescriptions in the name of person A when the patient is person B.  Why?  Person A has insurance while Person B doesn’t.  This is out and out fraud, but many people don’t see anything wrong with it because somehow most people have the idea that insurance companies are there to be cheated.  The same people who wouldn’t dream of going into their local Wal Mart and shoplifting don’t have a qualm about fleecing an insurance company.  Insurance companies know this, and so are constantly on guard against it to the point that they try to deny legitimate claims.  Their hassle over paying legitimate claims then enrages policy holders and makes them have even fewer qualms about screwing the insurance companies.  And the cycle goes on and on.
    I’m glad you’re enjoying the give and take with all this and the multiple view points expressed.


  21. “…slowly crumbling in the face of widespread suffering…”.
    When I hear hyperbole like this, my first question is “who is funding this propaganda?”
    The film shows an extreme, and very rare example. The Canadian system for the most part does not work that way. Canadians do have a choice of what physician they see, and what course of treatment they receive, and overwhelmingly they recieve it in a timely manner.
    When I want to see my doctor, I can always get in to see him within a day. When my son needed an MRI to diagnose a possible head injury, he got it the same day. When I dislocated my hip, I saw my doctor and got all my rads within an hour of showing up to the clinic without an appointment. When my brother in law needed a kidney transplant, his need was assessed, he was placed at the top of the list, and he got the first one available. They even apid to fly him to the hospital best equipped to handle his surgery. I did, however have to wait a few months to get my knee scoped once. I was able to walk, just with some discomfort, so I was not an emergency and was placed lower on the list. This is the norm, it’s how it works the vast majority of the time. The doctors examine your medical need, not your wallet.
    Dr. Eades, I respect your work when it comes to nutrition and weight loss, but attaching your support to such a disengenuous position seriously undermines your credibility.
    Hi Bryan–
    I imagine that most emergency treatment is delivered on time in Canada.  It’s the elective procedures that are a problem.  And the problem is who gets to decide what is elective and what is emergent.
    As to your problem with my credibility…I would suggest you read only the posts concerning nutrition and weight loss and not waist your time on the others.  Clearly your mind is made up and you don’t want other input.

  22. I think something needs to be clarified here:
    Our health care costs are too high.
    Our health care services are too unresponsive to consumers, treating us like crap in ways other industries would never dare do.
    We already have ridiculously long waits, needlessly, for our services.
    The thing is that the answer to this isn’t a socialized health care system…because that is the cause of these problems, already, here in America.
    Consumers pay less than 5% of their health care costs directly, already. This strips consumer control from both prices and service quality. If people paid for their health care directly, they would tend to force costs down. With people paying only one twentieth of their costs, health care often costs twenty times more than it should.
    Sound ridiculous? It’s no surprise if some Tylenol costs you $10 at the hospital…yet five percent of ten dollars would be fifty cents, which actually is still far more than the hospital actually pays for that dose of Tylenol, which it can buy bulk.
    What we need is LESS socialism, including less of the government-created health INSURANCE system, that does not reflect the failures of capitalism, but instead the absence of capitalism, as companies are bullied by tax punishments into offering insurance, or even required to directly.

  23. “A constant complaint of doctors all over the country is that they are working harder than ever and making less money. They are taking early retirement and leaving the profession in droves. Many are getting rid of receptionists and nurses and booking their own appointments and doing all their own nursing work to keep overhead down. ”
    That sounds like an “attitude of entitlement” rather than a market mentality. I’m a doctor, I deserve a Mercedes Benz. With all Options. And a yacht. Since I can only afford the base model mercedes, I guess I’ll fire my receptionist or retire. And god forbid I have to carry expensive insurance (made more so by insurance company fund managers who lost big in 02-04 and had to raise premiums). Because we know there isn’t a single other industry with a few high priced, fixed cost, overhead items.
    Mike. I’m sorry to say it, but the doctors you describe in your post have more entitlement mentality than any poor person I’ve ever met.
    Facts of the Matter: the system is broken. And it’s going to be burdened very large in the not very distant future. Countries with socialized health care have longer life expectancies (I would be remiss if I didn’t mention that US rich people live the longest… but who wouldn’t rather be a rich American?) and lower infant mortality rates. Oh, and in terms of total payments, they pay less. Yeah, maybe they wait more. And maybe they don’t get the benefits of every new innovation in treatment (most of which, in your field, you rip as unnecessary anyway… eg Alli, Olestra, etc). But, on average, they’re living longer and losing fewer infants. Oh, and paying less for those results.
    Now, perhaps French bureaucrats are uniquely gifted among civil servants. Perhaps there’s something cultural in the governments of Europe and Canada, Australia, Japan, and the rest of the industrialized world that is just missing here. That something being something that makes them more efficient or useful or something than my peers in the US Federal Civil Service. Now, if that’s the case, you have a solid case against any form of government medicine.
    Lastly, it really comes down to a basic question… If you believe that some level of healthcare should be a basic right (I do, not from fuzzy headed liberalism, but from effects on the economy, national security, and international competitiveness), then you probably believe that some expansion or revision to the medicare/medicaid system is needed. If, on the other hand, you think healthcare is on people’s own watch, then you probably want a complete revision to medicare/medicaid (elimination would be a revision) and want the whole thing to go market based. I’m sure you’d have reasons for that view that aren’t cold and inhumane. I don’t know what they are.
    Hi Max–
    I’m not going to allow myself to get sucked into this moronic debate.  It would take much more time than I want to spend to deal with the fallacies of European socialism vs longevity and infant mortality.  Try looking at their population homogeneity vs ours, for one.  You’re not comparing apples to apples.

    I will ask you re: doctors and entitlement if your masters there at the old house of Uncle Sam asked you to work half again as much as you’re used to working now and told you they were going to reduce your salary by a quarter, would you feel ill used?  If that happened and you griped about it, would that mean that you considered yourself entitled?  What if you quit over this, would that mean you have an entitlement mentality?

    I know of no doctors these days with new Mercedes with all the options, much less a yacht of any kind.  You are sadly misinformed as to the levels of income of most physicians.  The vast majority don’t earn much more annually than the cost of one of the new, big Mercedes with all the bells and whistles.
    And you’ve given yourself away as a total fuzzy-headed liberal by your choice of words – cold and inhumane – used to describe anyone who might not agree with you.  It’s not that those who disagree might have a valid opinion, or even a different opinion: they are cold and inhumane.  They want to bring back child labor and have smokestacks polluting the air nationwide, not to mention taking back the vote from women and doing away with school lunches for poor children.
    I never get long argumentative comments from my physician readers first thing Monday morning, but I always do from my government employee readers.  I don’t know what that means, but I’ve got a pretty good idea.  Were the passport folks at the Fed busy processing passports instead of surfing the web during working hours, we might not have had such a passport disaster.

  24. My biggest problem with the current health care system is the disparity between UCR (Usual, Customary, Reasonable) and what the non-insured pay. If I could raise my deductible and lower my premiums I would be more than happy to pay for many services out of pocket if I could pay what the insurance company pays.
    My guess is that doctors & hospitals would still make more money off of me because of not having to deal with an insurance company.
    You’re probably right.  I think the healthcare system took a wrong turn when insurance started covering routine things.  In my opinion health insurance should be for catastrophic situations that would bankrupt you if you had to pay for it, not for little piddly every day stuff such as sore throats, colds, minor sprains and strains, ear infections, and all the other stuff that makes up the lion’s share of most primary care practitioner’s patient load.  If these things were all cash on the barrel, docs would compete much more aggressively.  As the situation now stands, most doctors are trying to figure how to get the most reimbursement they can from insurance companies.  Doctors do this by raising prices; insurance companies counter by trying to not pay or to pay more quickly for a large discount.  It’s a bad system all around.
    Doctors would compete even more if it were a pay-up-front system because a lot of people would choose not to go to the doctor and simply wait to see if they get better on their own.  There would be fewer patients and doctors would keep prices low to attract them.
    When we ran our clinics we stupidly signed up to be a provider for a huge HMO, which was the first in town.  We did not take insurance in our practice – we filled our a superbill so that the patients could submit to their insurance company for reimbursement.  The deal we made with the HMO was that their patients would have no charge whatsoever – no co-pay – no nothing.  I couldn’t believe the kinds of things people came in for when they didn’t have to pay.  I remember one woman who brought her 5 year old son in to see MD because he had refused to eat breakfast that morning.  When MD asked him why he didn’t eat breakfast, his response was: I wasn’t hungry.  She gave him a quick once over and sent him on his way.  Had the mother been required to pay $30 – our office fee at the time – I seriously doubt that she would have brought the kid in.

  25. Wow, that Max kid certainly got you in a tizzy!
    It’s not just Liberals, though, it’s all authoritarians. They tend to be sociopathically vicious whether they’re Clintonistas or Bushies.
    I think it’s worth note that the doctors are simply wanting what people would voluntarily give them, as a reflection of what they think they RECEIVED from the doctor.
    Oh, and something people are, unfortunately, afraid to say in retort is “listen, doctors ARE WORTH MORE than ditch diggers”. In terms of payment for services rendered, anyway.
    Any moron without health problems can dig a ditch. But it takes a lot more to deal with the health issues of others…oh, wait! And the moron needs to doctor to ensure a lack of health problems, so he can dig, too! Bahahah.
    I understand why there’s a lot of backlash against doctors, though. It’s misplaced, but not surprising. The artificial shortage of doctors caused by the massive regulatory burden, coupled with the lack of consumer responsiveness caused by the socialization of American health care, produce horrific health care experiences.
    And people, being ignorant of the basics of economics, blame the official deliverers of health care for this problem; the doctors and hospitals.
    What they really need, of course, is to regain control of their role as consumers, as well as to get rid of all the lawyers.

    Wow, that Max kid certainly got you in a tizzy!

    Was it that obvious? 
    I can pretty much roll with the punches on most things, but I do get my hackles up when people accuse me of having the opinions that I do out of being a mean, cruel, inhumane, cold flinty SOB.  I had just spent a dinner with a dolt who is a mega Hillary supporter who babbled on all night about why he was a Democrat.  His rationale: he liked their agenda.  That’s fine; I don’t have a problem with that.  What I had a problem with was his yammering on about the Democrats cared so much for all the poor and oppressed and no one else did.  This guy has made a fortune and lives in a giant, palatial villa-sized house, the price of which could have supported a hundred poor families for a year, yet he was droning on about how much he cares.  What he cares with is other people’s money.  He views me and those like me, none of whom have his house, his cars, his money, as the evil rich, fodder for the high taxes to support his agenda because he cares and we don’t.  It’s that kind of nonsense that makes me want to puke.  I could barely finish my meal.
    The truth of the matter is that neither party gives a rats hind end about anything but staying in office and having the power that entails.  The Democrats do it by lying through their teeth and promoting class warfare between the poor the ‘evil’ rich.  The Republicans do it by giving corporate welfare (which the Democrats do as well, just not to the same extent) and pandering to the religious right.  Both of them suck as far as I’m concerned.

  26. Oh, and I agree about the insanity of health insurance covering routine things.
    Imagine if you did not buy groceries directly, but paid monthly for “food insurance”, which was then used by central authorities to determine what you should eat for the month.
    Not only would the price of food go insane, and your access to food plummet, because you would be removed from the role of consumer, but of course you’d also have horrible experiences with what the Food Industry and Insurance Industry would eventually decide to feed you, to keep costs down and profits up and their own liability minimized.

  27. I wondered if you had seen this. I received it a couple of days ago.
    This is the most interesting thing I’ve read in a long time. The sad thing about it, you can see it coming.
    I have always heard about this democracy countdown. It is interesting to see it in print. God help us, not that we deserve it.
    How Long Do We Have?
    About the time our original thirteen states adopted their new constitution in 1787, Alexander Tyler, a Scottish history professor at the University of Edinburgh, had this to say about the fall of the Athenian Republic some 2,000 years earlier:
    “A democracy is always temporary in nature; it simply cannot exist as a permanent form of government.”
    “A democracy will continue to exist up until the time that voters discover they can vote themselves generous gifts from the public treasury.”
    “From that moment on, the majority always vote for the candidates who promise the most benefits from the public treasury, with the result that every democracy will finally collapse due to loose fiscal policy, which is always followed by a dictatorship.”
    “The average age of the world’s greatest civilizations from the beginning of history, has been abo ut 200 years”
    “During those 200 years, those nations always progressed through the following sequence:
    1. from bondage to spiritual faith;
    2. from spiritual faith to great courage;
    3. from courage to liberty;
    4. from liberty to abundance;
    5. from abundance to complacency;
    6. from complacency to apathy;
    7. from apathy to dependence;
    8. From dependence back into bondage”
    Professor Joseph Olson of Hemline University School of Law, St. Paul, Minnesota, points out some interesting facts concerning the 2000 Presidential election:
    Number of States won by:
    Gore: 19
    Bush: 29
    Square miles of land won by:
    Gore: 580,000
    Bush: 2,427,000
    Population of counties won by:
    Gore: 127 million
    Bush: 143 million
    Murder rate per 100,000 residents in counties won by:
    Gore: 13.2
    Bush: 2.1
    Professor Olson adds: “In aggregate, the map of the territory Bush won was mostly the land owned by the taxpaying citizens of this great country. Gore’s territory mostly encompassed those citizens living in government-owned tenements and living off various forms of government welfare…” Olson believes the United States is now somewhere between the “complacency and apathy” phase of Professor Tyler’s definition of democracy, with some forty percent of the nation’s population already having reached the “governmental dependency” phase.
    Interesting.  Thanks for passing it along.

  28. RE: “Most ‘poor’ people have cars, cell phones, TVs, cable–all of which they want and freely pay for. And they pay to replace or repair these items as needed. Most could ditch their cell phones, TVs, cable bills and have more than enough to pay for health insurance. But they don’t want to. They want you and me to pay for it and feel righteously indignant if we don’t want to pay for it. That’s what I’m talking about as a sense of entitlement.”
    Hmmmm. My bottom of the line “pay as you go” cell phone (for emergencies only) costs $15 per month, and my cable (basic stations only) costs $10.54. My tv was free (from freecycle); it doesn’t work great, so someone gave it to me instead of throwing it away. A bigger expense is my dial-up internet ($19.95 per month and slow). All told, these luxuries cost me ~$46. The cost of health insurance for me, due to various pre-existing conditions: $530 per month. I earn too much for MediCade or MediCare (or whatever).
    BTW, when working poor, non-indigent people (like me) go to the ER, we DO get billed, and that is at the FULL rate, not the negotiated lower rate that an insurance company would pay. When we are lucky and persistent and willing to be humiliated, we can work out payments. If we don’t make those payments, it gets sent to collections. A study came out in 2005, saying that medical bills are a common reason for bankruptcy, and I doubt that has changed a whole lot.
    I don’t want something for nothing, but it sure would be nice to be able to, say, get my teeth cleaned (it’s been 7 years–3 since I lost a filling, which hasn’t been replaced yet), get an eye exam (including pupil dilation–the works, fancy that) and updated lenses in my 5+ year old eyeglasses, get a yearly pap smear/pelvic, and/or mammogram done. These are all distant dreams for me just now. It’s all I can do to slow down the pace at which my debt increases, what with interest and all.[/whining]
    Hi DLF–
    I know there are people out there struggling who fall through the cracks in the system we have.  I didn’t say all; I said ‘most.’  I probably should have said ‘many.’

  29. That Tyler/Olson piece is a bit of internet legend which isn’t entirely accurate. The people quoted apparently didn’t say the things attributed to them, and some of the numbers are wrong:
    Not that Snopes is infallible, itself, and the more correct numbers are shown there (Still showing “in favor” of Bush, though), but you might want to chalk some of this up with the Einstein ‘quote’ about honey bees.

  30. Dr. Mike,
    All respect. But seriously, the whines and cries of your profession, particularly the ones who are quitting the profession, are entitlement mentality. Lemme explain.
    So, let’s look at a hypothetical doctor of a certain age, let’s say 45. Well call him Sam. Sam went to a good medical school. Not Washington U or Harvard, but a good one. Sam graduated in the middle of his class, then went out, did his internship and residency, decided on a specialty, and joins an existing group practice or starts a group practice of his own. Either way, 7-10 years after acceptance to a med school, he’s a partner with profit/loss responsibility.
    Now, at this point, he’s what, 32? He’s got cheap malpractice insurance, has a regular set of customers, doesn’t worry that much about medicare/medicaid, but takes his lumps on those. He has some fuzzy notions about serving people and his Hippocratic oath. He also takes some lumps to his profit line from the insurance companies. But, on the whole, he’s doing fine. Maybe he’s not driving a AMD G-class, but he’s driving european automobiles, and living in a McMansion.
    Time goes by, and well, maybe his malpractice insurance goes up. Maybe his bedside manners have decayed a little and he’s getting sued for malpractice more (great study on this that I read a brief on recently… it’s the doctors who don’t look at you who get sued, not the bad ones). Maybe not, but either way, his cost is going way up. What once was a secondary cost to his group is now his main cost. So, he’s finding it tougher to make the same buck. And those fuzzy notions start to go away. Maybe he increases volume on the practice to spread his fixed costs over more units (I’m a cost person, it’s part of how I get paid). And this works for a bit, but his stress is up. So, he does what EVERY OTHER BUSINESS does, he tries to control his costs. He lays off one of his assistants. Eventually, between the stress and the disappearing profit margins, he hangs it up.
    Where’s the entitlement? The 10 years of good profits, of good return on his 7 year investment in becoming a full on doctor led him to believe that he was ENTITLED to that forever. That he shouldn’t have to work 60 hours a week (my GP doesn’t work ANYTHING like that… he is strictly 10-4, 4 days a week… Oh yeah, and EVERYONE that I got my advanced degree with works 60 hours a week, minimum). That he shouldn’t be burdened with a high fixed cost anything (like every other small business person). That he should be allowed to make ECONOMIC profits (as opposed to ordinary profits) despite providing a service that is becoming more like a commodity every month.
    Don’t get me wrong. I have great sympathy for the plight of doctors. But, there’s an entitlement culture present in the generation of docs who went to med school before the early 90’s. They had a belief that things were like they were in the 50’s and 60’s and maybe they got a taste, but that’s not there anymore.
    Last things, because I’m always about suggestions.
    1- I support market solutions where they are appropriate. Any economist that’s not from the Chicago school will tell you that there are times (public goods) where market solutions are less than ideal (national defense would be one, firefighting and police forces another). Even Adam Smith. And, it’s a matter of interpretation as to whether health care is a public good (aka not a good place for a market system) or not (aka a good place for one).
    2- My big idea for nationalized health care (which is not the same as anything I’ve heard out of anyone) is a two tier system with the bottom tier being a universal, catastropic coverage supplied by the government. Why the government? Because it’s the only option that wouldn’t preexclude based on risk. And that’s, uhm, well, a place I wouldn’t want to go. The second tier would be private insurance, that would basically be off the hook for catastrophic care. If you build the law and the regulations right, you don’t wind up with the GVMT paying for uninsured people using the ER for a stuffy nose. This is not too terribly dissimilar to the HSA’s pushed by a certain party that doesn’t happen to have a lot of liberals in it.
    3- A funny new trend in the libertarian thinking is that insurance companies are to blame for the current state of affairs. But really, aren’t they like every other business, trying to maximize profit? Preventive care is a strategy to reduce risk. Most folks who talk about improving the total system stress more preventive care. And if the insurance companies put incentives on people for preventive, it must maximize their profit. The mechanism would look like this: If you spend $20 today on a blood test, you can do $50 of work tomorrow, rather than a $50K open heart surgery down the road.
    4- To bring it all home: If preventive care is the new model of health care (because it’s most cost effective, and as a consumer, low spend on treatment = fewer surgeries, lifetime drugs, and other expensive, stressful junk), and it’s effectively crushing doctors under the current business model, perhaps it behooves the great thinkers in the industry to develop a different business model that is suited to that market. That doesn’t seem to be happening. It’s a hard solution to a tough problem, but perhaps, it’s the best one. At the very least, it would be better (to some) than government intervention.
    That’s all I’m writing on this, Dr. Mike. You’ve made up your mind on nationalized healthcare. Most of your readers have too. I think we can do better. I suspect you do too.
    I’m sorry, Max, but you’re wrong in your description of how the practice of medicine (the business, not the science) works. You wrote:

    Sam graduated in the middle of his class, then went out, did his internship and residency, decided on a specialty, and joins an existing group practice or starts a group practice of his own. Either way, 7-10 years after acceptance to a med school, he’s a partner with profit/loss responsibility.
    Now, at this point, he’s what, 32? He’s got cheap malpractice insurance, has a regular set of customers, doesn’t worry that much about medicare/medicaid, but takes his lumps on those. He has some fuzzy notions about serving people and his Hippocratic oath. He also takes some lumps to his profit line from the insurance companies. But, on the whole, he’s doing fine. Maybe he’s not driving a AMD G-class, but he’s driving european automobiles, and living in a McMansion.

    After 7-10 years after acceptance to medical school (which, remember, doesn’t even start until after graduation from college) Sam is just finishing his residency, during which has has worked at least 80 hours per week and done moonlighting on nights and weekends to make ends meet. Very few, if any, docs are living in McMansions at the age of 32. Most are just getting started with their actual careers.
    Malpractice insurance is less expensive when starting out and gets more expensive over time, not because an individual doctor is getting sued more because his (or her) skills are deteriorating; malpractice becomes more expensive because the doctor has seen more patients and the insurance company is accepting more risk. Every year in practice malpractice premium rise until they finally stabilize after around 6 years (the statute of limitations against a lawsuit) unless the doc takes care of kids, then it goes up a lot longer. Plus, whenever a doc decides to quit practice, he/she has to buy what’s called a ‘tail.’ This tail can cost tens of thousands of dollars depending upon the specialty of the doctor involved. Tails on even low-risk professions are many thousands of dollars. The tail insures the doctor against malpractice for all of the patients he has ever seen from then on. This giant expense prevents a lot of people from quitting because they simply can’t afford it. Or, the doc sells everything and puts all his/her assets in the non-physician spouses name and goes naked.
    I would maintain that under your definition of entitlement, anyone who works for a living would feel entitled, including you. As I said in my previous response, if you suddenly had to increase your work load by 50 percent while at the same time your salary decreased by 30-40 percent, you would feel abused. Anyone would, not just physicians. Does this mean you have an entitlement mentality? I would suppose so.
    If your GP works from 10-4 four days per week, I doubt that he/she is making enough to afford a new Honda every few years, let alone a new European sports car annually. It could be that your doc is married to someone who makes more or has family money or something, but physicians who work the hours you describe don’t earn squat.
    I don’t have a problem philosophically with a two-tiered system if it worked correctly. But I know how politics works, and I know where a two-tiered system would end up. That’s why I’m against it.
    If you made government health insurance available to those who can’t get coverage any other way, it will be extremely expensive. If you allow anyone who wants to buy it and pay the premiums to spread the risk, no one will buy other than those who can’t get insurance any other way. Who wants to have their health care run by the passport people if they don’t have to. The program will become hugely expensive as Medicare has become. Doctors will quit seeing patients paid for by government insurance because the government will put all kinds of dos and don’ts on it just as they have with Medicare, making it unprofitable for physicians to deal with. In fact, it will be much like Medicare. If a doctor sees a young, basically healthy person with a sore throat, it’s an easy fix, the patient is in and out, and the system works great. If it is a Medicare patient, the patient is older, has many more complex problems requiring much more time and effort, and Medicare pays less than an office visit for a sore throat. Most physicians try to limit the number of Medicare patients in their practices or refuse to take them at all. People may gasp at this because people think of doctors as being God-like. And people think doctors think of themselves as being God-like. But it really isn’t the case. Doctors see themselves as working stiffs just trying to make a living.

    It would be the same with government insurance. Then politicians would come along and start on the two-different-Americas pitch, and the next thing you know, you’ve got a national health service like Canada. Then, when people start realizing how screwed up it is, it will evolve back to a two-tiered system such as the one in the UK right now with people who are earning a living toting the note on the national health service that they never use while paying for their own private insurance. Now the Brits are discussing a co-pay for their NHS because it has become vastly too expensive as it is, even with most wage earners using the private system.
    I know that based on your government background you figure that all these problems can be fixed by the appropriate laws and public policy. I disagree.
    If this happens the quality of medical care will suffer and the quality of physicians practicing will decline.
    And remember what I said earlier. It’s a law just as sure as the laws of gravity. Brains follow money. Would you rather live in a society with a lot of smart doctors and a lot of mediocre lawyers or would you rather live in a society with a lot of smart lawyers and a lot of mediocre doctors.
    I remember a line out of one of the books I read that helped me make the decision to go to medical school. It was The Making of a Surgeon by Willam A. Nolen. Dr. Nolen came from a family of modest means. His father was a hard working lawyer, who, when he realized that his son was pretty bright, said to him: “Billy, when you grow up don’t be a lawyer, be a doctor. Those bastards have got it made.”
    We bastards really don’t have it made any longer, but kids who graduate from law school and who get MBAs do. That’s where the brains are going to go. My kid graduated from law school (3 years), did a one year clerkship with a federal judge in Boston (4 years total – the same amount of time I spent in just medical school, not including residency), went to work for a large law firm, and now, 6 years later, he makes more annually than MD and I combined ever did in any year that we were in actual medical practice.
    Given these income disparities, soon in this country most doctors will be imports from third world countries much like the two who worked for the UK NHS and who were just arrested on terrorist charges from the cars full of explosives found in London. (Not far from where MD and I will be staying in one week.)

  31. Interesting email, virginia. Too bad it’s untrue.
    Couple quickies.
    19+29 = 48. So, 2 states short of a full election. It was actually 20 to 30.
    Gore won the popular election. Bush won the electoral college. What this means is that more people voted for Gore than Bush.
    The passage is falsely attributed as near as anyone can tell. No one can find it in the writings of the cited author.
    Oh, and the murder rate is WAY incorrect according to DOJ stats. Full explanation on the link above. Gore’s regions had a slightly higher murder rate, which is probably accounted for by population density.

  32. This whole debate can be summed up quite quickly in this forum.
    Why should we (PP followers) have to pay for all the Ornish peoples’ heart problems?
    ‘Nuff said.
    I agree that insurance should cover serious health risks and that we should pay for the minor problems. That could also eliminate this ridiculous and dangerous demand for antibiotics and lower costs as a whole.
    Fewer people would pay the cash to check out their cold. But, if they have insurance they feel that ‘I’m paying for it, I might as well use it’ and then enjoy a ‘healthy’ dose of antibiotics.
    Very true.  The use of insurance drives a lot of unnecessary medicines and procedures. 

  33. Oy. I have yet to understand why I should trust the government, which has done such a stellar job with social security, income tax reform, and the welfare system with my healthcare.
    People who think Canada has a model system have never been stuck in that system, waiting months for a simple appointment for diagnostic work…weeks to hear the results…weeks to be properly treated in light of those results…and that doesn’t account for HOURS in the waiting room. I have a Canadian friend who drove from Canada to Wisconsin in order to have a podiatrist work on his infected ingrown toenail because he would have had to wait in pain for over three months.
    As imperfect as our healthcare system in the US may be, it is still arguably the best in the world and removing the free market aspect would all but eliminate the innovation for which we have been known and the quality to which we currently have access.
    (There is a REASON why people flock to the US for surgery from countries around the world.)
    Well put!  There are people who are traveling from the United States to less-developed countries for cosmetic surgery, which most insurance plans don’t pay for here.  These procedures can be more cheaply obtained in India, Mexico and other such countries.  It is the free market at work.  All I can say is: Caveat Emptor.

  34. I promised self I was done. But I apparently have a major personality flaw that will not let me. But, brief and civil.
    1- How you control costs in a two-tier, public-private health care system: This is the simplest solution, ever. The catastrophic policy that you get from the public sector (government) covers EVERY SINGLE AMERICAN, with no opt out. This eliminates all forms of moral hazard and self-selection problems (tech terms for your “only the sick buy insurance” problem… problems inherent in EVERY insurance proposition). Again, we are talking a tightly defined catastrophe as the only thing that qualifies for coverage. But we are talking universal coverage (for tax paying citizens) and we are talking complete coverage of the catastrophe, including followup and meds. What I am not talking about is a full on French-Canadian-English system of socialized healthcare. What I am talking about is a safety net for everyone, from the poorest (who have a net) to the middle class (who do not) to Bill Gates (who does not need one). Now, this is not what Speaker Pelosi is talking about. It is a very distant relative. It is not a small government solution, either. But it is smaller than anything anyone else is talking about (either socializers or health savings account-ers).
    2- Someone on here (maybe KAZ) called me an authoritarian. Fine. The difference between an authoritarian and a libertarian is the willingness to accept “Cut and Run” as a responsible solution. That is over harsh. But a libertarian solution to Iraq is “Leave.” A libertarian solution to health care is “let the market solve it.” A libertarian solution to crime is, “let it be.” While authoritarianism may have its extremes of wrongness, it is not about abdicating responsibility. That might be a fault, as there may be times when cut and run is the right answer (Vietnam).
    3- Doctors vs. MBAs. I would venture that your garden variety practicing MD is offering a largely commodity product. One is not terribly different from another, in the minds of the customer. I would venture that managed care has accelerated the commodification of medical practice. I would lastly venture that you cannot commodify leadership. My MBA program was about maximizing leadership potential, and that is the chief value I offer (beyond analytical skills, which are commodity goods). I cannot talk about Lawyers. It is not my field. But maybe the future of the MD degree looks 80% MD and 20% MHA-MBA.
    Hi Max–
    I think your #1 sounds great in principle, but I think it would ultimately be a financial disaster.  One of the non-engineering, non-premedical type of subjects I excelled in in college was economics.  It all made perfect sense to me.  One of the things I remember from the several economics classes I ended up taking was that if the government (or anyone, for that matter) provides a ‘free’ service, the only way to avoid financial collapse is to somehow ration the service.  Read about the train wreck that is the UK NHS or even the French system.  Don’t listen to the people who are the beneficiaries of the free care – they are of course going to tout is as being wonderful.  Look instead at the budget problems it is causing.  The French voted for a center-right candidate over Segoline Royal in great measure because she wanted to provide MORE health benefits through their health system.  The average Frenchman realized that the budget was already at the breaking point and that adding more outgo would cause an increase in taxes, which are already too high.
    If the government created a catastrophic insurance plan as you describe – which of all the ideas being floated is the least bad – I would reckon that the law of unintended consequences would rear its ugly head.  Many people who are now cruising along, paying for their own health coverage, would say: What the heck.  If the GOVT provides it for free, why should I pay for it?  Some businesses that now insure their employees won’t, thinking that the employees can get free care through Uncle Sam.  I imagine many, many more people would opt for the free coverage than your typical government planners would figure (remember the ongoing passport fiasco), and the GOVT would end up either raising taxes dramatically (which wouldn’t fly at the voting booth) or develop some kind of means test, which would put us right back where we are now. There would be much talk of the ‘evil rich,’ i.e., those making a middle class income using the system designed for the poor, etc.,etc., etc.

    As to #2…
    I don’t think you understand what a libertarian philosophy really is.  Your definition stretches a little bit to the holier than thou, which always puts me over the edge.
    You still haven’t addressed my question of feelings of entitlement.  If your bosses asked you to work 50 percent more and told you that you were going to be paid 25 percent less, would you feel ill used?  Would you quit or would you just Scotch tape up a big ol’ smile and keep on working?  If your answer is that you would quit, then you, too, have an entitlement mindset.  You’ve been working for however long it’s been, you’ve been doing X amount of work for Y amount of dollars, so you figure you’re entitled to at least that and probably more over time as you G whatever it is rating goes up.  In other words, you feel entitled; the same feeling that you scorned doctors for having in an earlier email

  35. Sorry about the pseudo post. I usually check with Urban Legends, etc. However, it seemed so plausible, from what I’ve observed of human nature.
    I was an R. N. When I started working, I was a sweet young liberal who treated my patients with utmost compassion. The older nurses seemed so harsh to me, as they would go into a room and tell a person in no uncertain terms what was expected of them that day in the way of self effort. It wasn’t long before I saw that they were right. Most people, left to their own devices, would make no effort to eat, move, bathe, or whatever else it took to recover. So the premise in the demise of democracy seemed very factual. I don’t really think the medical system can be repaired by human effort.

  36. We’ve heard about Canada and France and the UK. What about German and Swiss (both noted for their efficiency) nationalized health programs? Anyone have data on them? Not that the US would magically become more efficient or anything…
    Don’t ask me.  Most of my reading has been on the UK, Canadian and French systems.

  37. Mike,
    I’ve skipped the proposition that I could be asked to work 20 hours a week more for 50% less cash. Why? A few reasons.
    First, I already make more than 50% less than my average classmate from my MBA program. If I were paid 50% less than that, factoring the cost of living in DC, I would be below the poverty line. To have 50% of my payrate as a newly minted MD, you’d have to work in rural medicine or other “give back” work. And they’d forgive your federal loans. Together with the difference in cost of living, you’d be ahead. – This is already a giveback job. I went to a top 25 MBA program and only pursued non-profit and government work out of some sense that I would call the opposite of entitlement. (All this is post my 18% raise of this month)
    Second, If I got 50% more work, I’d have maybe 6 hours of work a day on average. I’m not slacking when I post here. I’m filling empty time. Trust me, it sucks for everyone. I’d rather work more. Everyone who is tied to paying taxes would rather I worked more. The only people happy with my volume of work is everyone who gives me work. Now, if they made me sit here for 60 hours a week instead of the 40 I already do (with 20 of those, on average, being empty), I might be very pissed indeed. Hell, my last assignment (I’m in a rotational program), I think I might’ve had 80 hours of work, total. In four months. I actually complained to someone that I wasn’t getting enough work. It didn’t solve anything.
    3- I already had a job where I worked 60+ hours a week for 50% less than anyone else on the show. I went back, got an MBA, and developed a new business model.
    Would I like being paid less for twice as much work? No. I’ve been there. I am there (I don’t work more hours than my peers, but total compensation is WAY lower and future earnings ceiling, well, let’s not start… it’s a choice I made. I’m looking at it like the Peace Corps). But, when I was paid less than everybody else and working more hours, and didn’t like it, I developed a new strategy. Got some skills (accounting) that made me more valuable. And therein lies the problem that doctors are really facing. It’s an eroding value proposition.
    Couple other random thoughts: Ongoing passport fiasco is a problem of unfunded mandates. Some folks, likely elected on promises of smaller government, lower taxes, and tighter security, passed some tighter security and then failed to increase the government size to match. More countries requiring passports = more demand which should equal a greater supply of workers. I don’t know the specifics, but I would guess that someone at the passport agency suggested that they might need a bunch more people and somewhere between the subagency, the agency, OMB, the president, the House, the Senate, the potus again, and the agency again, they didn’t get the FTEs. It might be a lingering problem from the continuing resolution we were working under for the first half of the fiscal year. Created an expansion freeze, without freezing the creation of new stuff for agencies to do. Frankly, if I worked for the right agency, I’d be happy to be on the phone or whatever doing some passports. There’s a lot of under utilitzation. But, that said, if Congress/POTUS acts on something and doesn’t fund it, well, you get the passport fiasco. A good understanding of the Fed Budget & Legislative processes would do folks some good. It’s a lot more complicated than “I’m just a bill and I’m sitting here on capitol hill.”
    Lastly, on libertarianism: My understanding is that it is a minimize the government and push market solutions for most things. I think there are places for smaller government (I am always on about cutting staff here, believe it). I think there are places for market solutions. But, as far as cut-and-run, I did say I thought it was a little strong. But you were suggesting disengagement from Iraq a few months ago, and we had a talk about why I don’t think that’ll work. Disengagement has not served this country particularly well at any stage in its history, save leaving Vietnam (which is working out okay, over the long run, though they are more commie than China).
    I’m done. Have a good weekend. I’m late for the metro.
    Hi Max–
    Interesting comment.  And interesting career choice you’ve made.

    I’ll make my reply brief.  Doctors, for the most part, don’t have the option to get more skills without going back into a three or four or five year residency program that trains them for a different specialty that may earn them more than the specialty they’ve already trained for.  The problem with the doctor situation is that there is absolutely no substitute for a whole lot of experience.  Everyday that a doctor is in practice makes him/her a better doctor.  There is no comparison in ability between that of a newly minted doc and one who has been in practice for 20 years.  The experience is a huge factor.  But the vastly more experienced doc gets paid about the same as the newly minted one.  When an older, highly experienced doctor who has done it all and seen it all leaves practice, it is a great loss.
    As to the cut and run…  I don’t think you can apply a libertarian solution to an authoritarian problem.  A libertarian would never have gotten us into Iraq in the first place.

  38. Hey Mike,
    I continue to contend that the problem facing doctors (under any system of health insurance) is a business model one. The story you are telling is of commodification (“vastly more experienced doc gets paid about the same as the newly minted one.”) The funny thing is, the biggest opponents to the simplest solution to a commodification problem, are doctors themselves, who fight any attempt to help a consumer sort based on quality.
    On Libertarianism and Iraq: If I recall correctly, you were in favor of the invasion at the time of the invasion (I, the authoritarian, was not). You later (and currently as far as I know) advocated pulling out on a short time table and letting the market of Iraqi factions sort their own problem (I, the authoritarian, feel this is irresponsible, since we created the problem in the first place). I was against Iraq for a lot of reasons (fuzzy idealism, resource commitment, didn’t believe the fear culture around Iraq, being the top three). But, with an authoritarian understanding of commitment and responsibility, I don’t think you can take out the stabilizing evil guy, and let it collapse (fuzzy idealism, fear of a second Iran, and “spice” flow being the top three reasons).
    This is not the time or place for Iraqi recriminations. What’s scary to me is that everyone is talking about Iran (which was the country they should have been talking about back in 02 anyway) and not a ton of talk about a solution for Iraq. The scary stuff isn’t what they do talk about, it’s about the things they don’t seem to consider. Peripheral consequences, finishing started jobs, etc.
    Enjoy Italy. I know I did.
    Hi Max–
    I agree that it is the doctors who are often the problem with a lot of the problems doctors have.
    I was in favor of the invasion of Iraq at the time.  My usually quiescent redneck tendencies overrode my more responsible libertarian ones.  I’ll admit, too, that I, like Bush, Cheney, et al, figured that the people of Iraq would appreciate us.  My excuse, though, is that I didn’t have the intelligence available to me that they had available to them.  They – and I – should have known better.
    I’ve always enjoyed Italy, so I’m sure I will again despite not being in a hotel with the greatest location in the world.  Concessions have to be made, I suppose, when traveling as part of a group.  I do hate any kind of European hotel that can accommodate 100+ people from one group.  I’ll live through it, though. 

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