Saturday, July 25, 2009

Health Care
“Those who are not liberal in their youth have no heart. Those who do not become more conservative with age have no head” -- George Clemenceau

I have waited to wade into this debate for a long time, since 1992 when I was 14 and a 1st year medical student taking “Medical Care Organization” in second semester. In the last 18 years I have been in the medical community, I have been a son & a brother, a patient, student, a resident, an attending physician in academic practice, a teacher of trainees, an overseas surgeon, and a researcher managing a budget of a lab group of about 10 people. These prisms of perspective inform my writing below. Although I have not (yet) been a husband, a parent, or a private practice physician, I hope I can take into account those frames of reference as well. I have also had the great fortune & privilege of knowing & working with citizens and physicians of Canada, Australia, Japan, and Britain who have lived in the US as well.

The health care issue is not just about cost, access, quality, value, profit, or innovation (we’ll get to those later), but about first principles:
  • What is a right vs. an earned privilege?
  • What is a public good vs. a private good?
  • What is the proper balance between harm reduction vs. personal responsibility?
  • What is the role of finance and profit in taking care of people? And how big of a sector should health care be in the broader economy?
My thoughts on these questions are that some things in health care (e.g., vaccinations, regular preventive care, a baseline level of prescriptions, and treatment for catastrophic or acute life-threatening injury or disease where there is reasonable hope for good outcome) are key elements for equal opportunity to life, liberty, and the pursuit of happiness, for being a productive and contributing member of society, and as such, should be ensured by society. Other things (e.g., Viagra, private rooms, brand-name medications when generics will do fine, LASIK, treatment which is in all medical likelihood futile) I think belong in the realm of personal and private choice and thus cost. Further, personal responsibility in taking care of oneself (in areas of diet, exercise, habits, risky activities/behaviors, adherence to treatment) should be acknowledged and rewarded. On the last question (profit motive in medicine), I’ll address that last. Now to cost, access, and quality. First, let me tackle the (glib) indictment of the American health care system, which usually goes like this:
· We pay more than other countries
· Our outcomes (e.g., infant mortality, life expectancy) are worse
· 47 million people have no health insurance

That we pay more is beyond dispute. On outcomes, the oft-cited statistics on infant mortality and life expectancy are, to say the least, unfair. America has significant minority populations (which Japan, Canada, and much of Western Europe do not) and these groups have a variety of socioeconomic and historical issues that compromise health outcomes (poverty, drugs, gun violence, out-of-wedlock births, distrust of doctors and non-adherence with medication, follow-up, and diet regimens,). Further, on infant mortality, Western European societies have a lot more abortion and make much less effort to save preterm infants born under 28 or 30 weeks of gestation (such births there are often recorded as stillbirths), whereas in the US, NICUs routinely take care of preemies born at 24 weeks or even younger.

On the 47 million people without health insurance point, that too is a statistic where there is less than meets the eye. First, health insurance does not equal health care (there are not just emergency rooms but cash-based clinics, and conversely, a lot of people with insurance don’t get good health care). Second, of that 47 million, 14 million are already eligible for existing programs (Medicare, Medicaid, veterans’ benefits, SCHIP) yet have not enrolled, 9.7 million are not citizens, 9.1 million have household incomes over $75,000 and could but choose not to purchase insurance, and somewhere between 3 and 5 million are uninsured briefly(<2 months) between jobs. That leaves about 10 million Americans who are chronically without insurance. Needless to say, extending the blanket of coverage to this group should not cost $1.5 trillion and require a wholesale overhaul of all of medicine.

Further, there is a lot of good in the American system. Far more foreigners come to America for their health care than vice versa. Same goes for physicians who want to practice medicine. Yes, Americans on the borders go to Canada and Mexico for prescription drugs, but Canadians and Mexicans come to America for surgery and even neonatal ICU care, evidence of a far superior infrastructure for high-intensity services. And, most importantly, our research, development, and innovation is unsurpassed – indeed, there is a good argument for saying that Americans subsidize other countries’ populations by allowing drug companies free rein in price-setting here (other countries have price controls, while we do not, which allows companies the breathing space for investment in R&D).

Ok, you say, but why does health care cost so much? So let’s look at the health care dollar, where it comes from, and where it goes. The US spends about $2.5 trillion on health care annually, and here's the percentage breakdown:

And the money is coming from:

Not well-accounted for in these figures are the costs of malpractice insurance and claims (approximately $10 billion per year) and of defensive medicine (estimates ranging from $60 billion to $100 billion per year; in some states, obstetricians and some surgeons must pay well over $250,000/yr in malpractice insurance premiums). With respect to health insurance companies, in 2007 they reported ~$15 billion in profits plus an additional ~$16 billion in stock buybacks (monies not used for paying claims or investments)

So to save on costs, the areas where significant monies could be squeezed from would be:
  • Hospitals and nursing homes
  • Physicians, dentists, and other providers
  • Drug companies
  • Insurance companies
  • Trial lawyers
Now, how would I go about deciding what to cut and how to save money and “bend the future cost curve”? I would rate behaviors & services on a scale of evil (which for this discussion I define as greed:utility ratio). So things that I’d like to see happen that I think would curb costs without degrading current or future quality of care would be:
  1. Significant tort reform where arbitration is used to weed out frivolous lawsuits and a system where negative outcomes are compensated reasonably, while criminal misbehavior is handled criminally. HMOs should no longer hold their privileged immunity from malpractice relative to physicians.
  2. Assigning the cost burden of unnecessary or likely futile services to patients or their families
  3. Eliminating television and direct to consumer pharmaceutical marketing (which all started only in the late 1990s) (drug company marketing is now about $57.5 billion annually, according to a PLOS study by Gagnon & Lexchin in 2008, which nearly equals the $58.8 billion spent in R&D by the drug industry. This would help reduce costs by allowing physicians breathing room to recommend older yet equally effective medications to their patients.
  4. Breaking the oligopolies of health insurance coverage present in many states & regions. 94% of insurance markets are highly concentrated. If ever there was a reason for anti-trust intervention, this is it. Consumer choice is constrained by such circumstances and costs are dramatically increased to patients and physicians. The solution to this is not creating a government monopoly of health care, but using deregulation & anti-trust law to allow cross-state insurer competition, and nurturing novel health care coverage systems through unions, community groups, civic associations, patient co-operatives, and physician-run organizations. Government could do a great service by jumpstarting the infrastructure to create such a true free market but it should not take over such a market.
  5. Encouraging charity care: Lawyers can treat pro bono work as a tax deduction; hospitals treat charitable services (which are often overcharged in the first place) as a tax write-off and get income tax exemption for being nonprofits. Physicians currently have no such benefit.
  6. Cost Transparency: A friend of mine who is a student in a professional school recently had an appendectomy and got a surgeon’s bill of $~3000 and facility bills of $13000. Insurance paid most of it, but he still paid $5000 out-of-pocket. By contrast, Medicare payment for appendectomies for the surgeon is $561 and for inpatient facility care is about $3000. Patients are charged wildly different amounts, and quite often indigent patients get stuck with full charges while Medicare or large insurance company patients get charged much less due to contractual arrangements. This process is just insane. If the rich or foreigners want to pay for concierge care and first-class service, so be it. But for the system as a whole, doctors should be allowed to set their own fees (which we, alone among professions, cannot – Medicare sets rates which we are obligated to accept if we accept Medicare patients), waive standard fees for the poor (remarkably, underbilling is considered fraud), and charges should be transparent and consistent. This ties back into the charity care issue, where some hospitals write off charity care at grossly inflated charge rates yet still make life incredibly difficult for the poor.
  7. Encourage innovation: Increasing tax credits for R&D, establishing prizes for translating discovery for big problems, and extending patent protection for new molecular entities while limiting patent extension for me-too drugs maneuvers turning Prozac into Sarafem or Wellbutrin into Zyban, would promote advances in drug and device development and maintain America’s edge in science & technology.
  8. Improve primary care: On this score, I think other countries like Australia and Canada are doing a better job. I feel lucky that as an ophthalmologist (which is mostly self-contained and which is alien to most other physicians), I can be the patient's doctor for almost anything eye-related, which helps me build the trust and rapport to exercise good judgment in deciding how frequently to monitor a condition, what medicines to use, what test to obtain, when to do surgery and when not to, and when to accept that there is an end of the road in certain situations. I feel that patients are missing that too often in their general health - before ophthalmology, I did a full 3 years of internal medicine residency, and care was so fragmented that patients (most of the time) did not have a doctor, in the classic sense of the word, someone who knew them, was their advocate, had a broad perspective of their life and values and conditions, and had their trust. This led to patients being dumped on the ER, diagnoses missed until it was too late, lab & radiology tests replacing clinical diagnosis, and great yet often unwarranted & futile efforts in situations without real hope. I think encouraging medical school graduates into primary care (full loan forgiveness, encouraging models like monthly or annual clinic "memberships" for patients rather than fighting for every bill or claim and booking patients every 10 minutes to make ends meet) would prove a long-term boon to patients and physicians.

Why do I think these are key measures which would be effective?
Our litigious system of jackpot justice does cause of a lot of unnecessary testing and drives a lot of medical practice, unnecessarily, to the ER or ICU where the full resources of a hospital are easily marshaled and engaged.
Costs in the last six months of year of life consume the lion’s share of health care spending; should the bill for that be covered by the hospital, the insurance pool, the taxpayer, or (in my view) the patient & family?
As for as marketing, television and direct-to-consumer marketing has exploded in the last 10 years, which has greatly distorted care, as patients often come in demanding specific medications, tests, or procedures. This has driven up costs but does not contribute to quality at all.
On the competition aspect, there is no free market in health care. We have the worst of socialism (regulation, poor service) with the worst of capitalism (corporate greed that seeks to distort and monopolize markets and imprison consumers into their own cartels of delivery networks).

Is the likely Democratic plan a good idea?
I have to say no. Expanding Medicare & Medicaid for all (which is basically what it boils down) opens the door to government price controls, which will devolve into wait-lists, poor quality personnel, salaried staff (who by definition are incentivized to give minimum effort), increasing physician refusal to see Medicare & Medicaid patients, and underinvestment in research and facilities (see Great Britain, and Canada). The Australian system, where public hospitals are well-funded and physicians can choose to accept government rates or charge higher, might be a viable option. The VA system (which was held up as an example by Hillary Clinton) is good at certain things (electronic prescriptions, some routine elements in primary care, traumatic brain injury, spinal cord injury) but is poor at infrastructure maintenance, efficient clinic and surgical flow, and customer service; further, its costs are held down as much of VA health care is in reality delivered by residents. The proof of the pudding on the VA is that the vast majority of VA patients are enlisted personnel; the retired officers go elsewhere.

Which of the plans bouncing around have useful ideas?
I think the Daschle-Dole idea of giving tax credits to all who pay income or payroll taxes to purchase health care is a good thing – equalizing the playing field of those with employer health coverage and those without. We want health insurance to be available to all contributing or productive members of society, but we don’t want free health care as a dole to contribute to persistent unemployment. The Daschle-Dole, Wyden, Ryan, & McCain ideas of capping the employer health benefit tax deduction , creating exchanges/marketplaces, small business pooling, and allowing cross-state and nontraditional insurance coverage and competition are all also great ideas.
Health savings accounts have potential but what I have noticed is that patients tend to use them to buy “nice things” – e.g., LASIK, nice glasses, a nicer wheelchair, etc. and then rely on government when they need their medications or life-saving surgery.
Encouraging preventive care and discouraging risky behaviors are all nice things but I’m not sure I want the government as nanny. However, certain employers (e.g., Safeway, my university) give lower insurance rates for enrolling in wellness programs.

What things should we keep in mind going forward?
As a society gets older and richer, it naturally will spend more on health care. Further, innovation and research cost money along the way - NICU care was probably not cost-effective 15 or 20 years ago, but is now. Neither of these points are in and of themselves bad. But we should allow patients the freedom of choice and with it, the responsibility to take care of themselves and limit unnecessary costs. Yes, in acute situations, it is unseemly and unfair to ask a patient, before anything else, what insurance do you have? And that is a great advantage of Canada that we can learn from. But some patients do abuse the system (refuse to take medications and then come in when they are really sick, or come in to the ER at 2 in the morning for itchy eyes which they've had for 2 weeks without pain or change in vision), and such behaviors should bear the costs.

We do not want to destroy a system that has led discovery and contributed so much to the world and led to unprecedented advances in life expectancy over the last century. As for profit, medicine should not be a business where the profit motive trumps all. Yet money does make the world turn; indeed, money from high-margin services helps support and allow the presence of charitable care, research, teaching, and humanitarian work (much as first class on airlines helps subsidize the rest of coach class). Removing money as an incentive for performance, R&D, and innovation would be stifling. Humans are naturally lazy, and greed can & should be harnessed to useful ambition. But corporate greed, market-distorting greed, and the greed of corruption and unnecessary services should be checked.


At 6:03 PM, Blogger swiftone said...

WV: doctot. Is this random???!

Thanks for a well presented post on a timely topic. I'm linking.. arrived here via Wretchard.

As a consumer and not much other standing for comment in the discussion of reforming health care, my reading and observation leads me to the following. A lot of distortion in demand for drugs and treatment comes from the disconnect of the "consumer" to the cost.

It's not an uncommon sense when dealing with an elderly parent with good insurance, that the industry sees a cash cow. Treatments get offered that are of dubious benefit to anyone but hospital accountants. As a loving grandparent of on of those 24 week preemies, I'm delighted that "our baby" came through NICU as a healthy little boy. But again, there is no sense of what all the treatment cost. SCHIP paid. I would have liked to see the billing.

Your excellent post is comprehensive and well reasoned. Thanks.

At 8:54 PM, Blogger Unknown said...

Amazing post. Really good treatment of the subject.

I would add only one idea to the mix for lowering the costs of health care (for Americans). Make a simple rule for pharmaceutical companies wishing to sell drugs into the US market: They can set any price they want, but it must be the same price for everyone - and not just in the USA, but including overseas too, just adjusted for real Purchasing Price Parity.

We can't force the Canadian or French governments to pay full price for a drug, but we can shut a company out of the US market if they don't play ball. I think we have the market power to make that stick. It's time for the socialized countries to pay for the American R&D they benefit from.

At 9:36 PM, Blogger Jeff Fuller said...

Great stuff Bala. I think you missed formatting #3 in your list. Even in private practice I see and treat plenty of patients with no insurance and wish there was a way to really write off a lot of that care for a tax benefit.

Your current #3 must be referring to IHC, eh? Yeah, that's a crazy monopoly-like system there on the Watsach Front.

Tort Reform is a must.

On your graph of costs I didn't see "diagnostic tests" anywhere. Are those lumped in between Hospitals for inpatients and "physicians" for outpatients? That's been an area of runaway costs the last decade.

You also need to list "deregulation" for insurance companies since state law nearly everywhere has raised the bar for minimum coverage to include some pretty non-essential things. Some states require fertility treatment, alternative care (accupucture, chiropractic care, etc . . ), and long-term mental health/substance abuse clinic care (which itself is often abused). People should be able to choose plans that cover those things, but it shouldn't be a minimum level of care required by the states. This is where the Federal government could set reasonable upper limit on minimum care and, like you say, allow for interstate selling of insurance plans

At 4:01 AM, Blogger Robert said...

I think a more effective solution for saving money related to malpractice would be reducing the need for either law suits or arbitration rather than further restricting the ability of injured patients to be fully compensated for their injuries.

We should reduce the number of patients who are harmed. Only about one to two percent of physicians are responsible for over half of all the money paid out for malpractice settlements and judgments according to National Practitioner Data Bank data. Many of these physicians have records that include multiple payments, often 5 or 10 or more payments yet no action taken to revoke their license or restrict their practice. Taking action to prevent these relatively few physicians causing the bulk of the malpractice costs from continuing their malpractice would do far more to actually reduce costs than would most tort reform measures, which tend to simply shift malpractice costs to the injured patients rather than eliminating the costs. Besides its effect on costs, dealing with the relatively few physicians causing the problem would improve patient safety and the quality of care.

Let's face it; we all know a few physicians we would not trust our care or that of our families to. Preventing them from harming others is the best solution to the malpractice cost problem. It would be treating the disease (malpractice) rather than simply the symptoms (law suits and attorneys).

At 8:29 AM, Anonymous Anonymous said...

Thank you for this comprehensive overview of the situation.

That said, I have a couple of questions:
1) How do you determine "last year of life"? If a procedure could extend life 6 months to 2 years? Who would pay for that? Is it not true that we can only determine "last year of life" after the patient actually dies?

2) Re: the cost of advertising drugs (and new procedures?). Some of the cost is to provide physicians with samples of medications which they pass along to their patients free. These presumably help low income patients with drug costs and provide some benefit. Example: An elderly woman on Medicare with limited funds is provided with a sample free of charge by the doctor, with the assurance that if the medication causes some side-effect or does not work, at least she will not be paying for the trial herself.

At 8:36 AM, Anonymous Anonymous said...

Doctor this excellent post is getting some play. Belmont Club, Powerline, Mark levin Fan all have links to your blog. Our country needs people like you in the national debate RIGHT NOW! If we end up with political solutions rather than professional solutions to healthcare reform we may as well all hold our noses and jump together, because this country will be headed right down the drain.

At 2:32 PM, Anonymous Rick Helm said...

I'm here from Powerline. Great analysis, and I like your differentiation of various types/degrees/manifestations of greed (often used as a pejorative for ambition).

You touched on the idea of market distortions, but I would make explicit that the employer-provided system, which is a response to gov't coercion, separates the ultimate consumer farther from the insurance pricing and purchasing decisions. Gov't mandates for insurance coverages, particularly routine costs that are not good uses of insurance coverage (analogous to insuring oil changes and engine repairs through auto insurance), have also distorted the supply and demand for services by hiding the true costs to the consumer. When a typical patient pays a $10 copay for his (semi-?) annual check-up, or more importantly every time he visits the doctor because he has a cold, he is unlikely to base his decision to make the visit on the actual cost, which includes the fixed cost of insurance premiums that are used by the insurer to pay the difference between the copay and the doctor's fee. (This is the same mechanism of price-demand distortion that necessitates rationing in countries that have socialized medical care.)

Even more insidious is that this system shifts the costs of routine visits, drugs, and other treatments from those who frequently visit the doctor (old and sickly insureds) to those who rarely visit the doctor (younger and healthier insureds). The political incentives for this system are obvious: older people are much more likely to vote, and specifically to vote on this type of issue. As a result, younger single Americans often choose not to purchase the artificially bloated coverage, and thus avoid cross-subsidizing older Americans, because the law prevents insurers from offering leaner policies that would provide a purer insurance only for low-frequency, high-severity incidents. That rational behavior in turn shifts even more of a cross-subsidization burden onto young parents and the middle-aged.

At 2:36 PM, Anonymous Rick Helm said...

I'm puzzled by your statement that "medicine should not be a business", a frequent talking point of the Left. Why not? What should it be: a hobby? 100% charitable? As you rightly mentioned, you could never get high quality, professional physicians without large profit/salary incentives. You couldn't even get minimally qualified physicians - certainly no one with years of medical school and residency training - unless you paid them some type of salary, wage, or fee.

Food is at least as important as medicine, so should food not be a business? What about real estate? Fuel to heat your home?

You might as well state that there should be no prisons because people should not commit crimes. In a utopia that might be true, but we live in a world in which people do commit crimes and prisons are necessary. Your statement that "medicine should not be a business" similarly assumes a utopian society that does not exist (which you sort of acknowledged later). In the real world, free markets, businesses, and profit incentives have generated an incredible standard of living for Americans. We would be wise to unleash those forces on the health care sector by reducing gov't interference in medicine and insurance.

At 1:11 PM, Anonymous Anonymous said...

Cannot agree. No matter what the distribution of the uninsured is, they cost money, and more importantly, they cost more than the insured folks when they do need services.

If you even study western European countries, like Denmark, you find that socialized medicine works best. I don't quite understand why the word "socialized" scares so many Americans.

At 8:08 AM, Anonymous Anonymous said...

Good post thank you. The end of life cost decisions could be shifted to family and patient by billing the individual's estate for cost occured in the last year. You could cap it at 10% of the total estate (maybe only above a minium estate). This would have to be phased in of course. But your resposibility to pay this could be easily taken care of by buying a permanent life insurance policy. Tax payers should not be on the hook for the expense of the wealthy persons end of life treatment

At 9:42 AM, Blogger Obliterati said...

Yes, tort reform. And letting insurance companies decide what is "unnecessary and likely futile".

Now how did I know you were going to write that?

At 10:52 AM, Anonymous Tarak Trivedi said...

Hi Dr. Ambati,

Thank you. Your blog is very informative. It is impressive that even under the busy schedule of an opthomologist you are able to take time out to write about your opinions and the state of healthcare.

As a second year medical student, I have only recently realized that healthcare policy is something I am interested in, so please forgive me if I do not intelligently discuss this topic. I have a few questions regarding your strategies for improving the system overall. Please consider that I am not criticizing; I am honestly looking for your opinion.

1. Malpractice reform- I agree that these many cases should be settled outside of court. I don't know much about law, but what kind of group could serve as a fair arbitrator?

2. Assigning cost burden would make for a great tactic, but what possible way is there to assign value to life or discomfort? I understand a large chunk of money goes towards performing end-of-life and prenatal care, and cost-assignment here would be the most logical choice. However, where can we draw the line? For example, a neurosurgical procedure to reduce pain in a terminally ill patient could cost a certain amount, but would be "worth" performing since they are terminally ill. Would this situation be different if the patient was not terminally ill? Basically, is there a way to ethically assign cost to life and comfort?

3. Ending direct to consumer advertising- The common argument against this is that pharmaceutical advertisement helped many people who were originally suffering from depression overcome the social stigma of depression, and ask for help. So many argue that advertisement is actually good for patient education. How valid do you think this argument is?

Point 5- Charity Care- It seems ridiculous that there is no tax-benefit in volunteering care. I was not aware of this. We have several student-run free clinics at our school, and it is often very difficult to recruit physicians to volunteer their time to provide this charity care. So usually, we get the same group of 10-11 physicians that just come because they don't want to say no. How can this be changed? What is the logic behind this in the first place? Is it because other volunteers would ask for the same benefits?

6. Cost Transparency- I know that uninsured patients get the worst hand in this deal, and often are charged the "cost" (the real cost times a multiplier). The reason I thought they are not transparent is because Medicare/Medicaid often only pays a fraction of the real cost, and the hospitals use this veil of secrecy to overcharge the private insurance (albeit, at a negotiated price) to cost-shift and make up the losses from Medicare patients. If everything became transparent, do you think that either Medicare would have to pay more or hospitals would drop Medicare patients due to unsustainable costs? That is the only reason that I can think of that this issue has not been tackled yet. The "veil of secrecy" article has been released for more than a few years, so why is the system still opaque?

If you get time to respond, my email address is If not, this is totally understandble, but I hope you can express your opinion on these issues in your next post.

Thanks for your time,


At 1:00 PM, Blogger JohnMcC said...

Excellent work. I salute you, sir. Just a thought however--going back to the 'first principles' section of your essay--you make the observation that protection from 'catastrophic' health crises is basic to guarantees of 'life, liberty and pursuit of happiness'. Does that not imply a social contract (perhaps not thru the gov't) that includes what everyone would call 'insurance'. And if not thru the gov't, who?

I think the other points are wonderful. But if your essay is thought by 'PowerLiners' and 'MarkLeviners' to be in opposition to a larger role for the gov't in healthcare, they are--as so often--wrong.

At 1:22 PM, Anonymous Anonymous said...

Lawyers are not permitted to deduct the value of pro bono legal services, only out of pocket expenses incurred in connection with the performance of such services.

At 1:32 PM, Blogger nerdybaldguy07 said...

This is very interesting data. Can you give me some references for where you got your percentage breakdowns for the charts above? I had a suspicion that there was more to the "47 million uninsured" than met the eye. I'd like to quote the original sources for those numbers because some of my friends who support a generalized government run health care proposal don't believe me unless I can point them to a reliable source for any numbers I quote.


At 3:28 PM, Anonymous Anonymous said...

"That leaves about 10 million Americans who are chronically without insurance." I would like to see some back-up on that claim, which I have a hard time believing. Otherwise I think this is an insightful piece.

At 6:14 PM, Anonymous nsam said...

Educational. You should write more on this important issue and contribute to the debate.

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At 7:04 AM, Blogger Noocyte said...

Superb post, and I'm glad to see it gaining wider visibility in the blogosphere.

The absolutist thinking and ideological posturing on this issue is, on every level, terribly unhealthy. It is refreshing to read such a thoughtful, well-reasoned essay.

Best, and happy birthday.

At 10:19 AM, Anonymous Anonymous said...

Hi Dr. Ambati,
I think you are an extremely intelligent observer (I didn't start medical school until age 21)with a lot of great ideas. However, why is 1.5 trillion dollars too much taxpayer money to achieve universal health insurance coverage? If I divide this sum by 10 million, which you state is the number of chronically uninsured Americans, then I get $15,000 per patient per year over 10 years. Did I make a math error here?

At 10:09 PM, Blogger Singularity said...

Subu bows to Doc. Bala for an excellent blog!

Great few points. My point, as I have brought up in person, is to make "Geico & Co." be allowed to offer competitive health insurance rates. Why not? I dont understand. It seems like a simple solution for a complex problem - an engineer's thought.

At 3:08 PM, Anonymous Ray C said...

Where does your data come from?

At 11:51 PM, Anonymous Ashish Pawar said...

very interesting, lot of data and number games. Eliminating television and direct to consumer pharmaceutical marketing is nearly letting them go nowhere.
Thanks for sharing once again

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You can still see the unemployment levels are high even after a few years of the recession first hitting. I like the fact that they try to call it a double dip recession vs calling it a depression but if it goes down for travel a couple years, then goes up briefly should it "count" as wiping the slate clean...You can see the effects in the honeymoons industry as people did not have the disposable income to book cruises or other activities that cost a pretty heft entertainment fund. Same is true with global brands joining other brands such as flight center to recapture lost market share...whatever happens people need jobs or they will begin to riot...once the unemployment checks stop.

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