Monday, December 10, 2012

Medicare Is Not The Problem, Your Hospital Is

Medicare is much discussed today in the current Fiscal Cliff standoff.  It shouldn't be.  First, because it is not an entitlement.  You and I pay a premium for it and the fund is solvent through 2024, even with our changing, aging demographics.  Don't let anyone call it an entitlement and demonize it.  Here is the real problem few except President Obama are discussing.  Many of our Democratic leaders are healthcare economics illiterates.  The problem is that we have allowed healthcare to become the most inflationary aspect of our economy--double digit inflationary. 

Who are we?  We the voters, at least those of us electing state legislators in the 80's.  We allowed them, Republicans and Democrats alike, to deregulate hospitals and healthcare institutions.  We were sold a bill of goods, told that it would create competition and competition would drive down costs.  Hospitals and their outpatient facilities were once regulated like utilities.  At least, in the majority of states where utilities were actually regulated, our Texas being an exception.  But, even in Texas, public owned and tax exempt hospitals were regulated to the extent that if your county hospital or local non-profit wanted to add an OB wing, or buy an MRI machine, they had to commission a study proving sufficient demand and file a Certificate of Need application to defend such a new investment with the department of health.  Some got turned down for reason of insufficient demand or need.

But states like California got the bright idea, sold by really good con artists that by unleashing unregulated competition, institutions like hospitals and outpatient centers would lower costs.
But quite the opposite happened during the hyper capitalistic Reagan era.  As Certificate of Need requirements were abandoned by legislators and regulators, a national movement spread like a brush fire.  Hospitals and outpatient centers began buying technology for their diagnostic and surgical programs, buying off high priced surgical practices like open heart surgeons and advertising these.  Technology manufacturers had an orgy of sales.  In short order, there were more unused million dollar machines than junkers in a used car lot.  Hospitals started advertising wars spending millions, extolling the virtues of their Gamma Knives, PET scanners and multi-million dollar heart surgeons with not enough work.  Soon, way too many beds, way too many suburban branches of medical center hospitals and soon, you or your parent’s insurance premiums started exploding.  And though they pissed these institutions off mightily by resisting raising Medicare reimbursements, Medicare too had to fork out more cash for exotic procedures and technology driven medicine.  Then came an explosion of for profit hospitals, later to consolidate into mega-mergers, driving competition further into a frenzied state.

These trends caused formerly altruism driven medical students into the chase for the big bucks in specialty medicine  like cardiology and orthopedics, away from general practice and primary care.  Soon came a shortage of primary care physicians, particularly serving lower income communities.

What we created was a crazy quilt of unsynchronized, uncoordinated, inefficient, dollar driven enterprises in the health care arena that we call our health care system today.  Not to excuse greed driven, hyper-profitable health insurance companies, but this is a lot of what they face.  And so does Medicare.  It is an out of control hodge-podge of ever escalating costs.

Add to that another phenomenon that drives inflation in health care.  What looks like a hospital with four reasonably square walls really is not.  Inside those wall is crazy quilt of for profit contact companies running the day to day operations of Mother Mercy Medical Center.  Mother Mercy is not findable.  What you find is the Emergency Room company, the surgical suite company, the nurse staffing company,  the housekeeping company, the IT company, the billing company, the anesthesiology company, the food service company, the pharmacy company,  the list is endless and total.  Mother Mercy has dozens of for profit contractors, usually parts of huge national hospital contract service companies. Yes, this is within your tax exempt, so called non-profit hospital.  Why? Well for one thing, it is nearly impossible to unionize staffs who work for disparate contract companies.  And another thing, it is a lot easier for a hospital administrator to rely on company specialists to stay abreast of the exploding technology and new processes that to know and stay on top of that stuff themselves.  You know, this is the age of specialization.  Hey, there are even companies that computer scan your hospital charges before they go to Medicare and do something called "upcoding" to make sure that the most expensive option of several billing codes applies to your respiratory therapy bill before it goes out to Medicare.

Are you sufficiently confused by this chaos that some try to persuade us is the "best healthcare in the world"?  How about efficient?  Wouldn't you think we should be hearing from medical schools and hospital administrator graduate programs about how to clean up this mess?  You won't.  They're cleaning up financially.

Thank your lucky stars President Obama had the guts to take this nightmare on.  He and we have a long way to go to make sense of this.  Medicare still runs with 2 % overhead.  Ask Mother Mercy Medical Center if they're doing the same.  You won't get an answer.  They're too busy wallowing in the chaos. Now you know who the real problem is.

Thursday, December 6, 2012

The Disloyal Republican Opposition

Now that November sixth is well behind us, I think it is time to look at the behavior of the Republican minority pre and post election. When I think of Republicans, Lincoln, Theodore Roosevelt and Eisenhower come to my mind. They are Republicans I can both respect and on many issues identify with, though I am a died in the wool yellow dog, populist Democrat. But the contemporary Republicans are another breed, especially those in their current leadership and tea party ranks. Compared to the principled, rational and respected Republicans mentioned above, this new breed are truly a sad lot, not worthy of the descriptor Loyal Opposition. On so many levels, this new breed are genuinely disloyal to many if not most of the American ideals we all were taught in our civics and history lessons. Let's first look at the pre-2012 election era and most of President Obama's first term. Here's at least some of their record that I find most troubling and for which I am seeking some rational explanation from a group supposedly espousing liberty and freedom.
l. Rather than countering Democrats with better ideas from their perspective to legislate, they sought to block virtually any and all Obama administration ideas, many of which were borrowed from Republicans of yesteryear.
2. Rather than save a collapsing economy and financial system with temporary measures to avoid a depression, they chose to block and limit solutions to pull us out of the ditch, advocating letting much of capitalism collapse in order to cast the blame on the majority in power.
3. Rather than offer proactive solutions to our unemployment crisis from the private sector whom they asserted can provide solutions that government cannot from their perspective, they chose to limit and block government solutions which have been proven to work.
4. Rather than improve America from their perspective, they chose to oppose all Democratic Party ideas with the pronouncement that their primary mission was to limit Obama to one term.
5. Rather than promote democratic participation they chose limit and reduce voter registration, especially where it impacted minorities and low income Americans. This view appears to revert to the early American years where only property owners could participate in the electoral process, long ago reformed and eliminated.
6. Rather than expand voting rights, a battle fought in an earlier era to include freed slaves with blood soaked battlefields and later women in an eighty year struggle to include all genders, they chose to suppress voting by these groups through a variety of restrictions on already won access to voting boxes.
7. Rather than improve the legitimacy of vote counting they chose to tamper with cast votes and challenge the legitimacy of votes cast by mainly low income people and cage votes through gerrymandered legislative districts.
8. Rather than offer alternatives to ending wars and improving our foreign policy, they chose only to criticize new approaches to diplomacy and international economics.
9. Rather than work on unresolved social issues facing our country with new thinking, they have chosen to reopen archaic issues such as abortion and even contraception, not with scientific and social science-based reasoning, but with theological arguments they wish to impose on those of differing theological traditions. 
10. Rather than improve rules governing legislation and policy making process with new ideas, they chose to subvert such reforms through misuse of the filibuster and introduce incivility into governance while also reopening previously healed wounds around the issue of State vs. Federal powers.
11. Rather than engage logic, science and historical experience into public policy making, they have introduced the alternate universe bubble, anti-science and evidence-free thinking into America, making discourse and collaboration impossible.
12. Rather than hide overt racism from Republican ranks as had been their public face, the disloyal opposition engaged in blatant disparagement of ethnic background of our President and fellow African American leaders and citizens alike.
The electorate spoke loudly and irrefutably on November 6, affirming the President's idea to move forward, not revisit the past.  There simply is no ambiguity about how the vast majority of Americans feel about solving our economic and societal problems.  Yet, as we see below, Republican post election behavior and rhetoric is in denial of the American approach to consensus making, advice and consent as well as functioning as the loyal opposition.

Since Election Day we hear Republican rhetoric in defense of the increasing disparity between the wealthy and those with modest or lower earning power.  We experience continued outrage over foreign affairs, especially the Benghazi attacks, compared to the silence from the right during the Bush years over the vulnerability of our foreign officers lost in at least a half dozen attacks and resultant loss of ten times the numbers of U.S.staffers.
Though the electorate spoke overwhelmingly about our desire for increased tax revenue from those long exempted from their fair share under our progressive tax system, Republicans continue to demand dramatic cuts to government operating budgets.  This includes Social Security, which is neither an entitlement nor even indirectly related to our deficit situation.
As they saw our attack on Iraq as somehow an appropriate response to 9-11 though in no way involved, they now advocate an attack on social insurance programs we taxpayers fund rather than unfunded wars using borrowed money which are a major cause of our debt situation.
Illogical thinking still prevails in their world, especially in the instance of simply economics and math.   They do not see the connection between a weak economy caused by households unable to both earn and spend money to increase their standard of living while priming the national economy pump.  They see as the solution now depressing consumer earning and buying power, austerity and continued lowering of our standard of living as a solution to a faltering economy. How irrational is that?  They advocate investment by business as the path to growth rather than the alternative debunked theory of saving and deferred spending their way to growth and greater earnings, but not for households.  Why does this economic truism not apply to both realms in our economy in their thinking? Is it because many in their ranks just cannot bear the thought of a black man whose forbearers suffered so greatly in this land,  leading us out of economic collapse?  I wish that were not so, but absent any solutions from them, I have no other explanation for their irrationality.

So, it would appear that President Obama and the country is in for another four years of obstructionism and disloyalty to the principles of democratic governance set forth by our forefathers and constitution.  The courage of Lincoln in supporting abolition, Teddy Roosevelt in taking on the imbalance of corporate influence and Eisenhower in addressing the military-industrial complex,  and even the tragically flawed Nixon in acknowledging the need to protect our environment, all great threats to our evolving democracy seems lost on the current Republican power structure.

Could it be that Republicans become extinct because of their disloyalty to American ideals and are replaced by the Green Party, with our party's reflecting the center-left orientation of our body politic?  Time will tell.