Health care costs do not need to be 16% of the GNP. Defense cost should not take up 51% of our tax payments. However, until the people stop worshiping the military and the government representatives and their employees, we will not see much change in the cost of health care or defense.

The military, the government employees, and most of the old people have single payer health plans that screw everyone else. There is no possibility that change will come as a result of any health care bill being passed in Congress. It is amazing that so many in Congress can oppose even the modest changes in that huge health care bill passed by the House and a similar one that will likely pass the Senate. Instead, the opponents all seem to scream that they is no money to fund healthcare for the non-government worker and non-big-business employee, but there is unlimited money to fund War and the military-industrial complex and to bail out the banks and Wall Street.

It is just arrogance to think that the people will not some day discover that they do not have to have such poor representation and such a bad government. Having a President who is glib and a Congress that, in the majority, is dominated by greed and self-interest does not give us the kind of country that their “quoted words” from the founding fathers describe.

Let us make the changes without them in our communities and with our families and friends. The President and the Congress can represent the two percent of the population who support them and we can represent ourselves. Pray that they do not use the military to shoot us.

We in the United States are faced with a moral dilemma: to uphold the equal constitutional regard for each and every life in our country, or to slide further in the direction of survival of the fittest (the richest?). I have been in the business of setting up and operating health care delivery systems for the past forty years, and I feel I have some worthwhile recommendations to make to the many options being entertained.

1. Outsourcing: One of the best suggestions I’ve heard is to outsource the management of the programs through competitive bids to Canada, England, France, Germany, or Japan. Maybe some of the African countries currently working with Partners in Health should be allowed to get in on the bidding. Since outsourcing has such a poor chance of approval—in spite of the genius of it—I’ll make an alternative suggestion.

2. Pooling:

A. First, let the insurance companies compete with one another for administration and payment of claims—just as they have to do with large, self-insured employer groups. In the 70’s, 80’s, and 90’s, the companies bid as low as 2.5% to do all administration and claims–.5% lower than Medicare’s expenditures for the same services.

B. Second, allow no underwriting profits. Put all expected claims monies into a common pool and pay claims from that pool. As with self-insured employer groups, the cost for each person would not vary, and no big blowout claims would kill off the plan. Let us allow all Americans to pool losses rather than just suffer them. Real claims costs would be determined from current experience and certified by independent actuaries, who would then set a rate for each person. [Perhaps the population could be separated by age and sex, but that might be a waste of time if the pool is hundreds of millions of people. Medicare has not found it necessary to do such separation, and its customers are the sickest people in the country.] The competing insurers would then bill and collect the premiums for individuals and groups, keep their administrative loads, and pay the claims portions of the premiums immediately and electronically to the “Claims Fund Account” based on actuarially certified rates.

C. Third, let there be defined benefits for the health plan similar to the simple provisions in the Medicare Advantage HMO plans. For example, there could be several plans with different deductibles–$250, $1,000, or $5,000—with lower rates for the greater deductibles. People who choose a higher deductible, however, would have to show proof that they have sufficient capital or credit to pay the larger deductible.

D. Fourth, design a more controlled system for medical care billing and costs. The current system is based on an open-ended fee-for-service billing and, in the case of Medicare, involves DRG (Diagnosis Related Groups) based payment for some facilities and RBRVS (Resource Based Relative Values Scale) rates that are tied to diagnosis and CPT (Clinical Procedures Terminology) codes for generation of professional fees. That kind of system is subject to manipulation and much abuse by health care providers and contains the wrong incentives for delivery of quality health care services. The DRG system of payment — which Medicare invented to protect itself against hospital billing abuses — is somewhat effective if someone other than the hospital is keeping an eye on it. If there is no independent, interested party monitoring the number of admissions and discharges as they happen, then too many admissions continue to happen and people are often discharged too soon after a necessary admission.

What I suggest is that the physicians should be required to be members of a team of about thirty primary care physicians and twenty groups that represent the main areas of specialty. The team chooses which hospitals it plans to use and then elects a quality-assurance committee and/or hospitalists to “watch-dog” the use of the facilities. These physician teams would be paid, using the professional fees portion of the claims funds, (which are based on the numbers of patients in the practices of the primary care physicians). Some sub-specialties could service more than one team, if the patient population served by that team was less than necessary to fill the practice of that specialty. The members of the team could make their own policies in regard to payment of each member, but what works well is “division by capitation” if the patient numbers are at the 50,000 to 60,000 capacity of the thirty primary care practices. I can guarantee that no member in that small democracy of physicians will get more than his or her fair share of money or work. Physicians know very well the work required in caring for patients and billing will be among themselves, rather than to some “evil” third party or a uninformed patient.

E. Fifth, if the U.S. government is unable to cooperate in the development and approval of health care reform then the citizens ought to do as the government dreams it could do: form cooperatives of millions of people and accomplish the reforms collectively. This method is not complicated, sacred, nor forbidden. It has been done by many people at times in the past, usually after a government – and its owners - have failed its people, certainly as is happing now.

The ideas of those who call themselves liberal or conservative do not reach to the base of the health care problems and their solutions. Health insurance could help if it were universal and comprehensive although it need not reach to the first dollar of expenses for every individual. The need for health care arises before the health care providers and patients ever make contact and before health insurance has any impact. The causes of accidents, diseases, and sickness are mostly unnatural and are best solved by correcting the environment, the production and distribution of food, unemployment, poverty, education, and training of more health care workers at every level. There is a direct connection between the reform of the health care delivery system and solving the problems that arise from the unnatural causes. There is almost no political will in our government to get at root causes and real solutions. It seems it is not a government of the people, by the people and for the people, but one managed by and for the short term interests of wealthy individuals and corporations.

Yesterday, I was surprised when a friend who is a marketing director for a large health insurance company told me he thought that “Medicare for Everyone” was the proper health insurance reform. He said this even though he was opposed to a government run health insurance system and he expressed the views of people who are politically conservative. He said such a solution seems very reasonable since the details of it were in place and there would be a need for supplemental insurance from the private companies based on prescribed benefits. He concluded that the benefit prescription, as in the Medicare Gap insurance, created a fair and competitive market. He assumed that the “Medicare for Everyone” would not cover from the first dollar and that given the current increases in medical costs the gaps in coverage would grow. A new system would take years to catch up to the operation and regulation that is already mature in the Medicare system such as; contracting with providers, determination of rates, claims administration and quality assurance measurements.

I suppose the political objection to “Medicare for Everyone” is that the big insurance companies would lose administrative income and underwriting profits and the beneficiaries of the current payment system would have to accept Medicare rates which are thought to be too low by the hospital corporations and some of the doctors. The big six: United Health Group, Wellpoint, Aetna, Humana, Cigna, and Health Net may not be willing to just sell Medicare Gap Insurance in competition with the thousands of other insurance companies that would be able to compete with them. Reporters for newspapers and TV stations keep telling us that the majority of the people support a single payer health plan. Is that not what Medicare is? Why is it that someone can say he would be in favor of “Medicare for Everyone” in one breath and then be against a “Single Payer Health Plan” in the next breath?

It could be that “Single Payer” sounds like the elimination of Medicare and Gap insurance and it would pose a threat to insurance jobs and current medical fees. Whereas, “Medicare for Everyone” is a known system, has established rates and defined benefits.

Insurance has never reached down to the level of payment for basic health care services. Yet, people will pay premiums for 1st dollar coverage in order to maintain a monthly budget even when such premiums are more than their routine expenses over a short term. I think like my friend, the marketing director, that “Medicare for Everyone” is the most practical choice for health insurance reform but I understand why the President and Congress may want a “new program.” They do not represent the people, conservative or liberal, but represent the money that put them office and keeps them in Washington. They love the way lipstick looks on pigs.

If you want to reform “Health Care” then you should ask Dr. Paul Farmer and the other physicians who work for Partners in Health for their recommended solutions. They stand head and shoulders above every health care expert in the country. Health insurance is simple compared with health care and health care is simple when compared to solving health problems that arise from the unnatural causes. If the government actually wants to fix the “health insurance crisis” they have a system in hand to do it and the majority of the representatives know it. If they lack the political will to oppose the lobbyists then perhaps the people can send new representatives. If they want to fix “Health Care” they had better get to the roots of the problems: environmental degradation, industrialized food, unemployment, poverty, education, and lack of training for a broader range of health care providers.

Don McCormick

The problem is you can’t write well after you’re dead.
Yet, it is difficult to say what you want to say while you are alive.

You need to be someone else so you can talk frankly and expose
everything about the other people and everything that spins around them.

Supposedly, God knows everything and what difference would what you may say make to her or to anyone? Does she give a shit?

This little dirty deed, that little dirty deed, pretty soon you can’t get a loan or sign as a witness for a friend.

You are held back from expressing your true thoughts.
If you wrote them, your roommates might not see you the same way.

The time has come to put aside the notion of writing after death.
I need to write what I know so that everyone can see how little it is.

Don McCormick

Luke is still dead, but from time to time his sisters channel him to me as nonchalantly as they would toss a scarf over a shoulder. They say he is there all of the time or, more correctly, we are here spinning in space and he is not. He no longer has a left brain. The lying part of him has been consumed.

Yesterday his eleven year old son, Dominic, said to me that both his mother and his father were crack-heads and his grandmother hated him and his heart hurt. I told him it was not so, that he was wrong, that he would feel better later. I let him walk away. Then, I could not let him walk away and I went after him and I asked him to come back to my room. I told him that his father had been my little boy, my big boy, a man that I had loved. I told him that neither his father nor his mother had intended to do wrong and especially not to him. In their lives they did good and bad, but more good than bad. I had loved them. I missed them.

I hugged Dominic. I kissed him on his curly hair. I cried for him and for what his Dad could have learned on earth that would have made that timeless place his sisters touch better for him. His wife is wandering around still trying to find a home, still destroyed by all of the children she has lost and all of the ways her life has been pulled from under her feet since she was born. She is a poster child for everyone that comes into the world on the street side and has no address for her letters. All of her children have good looks and good brains, and for their sakes they all are in the care of others. They have homes and families even though their father is dead and their mother is wandering homeless.

Nushka, my wife, thinks all of Dora’s children will be damaged by what they have lost, a mother, regardless of how soon she left them all; even though she did not want to leave, even though they were all taken away by due process of law in the full light of day while God was crying. It is a mysterious kind of damage that Nushka sees. It is in that place where there are no words and no thoughts, the place where things are and are not. Jeni and Annie have devices to deal with this condition and friends who see things and tell them secrets. Nushka and I have Jeni and Annie. We still cry. We still just spin around the earth and the earth around the sun and the sun around the milky way and we wait for the first coming and the second coming and as many comings as there needs to be to cure what is wrong with time and people and our lying left brains.

Don McCormick