I've read your two responses a few times to make sure I understand what improvements you are suggesting. I admit, I don't understand some of them. I'll include the pertinent quotes from you and my response. If I have somehow trimmed your quotes to the detriment of your meaning, please let me know as that is decidedly not my intention.

“like paying for results rather than treatments, and not doing tests that don't tell anything.”

Three issues with this, how do you pay for results and not treatment? Are you saying that if a treatment is not effective, we don't pay? If so, I suggest you don't understand medicine; a treatment that works for one does not necessarily work for another. Second, what kind of test tells you nothing? More importantly, who decides that a test is unneeded? The insurance company?, the doctor?, the lawyer of the doctor who is trying to save him from malpractice?

You see, I agree with your point about malpractice as long as truly egregious practices are still nailed for all their worth. I believe the only thing worse than lawyers making a killing through questionable lawsuits are doctors that damage a patient through true negligence. Operating on the wrong leg is a good example.

“We should stop discouraging integration of medical records through HIPAA–indeed, we should require them to be integrated”
I agree 100%. Medical computerized records accessible by any medical person will reduce cost, improve treatment, and virtually eliminate medical errors treatment errors.

“certification requirements for nurses and other practitioners, which unions have successfully inflated to discourage competition and create shortages.”

I would suggest you don't know the facts here. There are 2.5 million nurses in the US, and only a very small portion are unionized. You favorite union, the Service Employees International Union, is the nation's largest health care worker union, only has 110,000 nurses as members out of 900,000 total members. The vast majority of nurses are on the own employment wise.
The constant cost cutting that goes on at hospitals always lessens the number of RNs as a way to save money. One of the reasons my wife, and RN for 30+ years, quit floor nurse work was due to the fact that fewer and fewer nurses were asked to be responsible for more and more patients. It wasn't the work load she shied away from, it was the safety issue for the patients. You can't be in two places at once.
You may not know that an interesting effect of unionized nurses is that union hospitals have a lower mortality rate among patients than non-union shops.

“we simply encouraged a more direct payment model–you pay a co-op a flat rate” Do you mean no deductible or do you mean that people get insurance outside of work?

” they can make a buck by offering cheaper options to consumers, coverage at a wider range of price points will emerge,”

Where do the cutback of services occur in the cheaper plans? The definition of what's a catastrophic illness is defined in medical or financial terms? Is reconstructive plastic surgery a luxury? How about a kid's hair lip at birth? I think I know where the lines are drawn if the insurance company makes the call.

Thanks for your clarification.

I've read your two responses a few times to make sure I understand what improvements you are suggesting. I admit, I don't understand some of them. I'll include the pertinent quotes from you and my response. If I have somehow trimmed your quotes to the detriment of your meaning, please let me know as that is decidedly not my intention.

“like paying for results rather than treatments, and not doing tests that don't tell anything.”

Three issues with this, how do you pay for results and not treatment? Are you saying that if a treatment is not effective, we don't pay? If so, I suggest you don't understand medicine; a treatment that works for one does not necessarily work for another. Second, what kind of test tells you nothing? More importantly, who decides that a test is unneeded? The insurance company?, the doctor?, the lawyer of the doctor who is trying to save him from malpractice?

You see, I agree with your point about malpractice as long as truly egregious practices are still nailed for all their worth. I believe the only thing worse than lawyers making a killing through questionable lawsuits are doctors that damage a patient through true negligence. Operating on the wrong leg is a good example.

“We should stop discouraging integration of medical records through HIPAA–indeed, we should require them to be integrated”
I agree 100%. Medical computerized records accessible by any medical person will reduce cost, improve treatment, and virtually eliminate medical errors treatment errors.

“certification requirements for nurses and other practitioners, which unions have successfully inflated to discourage competition and create shortages.”

I would suggest you don't know the facts here. There are 2.5 million nurses in the US, and only a very small portion are unionized. You favorite union, the Service Employees International Union, is the nation's largest health care worker union, only has 110,000 nurses as members out of 900,000 total members. The vast majority of nurses are on the own employment wise.
The constant cost cutting that goes on at hospitals always lessens the number of RNs as a way to save money. One of the reasons my wife, and RN for 30+ years, quit floor nurse work was due to the fact that fewer and fewer nurses were asked to be responsible for more and more patients. It wasn't the work load she shied away from, it was the safety issue for the patients. You can't be in two places at once.
You may not know that an interesting effect of unionized nurses is that union hospitals have a lower mortality rate among patients than non-union shops.

“we simply encouraged a more direct payment model–you pay a co-op a flat rate” Do you mean no deductible or do you mean that people get insurance outside of work?

” they can make a buck by offering cheaper options to consumers, coverage at a wider range of price points will emerge,”

Where do the cutback of services occur in the cheaper plans? The definition of what's a catastrophic illness is defined in medical or financial terms? Is reconstructive plastic surgery a luxury? How about a kid's hair lip at birth? I think I know where the lines are drawn if the insurance company makes the call.

Thanks for your clarification.

But that's only half the problem. To solve the other half, for people who still can't afford even basic coverage, the government needs to get involved. It should do so by writing these people a check, not picking up a stethoscope.

But I'm not in the medical field (and even the healthcare-reform-harridan field is just a hobby), so my visibility is limited. Those are some inefficiencies I notice, which means they're large enough to be seen from outer space. There are literally a million more where they came from, and they're below the radar of what any central authority will notice or be able to fix. That's precisely the power of the market. Once you get millions of brains engaged on the task of looking for incremental improvements, they find them, and those add up. Computers have gotten a million times more powerful over the past few decades, not because of one sweeping reform, but because of many incremental improvements. We could use some of that magic in health care.

That last one obviously doesn't mean walk-ins to the emergency room is acceptable.

I just haven't heard your list of improvements. This certainly isn't some kind of challenge.

I wouldn't advocate imposing coops as the reform, though. They won't be the right answer for everyone. I'd rather reform focused on flexibility–fixing the market so it was easier for coops to catch on if and where they made sense, and easier for them to evolve into something even better some day.

This is the single most broken aspect of our health care system. It means you don't have much choice of insurers and will lose your insurance when you lose your job. COBRA laws give you 18 months grace before finding a new job (and a new insurer you didn't choose), but if you miss that you'll have to buy insurance on your own and face the pre-existing condition hurdle doing so. The arrangement saves you money, but you pay for it in risk and lack of choice.

Worse still are the systemic effects of this single tax policy, because they create a situation where no one really cares about value for money. You don't care how much your insurance costs, because your employer pays for it. You and your employer don't care how much your doctor costs, because the insurance company pays for it. They care how much the doctor costs but don't care whether you felt better after seeing him. Even if they did they'd have no way to tell, because your specific case gets lost in the averages when they renegotiate their contracts.

This is the weirdest industry we have. It's entirely about delivering value to to individual consumers, yet consumers can't make any real decisions, and providers care so little about them that large numbers are simply priced out of the market. The solution is very clear: take the power out of the hands of HR departments and give it back to the consumers. This is the single most meaningful health care reform we could enact.

If companies pay for health insurance coverage, it's a business expense just like payroll./ I'm not following your logic here. Is somebody trying to take away a business expense?

I would honestly ask if you really think ANY of our discussions are more than pipe dreams. The fruits of our logic and intellectual rigor used to analyze and debate could possibly find real solutions to these problems. But even if we did, it would never be heard in Washington. We don't have the price of admittance without the big bucks to hire a lobbyist.

A Constitutional amendment changes the legal foundations of laws that follow. If the lobbyist system is to be broken, it will have to go through a change in the constitution, not through prostitute legislators

Big Pharma et al are the only ones who stand to ake a profit here. You may believe that unions are involved (I've seen nothing along thos line but could have missed them) – but unions only stand to save money, not make it.

The current process ignores the whole idea of reform. Could things be done cheaper, more efficiently, made more universal? of course. is there any great effort to do so? nope. Efficiency is bad for profit as I stated before. Which debate is taking place, saving profits or creating efficiency?

Efficiency helps those of us who pay.
Inefficiency helps those who are paid.

Like one of my entries the other day, I'm ready for the current effort to fail as the plan so composed will only guarantee costs to continue to skyrocket. That's not good enough for the general welfare.

Fine as long as you know that it's just a pipe dream and that any attempt in the real world to implement it would fail to meet those criteria and in fact could make problems worse instead of better as people find ways to game the new system.

And the way to get the legislators to figure out how best to govern by thought, not money, is to have voters who won't reelect them if they govern according to who lines their pockets the most. If the lobbyists and special interest groups want to give tons of money, and the politicians reward them with policies that aren't in the public's interest in order to keep the gravy train going, then the voters shouldn't reward that behavior.

A big part of the problem is that a lot of voters don't believe that THEIR party is guilty of this.

I agree it's wrong, in the sense that I don't see it happening in the sense you mean. Insurers and pharma companies are trying to shape reform, for sure. But so are unions, and practitioners, and the AARP.

And I disagree that profit is a dirty word, because health care reform is mostly about money. The problem of the uninsured is much more financial than medical–if they get sick, they will generally get treated but risk being wiped out in the process. Everyone from corporations to unionized nurses to retirees to taxpayers is weighing in on the reform process, and they're all looking after their bottom lines. Nothing wrong with that, and again, it's hard to imagine the system could work differently.

I'd like to see legislators be more thought-driven than money-driven too. But I think the fundamental barrier is voters' limited attention span. Voters can't keep track of hundreds of complex issues, understand the tradoffs involved, and evaluate their representatives fairly on their own. So representatives (both incumbent and aspiring) are forced to market themselves and try to win voters over to their positions, and they need money to do so. If you successfully restricted most of their funding, it's not at all clear to me that voters or legislators would do their jobs any better.

My intent is simply, I want the legislators to figure out how best to govern by thought, not money.

” And honestly, I don't see what's necessarily wrong with how things work today”

Really. I find that the whole idea of health care reform being driven solely by those who stand to make a profit is very wrong. The general welfare drives my concern.

I do feel, moreso than Dr.J, apparently, that money is a problem in our system. But like him, I don't think that you solve it by trying to regulate the money. I think the only real solution is an informed electorate and transparent donation policies so that smart voters can hold the politicians accountable.

And honestly, I don't see what's necessarily wrong with how things work today. Money talks, but only indirectly, in the sense that it allows politicians to buy the votes that will keep them in office. It's ultimately us voters who are for sale. And it's not like there's only one set of lobbyists. As that list of groups trying to influence health care legislation shows, there are many different voices at the table representing the diversity of the so-called public interest. I dunno, it looks kind of like democracy to me. I'm not sure what else democracy *could* look like at national scale.

Seriously, it goes back to the minor dissertation I gave above about the two basic ways that “the General Welfare” clause has been interpreted. Despite the rigged game I see in Washington, I believe many there really are interested in the welfare of the populace. They are just fighting an uphill battle.

My Senator claire mccaskill is a case in point. She served here in Missouri as State auditor for quite some time before going to Washington. I still watch her like a hawk, but she seems dedicated to the general welfare as I see its definition. Yet, I had reason to disagree with some things she's done.

I don't ask that these people be saints, just accountable.

I know you distrust Obama, and again, there have been things with which I disagree. But all in all, he's seemed to me to follow that same desire to help those in our society who have the least control over their existence.

The past two terms of Bush has pretty much put me off of the “conservative movement” as it was manifest under his reign. The elitism that I oppose above has never in my lifetime been more obvious that in his times. Conversely, William F Buckley was magnificent, even if I didn't always agree with his points.

Both Buckley and Obama are wicked smart. Maybe that's the common attraction for me.