Health Care Solutions Part 1

So, I’ve listed what I think are the top issues confronting us in our current health care system. Now it’s time to list some of what I believe the possible solutions to be. This is the difficult part and where I’m likely to part company with most of my more conservative brethren. I’ll tell you up front, I think the wimpy public “option” currently under discussion doesn’t go far enough and that’s one of the first things I’ll be addressing as I go forward. So, word to those with a weak stomach for things they regard as socialist: I’ll be treading heavily where our president and the body politic fears to go.

For anyone open to alternatives not being seriously discussed in our pathetic sound and fury public debate, read on. I think you’ll find much of this new ground. For those of you reading these words with amusement from other parts of the globe that are grappling with different problems, you still may find something of interest here. Either way, I’d love to hear from anyone who chances across these pages. Let me know if you think I’m a crank or a reasonably thoughtful individual. More importantly, share your actual beliefs and suggested solutions to the problems we face.

For today, I’ll tackle Access to health care regardless of the ability to pay. I’m sure I’ll lose at least half of the two people reading.

Up front let me say that our current system will not support health care for everyone regardless of ability to pay. . . at least not without massive and distortional taxation. And a big part of the problem is the profit motive. There’s nothing wrong with the profit motive in most areas of life but most of us will agree that we like to remove profit from areas where it may either cause grievous moral problems, or negatively impact life and death issues. Off the top of my head, I can think of two major areas where we generally try to avoid profit as a motive: policing and national defense. Oh wait, we can also quickly extend that to other areas of our mutual safety, fire fighting etc. We pay for these and other services out of our tax dollars and I don’t hear any loud calls for privatization of any of these services. We generally think highly of our men and women in uniform and think they do a splendid job.

We even have some other services that compete directly with the private sector. The post office springs to mind. Yes, some might complain about the post office but it truly is a marvel not easily replaced by the private sector. Fedex and UPS may be marvels but they don’t serve every address in our vast and sometimes sparsely populated land for the price of 44¢! They’ve even improved their customer service and compete well and profitably with UPS and Fedex in the express arena. Yes, they do occasionally need more money or to raise the rates. But wait, what business doesn’t raise rates to cover costs. The post office exists in a monopoly world. They could easily raise rates beyond what they currently charge. There is no alternative for mass distribution of magazines and other printed material. The fact that they go to congress to ask for the right to raise rates doesn’t make it any different from any other concern having management make that decision. Rates are artificially low because we have generally considered this a worthwhile social good. Some will disagree but I would propose that, prior to the advent of email for the masses, the post office was undeniably a positive force for our society and economy. It may very well become obsolete through technology but not by some more efficient private competition. Ask UPS if they really want to carry letters and magazines to every home in the country for a pittance.

So, the government isn’t always terrible at providing certain kinds of unique public services, especially ones that concern important national goals. I would also submit that the government isn’t always significantly less efficient than large private entities. Those of you who work for large corporations, none of which is as large as the defense department, can attest to the waste and even fraud that occurs in your little miracle of modern corporate governance. We need only think of the massive destruction of wealth that has just occurred in the financial sectors to think of how poorly many companies may be managed and how they squander resources. The US automobile industry was once the envy of the world and has been descending into ruin for decades. They can blame their woes on the unions, health insurance costs or whatever they like but the fact remains that most of the European competitors have far more onerous unions to deal with that have seats on their boards and they too must pay a share of the health insurance burden as well as pension contributions and all that while providing 6 paid weeks of vacation a year and more holidays that we can imagine. Do I think our companies should mimic foreign ones in all ways? Of course not. I appreciate the American service ethic, though it’s fallen on some hard days. Still, private doesn’t always mean better and the market doesn’t always pick fairly, honestly or even best. If you want an earful on bad and messy choices, just ask me about the transition to an HD optical disc format!

So, having dismissively trashed the concept of private being innately better than a well managed public entity, you probably believe I want a public health service where all doctors and nurses are public employees and the government manages all aspects of our health care system. I don’t.

Firstly, there is already a large public sector in health care provision and it is likely to grow. I have no problem with that and think that the two can coexist well and may interact even more in the future. There are certain things better handled by a public institution, as I’ve said above, and one of those, for example is infectious disease monitoring and research. The CDC (Center for Disease Control) is just one of many publicly run health care organs that exists and could not be adequately replaced with a privately managed group.

Still, there is no reason why doctors shouldn’t be free to choose their own areas of practice, location and manner and method of service. People are individuals and nowhere are they more individualistic than in their approach to their health and their bodies. It follows that doctors, as individuals will be better able to meet those disparate needs better than large organizations.

The vast majority of doctors working in Germany are in private practice. They do not work for the government and they are just as differentiated as American doctors in the way they approach their practice. There are holistic practitioners, those who focus on nutrition, personal types and mechanical types. There are the renowned “Gods in white” and those who work in partnership with their patients.

So, what’s different in Germany and how does it apply to the US? Germans pay for their health care very much like we do. Employers pay half and the employees pay half. The difference is in how the amount they pay is determined. For the vast majority of Germans, their insurance rates are determined by their income. They pay a percentage of their income, much like a dreaded TAX, to cover all of their health care needs. They do not pay this to the government though. They pay this to a publicly chartered private insurance company. The largest of which is the AOK. These “Gesundheitskassen“ then pay all the claims and manage the money on behalf of their ”clients.“ As you earn more money you pay more money. . . up to a point. Currently, Germany has an income cap that permits you to opt out of the ”public“ system once you exceed it. You are then free to purchase private insurance instead of public. This is somewhat cheaper for high earners because it is no longer based on income. Everyone else is free to buy supplemental insurance and Germany has a booming market for such policies as the Germans LOVE to be insured for everything!

The other big difference is that you do not lose your insurance when you lose your job. You stay with your insurer and it is paid by unemployment insurance. If you exhaust your unemployment insurance than you switch to the social insurance and that pays your health insurance. At no time will you and your family be uninsured.

Other differences? Your insurance pays just about everything at 100% so your insurance expenses are your ONLY medical expenses. You’d think this would result it overuse and abuse of the system and while there is fraud, just as in the US, the German system is vastly more efficient and delivers better results for less money. The Germans do have a fiscal problem with this system but it is not primarily due to fraud or abuse. The problem is the income cap! If, instead of permitting people to opt out of the system after reaching the cap, the government simply capped the amount of income taxed, the system would be more than solvent and its fiscal problems would be, for the most part, solved. Such a system would look more like our social security system, though not in terms of the looming fiscal insolvency, just in terms of the taxation limits.

This is a clearly progressive system that provides solid health care for all citizens at a price they can afford. The costs are also not as negative for employers of the low wage workers because their health care costs are tied to their earnings and, as a result, are very low.

I think this is the only fair way to create a comprehensive health care system and, with the exception of the rates being tied to income, would be relatively simple to implement with our current structures.

Comments? Ideas? I warned you about reading on but I’m glad you did.

Health Care - Part 1-7 Removing the stress from health care provision

7) Removing the stress from health care provision.
What the hell does this have to do with health care reform and won’t any new universal program just be more paperwork and hassle. Let me put it bluntly. Since returning the US from the socialist workers paradise of Germany (that’s a joke, people) I’ve had more stress and heartache dealing with health insurance than at any time in the past. I spend more time on the phone with insurance agents, medical billers and doctors about insurance and payment issues than I ever do in getting and dealing with health care.

Isn’t the point of a health care system to keep you healthy and to return you to health should you suffer an unfortunately illness, disease or accident? How can it possibly help when you are forced to battle your insurance provider to get the benefits you are paying for every month? How can it help to navigate your way through a thicket of rules and regulations that has spawned an entire industry just to manage it. I often deal with customer “service” agents or medical billing staff who seem just as confused as me about the proper billing codes they are to use to ensure that my yearly check up is billed as preventative care and comes out of the right pot of money. God forbid the Dr. perform one test not covered by that rubric, then the entire visit can be reshuffled into the regular office visit category and a long and tedious fight awaits the customer who attempts to have that visit reclassified to avoid paying the deductibles and co-pays that requires.

One of the things that amazed me when I returned to the US after an eight year sojourn in Germany was the size of the office staff required to sort through the paperwork and billing complexities forced upon doctors by the insurance industry. You may be surprised to hear that there is no medical billing industry to speak of in Germany. Dr.’s offices are smaller in Germany because they don’t house legions of personnel handling insurance issues.

Let me describe my typical doctor’s visit in Germany. I walk in, hand the office manager my insurance card, she swipes it through a card reader and hands it back. I wait for my appointment, see the doctor and leave. If I have a prescription to be filled, I take it to any pharmacy and hand it to the pharmacist who also scans my card and, moments later, I leave with my prescription.

In neither instance do I pay anything to either the doctor or the pharmacist nor do I receive a bill for services rendered or a co-pay at a later date. I pay for my insurance and, with few exceptions, everything else is covered by the insurance.

The same is true of my dentist visits and, with the exception of the frame costs, the optometrist. In that case, there is a limit to what the insurance will pay for the frame and, should I wish a more stylish one, it is incumbent upon me to pay the difference, as is only fair.

Once, when my youngest child had a mysterious skin disease, I went from doctor to doctor in search of a cure that worked. In all honesty, it might be argued that the insurance could reasonably have denied my claim since I went to so many doctors for the condition but they did not. In fact, I never heard from the about it at all. Each doctor tried something different and it never went away. Interestingly, it did get somewhat better but worsened during a visit to Los Angeles. There we went to a top dermatologist who recognized the rare condition and prescribed an unusual and, no banned, topical treatment for it. It was finally cured and our insurance, private German insurance at that point, paid it without question. That brings me to another point I will address in the future, public and private systems can live quite comfortably with one another, as they do in Germany. Many people buy supplemental policies for “luxury” features they are willing to pay for, private rooms in hospital etc.

So, for me, the stress of health insurance in this country is a serious issue. Granted, it’s not one that requires a public option, per se, but it does require a different approach and some restrictions and norms applied to the private sector.

One part of the problem is the sheer bewildering diversity of health care insurance in this country. It’s no wonder that an entire industry has grown up around medical billing. With hundreds of companies each with their own codes for each and every procedure, it’s difficult if not impossible for a small doctors office to handle the complexities of billing even a simple office visit. It’s even worse from a consumer’s point of view. Have you ever TRIED to decipher your EOB (explanation of benefits)? I have. . . from a number of companies, as our insurance has changed many times over even while remaining with a single employer. It’s migraine inducing! And when I’ve called to ask why my yearly check up was billed as an office visit and billed in full to me and applied to the deductible rather than paid in full as a preventative care visit, the explanation of the wrong billing code is less than helpful. Call the doctor’s office and they’ll insist it’s the correct billing code. How the hell should I know which code is correct and why should I even be concerned with such issues. With my insurance in Germany I NEVER faced such issues.

Another stressful issue relates back to the freedom to choose your doctor. As I mentioned, our insurance providers changed numerous times during 7 years of employment with a single employer. As the insurance provider changed so did the list of “in network” providers. Often one or more of our previously in network doctors would no be out of network and we had to choose: Find a new doctor or pay money we didn’t have to stay with the old one with significantly reduced benefits? What kind of choice is that and why do we have to make it? I thought we had freedom of choice?

Worse yet, on occasion, a doctor would mysteriously go from in network to out of network without us enduring a provider switch. My wife’s gynecologist went in and out of network so often we had to call just before every appointment to confirm her status. Eventually she simply stopped taking insurance of any kind (other than medicare and medicaid) directly and negotiated her own discounts for her patients who then had to submit the bill for out of network reimbursement.

Sound stressful enough for you? Share your own stories of health insurance stress.

Health Care - Part 1-6 Equitably sharing the costs of health care among all members of society

6) Equitably sharing the costs of health care among all members of society.
OK, here’s where we get into an almost purely ideological debate, though one tied closely to the entire question of providing universal coverage at all. Here’s the rub, when we talk about mandatory coverage and don’t take into account people’s ability to pay, we create a new problem while “solving” the old one. Now we have forced a new group of people into or further into poverty just to pay for health care. Many people without health care will still not be able to afford it just because it’s a “public option” or because some of it is paid for by an employer or even a tax credit. The reality is, sometimes every penny is already spoken for.

What’s the solution? Stay tuned for my truly socialist addition to the mix. Here’s where I share the wealth to. . . aw, that rhyme is just too awful.

Health Care - Part 1-5 Ensuring the freedom to determine your treatment plan in consultation with your doctor without undue restriction

5) Ensuring the freedom to determine your treatment plan in consultation with your doctor without undue restriction.
People are fulminating about “rationing” of health care. Listen up! If you have the money, health care is NEVER RATIONED! You can go anywhere and buy anything you want. You can get yourself a black market kidney and get a transplant. Just pay up. That will never change. If you don’t have that money, health care is ALWAYS RATIONED by what you can afford and what the insurance company is willing to pay. Check your policy, you have a lifetime limit on what the company will pay for your care and, trust me on this one, it can be exhausted pretty quickly with our outrageous medical costs and a series of serious chronic conditions. Just a transplant or two along with the care for life that follows is enough to max out many plans. Think that’s not likely? I personally know two people looking at transplant number two.

No system, public or private, pays for anything and everything for everyone under all conditions. You want “death panels?” You already got ‘em!

The real issue is that reasonable treatment that has a good chance of extending your life and/or improving the quality of your life should never be denied or delayed and the provision of that care should not depend on whether you are currently employed and have enough insurance and money.

Health Care - Part 1-4 Ensuring the freedom to choose your health care providers

4) Ensuring the freedom to choose your health care providers.
What? Isn’t this what the opponents of health care reform are fighting for? I thought the government was going to run health care and choose my doctor for me once “Obamacare” was the law of the land. Let’s examine this for a moment.

First question: Who out there can visit any doctor they want to for any service whatsoever? That’s correct, everyone! Yes, assuming you have unlimited dollars at your disposal, you are free to visit any doctor you like at any time, providing they are accepting new patients and have room in the schedule.

So, let’s ask that question differently: Who out there is free to visit any doctor they want to for any service whatsoever and have it covered by their current insurance? Ah, now we have a different result. I can see very few virtual hands. . . practically none. In fact, the few people who have their hands up seem to be elderly. Why is that? because just about the only system that has anything even close to universal acceptance and coverage in the US is the medicare system, which covers senior citizens and is a single payer government system. Also interesting, the vast majority of seniors are much happier with medicare than most of us are with our expensive private insurance schemes.

No, medicare doesn’t cover EVERYTHING. No insurance does. However, most private insurance is much more restrictive about which doctors you can and cannot see and what you pay to see them. My PPO, for example, allows me to see any doctor I want BUT only if I am willing and able to pay a much higher out of pocket maximum per year as well as a much larger percentage of the cost for each visit or procedure. As a result, my much vaunted freedom of choice is an illusion. I don’t have the resources required to go “out of network” and so I don’t. My network is pretty good but my insurance is outrageously expensive too. The alternatives provided by my wife’s employer, who shall remain nameless, all offer more restrictive options and, though they cost less than the one we have chosen, they are still expensive. If you have an HMO you probably have little, if any, say as to which doctor you see. Only medicare is close to universal, though it too falls short.

The fact that medicare is so pervasive and well thought of while the debate about health care is so dense and full of misinformation leads to people screaming at the top of their lungs to “keep the government out of my medicare!” What fun. Want to see the lengths this gets to? Check out this gem from the supposedly respectable Arthur Laffer:

http://www.bobcesca.com/blog-archives/2009/08/doof_quote_of_t_58.html

Laffer knows better and that’s a big part of the problem. Rather than represent their arguments with solid facts and figures, opponents of health care reform would rather scare monger and inflame opinion. It’s an old game plan and one that is all too effective. Of course, proponents are only somewhat better, making weak arguments for their positions and claiming more than they can deliver with half hearted reform plans. Still, that’s a far cry from the government “death panels” garbage people like Sara Palin are spreading about.

Health Care - Part 1-3 Controlling the cost of health care while ensuring adequate standards

3) Controlling the cost of health care while ensuring adequate standards.
This is a technical topic so I’m not going to go into it in any great depth here. I’ll cover that in later arguments on specific areas. For the moment, suffice it to say that our current system accomplishes neither of these tasks. That’s not to say that there aren’t bright spots in the health care landscape. A small number of HMOs and the medicare system seem to have a decent record in this area. I’ll trot out figures to back that up later. Here I just want to state for the record what has been said so many times before: the US has the most expensive health care system in the world! Does this bother you? It wouldn’t necessarily bother me. Hell, we’re also, still, the richest country on the world. So, what’s the problem? Well, the problem is that this is actually a compound sentence. The second part of this statement is: “The US enjoys among the poorest health care outcomes in the OECD.”

Here’s a little taste of international studies on the subject, courtesy of Wikipedia:

“The World Health Organization (WHO), in 2000, ranked the U.S. health care system as the highest in cost, first in responsiveness, 37th in overall performance, and 72nd by overall level of health (among 191 member nations included in the study).[11][12] A 2008 report by the Commonwealth Fund ranked the United States last in the quality of health care among the 19 compared countries.[13] The U.S. has a higher infant mortality rate than all other developed countries.[nb 1][14] According to the Institute of Medicine of the National Academy of Sciences, the United States is the “only wealthy, industrialized nation that does not ensure that all citizens have coverage” (i.e. some kind of assurance).[15][16]”

For the original article, look here:
http://en.wikipedia.org/wiki/Health_care_in_the_United_States

No one questions that costs are too high and health professionals are also agreed that the provision of health care is skewed as well.

Health Care - Part 1-2 Access to health care regardless of pre-existing conditions.

2) Access to health care regardless of pre-existing conditions.
Recently someone defended the practice of denying health insurance for “pre-existing” conditions with the analogy of an auto insurance provider being required to cover someone for an accident that occurred prior to coverage. Does this sound like a relevant analogy to you? Well, it’s probably one of the most relevant analogies I’ve heard and yet it’s wholly irrelevant.

The assumption is that “pre-existing” conditions are both predictable and the fault of the individual and that they should have had insurance before. There are so many levels on which this is a bogus comparison. Let’s take the congenital condition. Many, if not most, inherited conditions are undiagnosed and none of them are the fault of the sufferer, though some may be exacerbated by lifestyle issues. Yes, we have legislation that prevents discrimination based on genetic information/testing but we don’t have legislation that prevents discrimination based on the health outcomes of those conditions. Once that condition is present or determined to be something that should have been disclosed/known prior to insurance being issues, the company is free to either deny or rescind coverage.

Well, you ask, why don’t such people have insurance already so that the condition can’t be considered “pre-existing?” As I’ve mentioned before, it’s very easy to lose coverage as a result of a long term illness or a chronic condition, as many congenital conditions are. If you fall ill due to such a condition and lose your employment and, as a result, your health insurance you will find yourself in the position of having a “pre-existing” condition when you apply for health insurance anew. So, even if you manage to recover sufficiently to resume working and have sufficient income to pay for insurance you are no longer insurable. . . or, at least, the condition for which you most need insurance will be excluded.

And then, of course, there are children. What happens when I child is diagnosed with any condition, let alone a congenital one? Well, if there parents manage to maintain insurance, no problem. They should get the care they need, assuming the insurance company does deny the claim for other reasons. What happens when the child is either uninsured or loses insurance because the parent loses a job, is also sick or something else breaks uninterrupted coverage? Well, when circumstances allow and the child is to be insured again, they now have a “pre-existing” condition that may call for wholesale or partial exclusion. If the child wants to purchase that same insurance as an adult they may well find themselves locked out of the private insurance pool.

OK, I have to be honest here. There is an insurance pool for people with pre-existing conditions. Yeah, I know, gotcha. Not so fast. These are high risk insurance pools, they vary in the terms available, quality of care and cost, which is generally astronomical. The problem with charging such high rates to people with such chronic conditions is that they are just the type of population least able to bear the burden of such costs. They may miss work or even change or lose jobs often due to health issues. Many times they find their earning potential limited by their health problems or they enter a downward spiral of increasing health care costs and decreasing income.

I can go on and on but I do want this to be readable and digestible and I’m afraid I’ve already exhausted the patience of my readers with this tome. So, on to. . .

Health Care -Part 1: The Issues According to Me

So, I promised to write about health care and the first thing on my list was an examination of the main issues with our current system. This is my list and my view of things. Many people won’t share my concerns and, in some cases, there is no common ground. If you simply don’t believe that it is incumbent on us to try and find a way to provide health care to those that want and need it, regardless of their ability to pay, then we will have to agree to disagree.

Call me a socialist but I do believe that there is a role for society to ameliorate the most crass distortions and human costs of our economic system. I do not want to “destroy” capitalism. I enjoy the energy, innovation, vibrancy and variety that our semi-free markets provide us with. Still, I am under no illusion that ours is a truly free market and I’m glad that is the case. I am glad that the government requires pharmaceutical companies to adhere to standards of testing and manufacturing to ensure our safety. I’m glad that our slaughterhouses generally adhere to minimum standards for health and safety for their workers and even for the animals processed there. . . though clearly there’s a ways to go in that area. I’m glad that there are some constraints on the financial markets, however imperfect and fecklessly enforced they may be and I’m happy that contracts and transparency are regulated to some degree by law. In general, I see a role for our government in moderating our economic activity through both laws and institutions to enforce them and I’m certain most of my fellow Americans would agree. If you don’t, stop here. You’ll just cause your self unnecessary indigestion by reading further.

So, what are these issues confronting us in the health care system in the US? I list the following:

• Access to health care regardless of ability to pay.
• Access to health care regardless of the presence of pre-existing conditions.
• Controlling the cost of health care while ensuring adequate standards.
• Ensuring the freedom to choose your health care providers.
• Ensuring the freedom to determine your treatment plan in consultation with your doctor without undue restriction.
• Equitably sharing the costs of health care among all members of society.
• Removing the stress from health care provision

Of course there are other issues and I’m certain many would disagree with my choices. I will make my arguments and you’re not only free to disagree, I hope you will make your own and post them in comments to this discussion.

After writing for a while on even this relatively straightforward subject, I found myself to so deep in the material and cranking out such a volume of words that I felt it best to break this into smaller chunks. This is as much for my benefit as for yours. There’s simply too much to go over to do it any justice in a quick entry and the length of the entry I was in the midst of writing was exhausting to read as well as write. So, one post per issue and one issue per day will be the order of things.

Let’s take them in the order I’ve listed them, though that’s not necessarily indicative of any real priority.

1) Access to health care regardless of the ability to pay.
To me this is fundamental and encompasses much more than the issue of insuring the poor, though that alone is reason enough to consider this a critical issue. The argument I most often hear against ensuring everyone is that people must earn their keep and we shouldn’t support those amongst us who don’t work. Well, the reality is that the majority of those who don’t work at all already receive health care through the government’s medicaid program. This is the health care part of the welfare program. Whether or not you agree that this is a good thing, it is so and so it brings us to consider who we are talking about when we speak of the uninsured?

Here are the main categories of uninsured people in this country:

1. The working poor. This group of people earn too much to qualify for most assistance but not enough to pay for health insurance. Even those fortunate enough to work for an employer who offers health insurance often earn too little to participate in the plan or can only afford catastrophic coverage. Even more work part time or for companies that offer no such coverage and so are unable to purchase subsidized insurance. These people do work but still they are uninsured or massively underinsured.
2. Young people. I was once among those who didn’t have insurance because they believed themselves young and healthy and immortal. To be honest I had health insurance on and off but it was never a priority. I found out only later that I had a congenital condition that could easily have caused me to be hospitalized or worse. Accidents do happen and even young people should be a part of the insurance pool to ensure the necessary mix of healthy and sick people required for the system to work. We protect our own children against their occasional folly. Shouldn’t we do the same for our societies most precious resource?
3. The unemployed. No, this isn’t necessarily poor people and it’s not the working poor. It’s almost anyone who endures a long period or unemployment in this country. Even if we had insurance and have some reserves to pay the inordinate costs of COBRA to maintain it while unemployed, we can only do this for a certain period of time before it runs out or we run out of money. Right now, in this country, losing your job generally means losing your insurance. . . unless you’re wealthy, of course. Should that be the case? I don’t believe so.
4. The sick. What, you ask? How can it be that the sick are a “category” of people who are uninsured? Well, they aren’t, exactly. They make up a composite of other groups. Being ill in this country carries serious consequences that may include the loss of your job, home and health coverage! Yes, extended illness can see your income evaporate and the employer provided health insurance along with it. The debts you incur can cause you to lose everything you own, including your home and, with the money all gone, you will have no resources to pay for the health care you need. Yes, theoretically, you may then qualify for medicaid and receive health care, once again. Unfortunately, it is required that you be financially ruined before society will lend you a hand. You must go through that stress in addition to confronting your health condition. Only then, when it may be too late, do we have a “safety net.” It’s a bit like scraping the trapeze artist up off the floor after a fall.

So, should we provide coverage for these people? I think so. We have other priorities in this country that we fund and that I believe are not nearly as important or even critical to our long term security. More than that, I feel this is truly a moral issue. No one should be required to suffer the indignity and very real harm that the gaps in our system can cause.

Health Care Intro . . .

Well, dear reader, I meant to start a discussion on health care earlier this year and wrote the following in February upon receiving my first bill of the new year All I’ve done is complete the thought as an introduction to my coming pontifications on the subject:

So, as the new year dawns my introduction to the coming 365 days of American health care is. . . another bill to call my insurance company about. Yes friends, my very first bill of the year requires my attention. To be honest, this is no surprise. I’d be hard pressed to think of a single statement or invoice that didn’t require my personal attention. If I didn’t call about an invoice it wasn’t due to it’s being miraculously correct but rather to a lack of energy on my part to take up battle with the insurance and medical billing industries. And I have “good” insurance! What is life like for all the poor schmucks out there with a bad insurance provider. To me it’s quite obvious that we grade insurance companies on a curve and the poor grade for the best performers lets the others of the hook. I don’t know anyone who isn’t wealthy who would venture to give their health insurance provider better than a C. I guarantee you that the stress caused by my health insurance is bad for my health and just about offsets any good it does me.

OK, so I’m certainly not the first to notice or comment on the pathetic service provision and high costs that distinguish the US health insurance industry. What makes my bitching any different from the myriad voices crying in the ether for attention? I’ve lived in different countries and experienced the benefits and pitfalls of different health insurance approaches. That certainly doesn’t make me an expert on health care and despite my years following the issue closely and being a reasonably assiduous consumer, I wouldn’t begin to claim that label. Still, the issue is what is it like to actually live with the various systems in various countries and what elements of the experiences of other countries should or could be transported to our own.

With that, and the hope of engaging in a reasonably rational and profitable debate about the actual issues surrounding our health care morass, I will be writing a series of posts on the issue. I expect them to break down roughly along the following lines:

• A cursory examination of the main issues confronting US health care as I see them
• A look at how the countries I’ve lived in confront these issues
• A comparison of actually living with the health care systems of two different countries both with and without a family
• A suggestion of how our system can be combine the best of the other systems with what, still, works in ours.

What I’m NOT going to do is look at the realities of our political system and the likely impossibility of enacting more than minor reform to our current, broken, system. I want to further the debate among reasonable people. There are legitimate differences of opinion and concern about all manner of tradeoffs that may be required to deal with the challenges we face in health care. I don’t deny that and don’t have a “quick fix.”

I’ll also be clear about my biases and I’ll do that right now:

1. I think it is an imperative that we look at health care as a basic human right.
2. I think that we should focus on providing health care for those who can’t afford it in our current system via regular health care practitioners and NOT via expensive and ineffective emergency services
3. I believe that we can have a healthier and more productive population by alleviating the stress of worrying about health care and concentrating on preventative care.
4. I believe that the wealthy will always have access to health care options most of us will not be able to afford regardless of our insurance coverage in either a public or private system
5. I believe there is a role for private insurers in health care
6. I believe that the government has a role to play

For the moment I’ll leave it at that. I’m going to try and keep this discussion free of unnecessary technical details but there will be enough dry data to go around. Feel free to comment and add to the discussion. I have no illusions about the reach or impact of my little blog but I do think we all have a responsibility to talk soberly about the great issues we face or we must accept the current stagnation and inevitable decline and societal discord this will lead to. Agree with me or not, please debate me.

Microsoft cuts 5,000 jobs. Is that really necessary?

OK, this is not a rant against Microsoft. This is a bit of a rant against our system in general. The short term obsession of our quarterly results based financial system is going to be the death of us. Quarterly and even weekly figures may be very interesting tools for planners within a company to make micro adjustments or spot developing trends but they are NOT for use as the blunt instrument for which they are misused in our world. Just read this excerpt from today's report on the Microsoft earnings report:

Microsoft posted a profit of $4.17 billion, or 47 cents per share, in its fiscal second quarter ended December 31, versus a profit of $4.71 billion, or 50 cents, a year earlier. Analysts were looking for earnings per share of 49 cents, according to Reuters Estimates.

Revenue rose 2 percent to $16.63 billion, missing the average analyst forecast of $17.1 billion.

Microsoft's elimination of 5,000 jobs -- 1,400 of which on Thursday -- amounts to about 5 percent of its estimated 96,000 work force, the biggest reduction ever by the software maker.

What's wrong with this picture? It's not that MS profit is down. That's not really the surprise it's being painted as. It's not even that MS is unwilling to provide forward guidance, a questionable practice in many cases anyway. No, what's wrong here is that MS is going to dump 5,000 highly skilled people onto a depressed job market when it made a PROFIT OF $4.17 BILLION in the recent quarter!!!

Now, it may very well be that MS is projecting much lower revenue in the coming quarter or two. It may also be that MS is concerned about all sorts of product lines under attack. And it may even be that MS is simply using this opportunity to trim less productive staff it picked up during better times. Blah blah blah. I have to call this BS as I see it.

One of the world's strongest companies is chopping heads while making boatloads of money and sitting on the world's largest pile of cash shy of the Chinese government!

Why is this wrong? Isn't this what prudent companies are supposed to do? Would that make them welfare states if they held on to these people? I have to ask a different question: doesn't a company owe its employees anything more than a paycheck and some benefits? Doesn't a company that is wildly successful and profitable owe its employees some share of that success in the form of security? Not every MS employee gets bucket loads of options and bonuses. Many are lower level employees and many more are contract employees with few if any benefits. These employees also contribute to the success of MS. Do they deserve to be let go when the company is still printing money?

This is wrong on another, corporate governance, level as well. Firing staff over short term setbacks, when the company can clearly afford to retain them, leaves MS short of staff a couple of quarters down the road when things should pick up again. This shortsightedness can destroy a company's long term prospects, depriving it of the oxygen of good people and ideas necessary to compete.

This is not unique to Microsoft. Many a successful company has dumped employees in the midst of recession or short term transitional instability. The numbers here are just so glaring. For failing to make some analysts quarterly numbers, 1,500 hard working people are out the door! And this while the company pays a dividend of $0.13 per share.

Unless MS is bracing itself to become a much smaller company in the future, there is no need or justification for this kind of retraction. employees can be moved within the company, shifted to new projects that will prepare for the future, retrained, sent back to school for advanced degrees. There are many ways for MS to deal with this kind of market turbulence but adding 1500 workers to the unemployment lines is the worst of them. Fewer people who have the money to buy their products, fewer evangelists, fewer minds to drive the company forward. . . an impoverished country and an impoverished Microsoft.

If companies like Microsoft aren't willing to at least stay the course while making huge profits, who will invest in the future of our economy?