The Alan Katz Health Care Reform Blog

Health Care Reform From One Person's Perspective

Health Care Reform Disruptions Help Nothing

Posted by Alan on August 7, 2009

It’s a sad day when silencing opponents becomes a substitute for civil discourse, especially on issues as important and complicated as health care reform. Yet, that’s what’s happening as national organizations encourage local residents to disrupt Congressional town hall meetings being held around the country during the Congressional August recess.

That people have strong opinions on health care reform is a given. There are few issues that touch Americans as deeply as the health and well being of themselves and their families. They should care passionately about changes to the American health care system and they should communicate their questions and concerns to their representatives.

Bringing town hall meetings to a halt, however, is not debate, discourse or discussion. It’s political thuggery aimed at preventing the exchange of ideas, not promoting them. The anger generating this misbehavior may be genuine, but the tactics are orchestrated. The campaign organization distributed a memo on how to hijack town hall meetings. To be fair, after calling on opponents of the Democratic reform package to pack the hall and shout-out questions and objections, the memo cautions “Don’t carry on and make a scene – just short intermittent shout outs.”

Needless to say, this advice has gone by the wayside as some of these demonstrations have turned violent, members of Congress have been hung in effigy and lawmakers have had their lives threatened all while the media’s attention has shifted from the value of a public health plan to the whether the outbursts are genuine or orchestrated. (I think we can all agree that it’s more exciting for the media to cover a fist fight than an explanation on how comparative effectiveness of medical services might lower health care costs).

And it’s not that the demonstrations have turned ugly. Some of the rhetoric and fear mongering has gotten downright silly. Some have accused Democrats of promoting the killing of seniors because the bill allows Medicare reimbursement for consultations concerning living wills and other end-of-life issues. C’mon people, really? Or my personal favorite: calls to “Keep your government hands off my Medicare.” Umm, for those paying attention, Medicare is a government health plan. 

It’s not just conservative organizers like the FreedomWorks that are to blame for this lack of civility. House Speaker Nancy Pelosi has taken to calling insurance carriers villains and immoral. That doesn’t help with the tone. And now liberal groups are organizing to confront the conservative groups disrupting the town hall meetings.

Nor, by the way, are these kinds of tactics new. In 1996, shortly before election day, I was moderating a panel discussion featuring four health insurance executives when demonstrators, trailed by television and radio reporters, burst in, chanted slogans and dumped buckets of beans on the stage. They were there in support of a single-payer initiative on the California ballot – an initiative that was handily defeated.

Trying to silence the opposition through intimidation and disruption is an old tactic shared by the right and the left. That doesn’t make it correct nor is it helpful. There are serious issues that need to be debated. And there is a legitimate need for changes to the status quo. It would be nice if we dealt with the substance of what’s at stake, but that’s hard to do in the midst of intentional chaos.

Of course, it’s easier to shout someone down than to persuade through ideas. Perhaps what these demonstrators fear is that, in a real dialogue, they would be able to express their ideas, but they’d have to listen as well. And that might lead to someone actually learning something.

Would that really be such a bad thing?


32 Responses to “Health Care Reform Disruptions Help Nothing”

  1. Medicine is first and foremost a business. The proof is that as many as 99% of c-sections and 98% of hysterectomies can be avoided with conservative treatment options, or no treatment at all. Curbing the overuse of these two surgeries alone would save taxpayers tens of billions of dollars each year. That savings could be used to provide emergency medical care to the quickly growing number of uninsured Americans. See the book THE H WORD by Nora W. Coffey and Rick Schweikert for over 400 pages of juried medical journal articles and personal testimony that attest to the fact that America would be healthier with less medicine. What we need is emergency care for everyone and to stop making doctors and corporate executives rich with damaging, unwarranted surgeries.

    • Dave Wood said

      Heya Denise, great post. Just wanted to add that indeed over use us major problem with American health care. Not only does it occur with child birth, but with angioplasty, misdiagnosis of depression, back surgerys, and on and on.

      The problem is that our system has no ONE authority that can tackle this delicate issue. The entire structure of our system has no one to lead.

      Even medicare and medicaid has no single person since the program is ran like this…….congress is made up of 532 people, who vote on the money, then the sec. of HHS runs the program through an agency called the CMS, then the states chime in with their own rules and regulations, then providers get the money for their services.

      Any reform must go through an act of congress. Even a simple raise in the payment for an office visit.

      Without any single authority we get no accountability, except for the profiteers, who manage to get what they want. The congress is not held accountable for the deplorable mess they have created over the decades. Nor are they even held accountable when glaring problems occur, like the reports that Walter Reed Hospital was full of problems.

      What the Europeans have is ONE main authority to run a system and to hold accountable for their actions. We have the congress and state govt. who are really NEVER held accountable for much of anything.

      Yes Bush screwed up big time, and the republicans got booted out, but how often does that happen?

  2. Alison said

    I can honestly say that if I take all my hats off that are related to how I make a living, I think what scares me the most is the ripple effect this is all going to have on our nation, our children, our parents, our deficit, our vulnerablity to those our country owes from all the spending/borrowing. I am sickened and afraid. I feel afraid for our freedom as much as I am worried for the outcome of the way our healthcare is run. I try to stay focused and behave appropriately as to not bring attention and make the delivery of my messages speak louder than the substance of my message, but it is so difficult. I think me screaming from the roof tops allows people to invalidate my message in a convienent way for their use/spin. I question my integrity because of what my profession is and try and stand outside myself to look at all sides, I really do.

    I feel like alot of the emotion expressed under the title of Healthcare Reform is also about all the previous decisions that feel like they were made without me and with an agenda. I think many things have snowballed with our economy to the point where Healthcare Reform is catching alot of emotion from people that is actually from several things (banks, GM, big business, bailout, stimulus, etc) causing the deficit to skyrocket. I feel powerless and my emotions feel out of control too. I personally do not think all of this emotion is from Healthcare Reform and its being delivered by media and others as all being about this and I dont think it all is. The townhall meetings are a collective scream about a series of events not just this. All I can do is check myself and continue to do what I think is right in a way that will be most effective to what I believe is right. To have some integrity and priniciple in my own behavior.

  3. Molehead said

    The problem is both sides Republican and Democrat have been using bureaucracy to accomplish personal goals. The system is corrupted by a bunch of self serving individuals that over the years have banded together serving favors
    back and forth creating a system that is no longer “for the people” but “for those who rule”. This healthcare bill will only give more power to these same people in ways that frankly the public can’t tolerate! Then when the public is screaming loudly to these people, they turn their back and say we are just a bunch of stupid sheep that someone is puppeteering. I quite frankly find this insulting! Below are some things I know about the bill that freak me out:

    – Government audit of the books of all employers that self insure.
    – Healthcare rationing, who will get to rule who gets what, bet it will not be people we vote for!
    – Healthcare being provided to non-US citizens… WHY?
    – National ID Health Care Card (Designed to have our financial and health records)
    – End of Life Counseling…incorporating assisted suicide options (Open door to involuntary assisted suicide)
    – Government has control of life sustaining treatment
    – Government deciding what level of treatment you will have at end of life situations
    – Government control of Marriage & Family Therapy… huh??

    And you wonder why people are upset… hmmm.

    • J Williams said

      You don’t know those things! Those are all BULL! I don’t want full socialism any more than you and you don’t have to worry because human greed will eventually undue any social programs anyway. We do have to gard against dictatorships! Sortive like what insurance companies are becoming, for example when a CEO makes $100,000 per hour! How does that help anyone except for that CEO?? This is the system you like and want to protect?
      I wish I could understand people like you but I can’t begin to understand what you are thinking!

  4. rxvette said

    To all you GOP individuals out there…

    If universal healthcare is so BAD then why is the U.S. the only advanced nation without it? Moreover why hasn’t one single country gone back to a for profit capitalistic private healthcare system and abolished their own universal care system?

    How can you rage against reform because it will “RESTRICT everyone’s choices” and yet you also are against reform because it doesn’t RESTRICT covering abortions?

    If government healthcare is so bad then why aren’t you proposing that we strip veterans of their VA and Tricare benefits? Why don’t you propose stripping the poor of their Medicaid benefits? Why don’t you propose stripping seniors of their Medicare benefits? Why of all people hasn’t one single GOP member voluntarily given up their own government health care benefits package yet? Why haven’t you proposed forcing all the above mentioned individuals into the private health insurance market if government health care is so awful?

    One more thing as ultraconservative as you GOP supporters are why haven’t you advocated one of your core values…. Everyone needs to take personal responsibility for living a perfect healthy lifestyle and eating a perfect diet so we can all reduce long term costs to the health care system?

    I’m a medical professional and would love to hear your answers. Just so you know I’ve actually spent hours researching how to best achieve universal care in America and here is my very well referenced article regarding this –

    • Ron Masters said


      Let me congratulate you on your study of the debate, though I could not disagree more with your conclusions. Of course, not being a clinician, my views are not always taken with the same level of sanctity. But I trust they will at least be viewed with fairness.

      Please allow me to offer my view on some of your assertions. Full disclosure by me here, I have voted Republican, though I consider myself more a conservative than a party line Republican these days. Also, I apologize in advance for my lack of brevity.

      As for the VA and Tricare. Tricare is a model that policymakers should to look to for what works as a public-private sector strategy. Depending upon geographical considerations and availability, Tricare utilizes military medical facilities for some modalities of treatment, physical therapy, x-ray, etc. however commercially available PPO (Preferred Provider Organization)networks or other MCO (Managed Care Organization) models for the professions component. Additionally, Tricare uses private sector Pharmaceutical Managers in most parts of the country in addition to post or base pharmacies. Even with Base Closure and Realignment (BRAC), bases such as Mather, outside Sacramento which has been declassified a U S Air Force “flight” base, some medical facilities remain in operation for the area’s vast military retiree population. A government plan in its entirety no,in financing, partially. Retirees have deductibles and co-payments and as I am told by friends who are retirees, most are satisfied with their coverage.

      As for GOP, other members of Congress and members of the administration giving up their “government program”. It is government in financing only. FEHP, Federal Employees Health Benefit choices are all either private sector commercial insurers, HMOs or Health Care Service Plans or serviced by private insurers or private administrators. So the “government plan” to which you refer is one that our elected officials are not in the least bit desirous of relinquishing for the “Public Plan” being required for we the people in their legislation. It is no wonder they are not including themselves in that language with the myriad of options available to them. Here is a link to the website if you’re interested.

      Medicaid. Finally sir, as a result of two strokes 20 months ago I find myself on MediCal, California’s “designer” version or Medicaid. And I am now investigating how I can use my MediCal healthcare expenditures to secure private health insurance once again.
      During the past 20 months on MediCal the waits for specialists, prescription errors and delays, wrong diagnoses and just plain inferior care has left me not only wanting but placed my health at risk on more than one occasion. Thankfully I understand health care systems and public and private sector financing models, and their peculiarities and foibles since I have spent over 35 years in the insurance industry.
      Had I not known how to save myself and direct my own care through a system that is is overburdened and under staffed I would not be here to participate in this debate today. I cannot imagine what it will be like with more “insureds”place in this system.
      As for insurance companies “killing people”, I am one who was nearly a statistic from MediCal. I contend we will never hear from the MediCal beneficiaries without a background and experience as I.

      Private coverage is cumbersome to be sure, but I’ll gladly be armed with it any day over what the government has shown me.

      Have a good day.

    • Rick said

      “France Fights Universal Care’s High Cost”. Page 1 Wall Street Journal, Friday August 7, 2009. Suggest you read the article. It will explain how difficult it is going from a government run plan to a free market type. Paragraph 3 ” Soaring costs are pushing the French system into crisis”. “The result: As Congress fights over whether America should be more like France, the French government is trying to borrow U.S. tactics”.

    • Nosedoc said

      Rxvette, I believe it is time for you to lose your political innocence. The need for meaningful health care reform is recognized by both parties, the AMA, the insurance industry, the pharmaceutical industry, the hospital associations, etc.–while each interest may have its own self-serving agenda, each recognizes the need for substantive changes to ensure a sustainable outcome. This transcends political affiliation, and is why everyone is “still at the table.” Besides, my take on reading this blog is that the majority of those individuals writing opinions, while perhaps fiscally conservative (in my opinion, fiscally realistic), are otherwise very moderate in political ideology–and we’re also, with few exceptions, refreshingly honest–in sharp contrast with that oft repeated, but always disingenuous “If you like your health plan, you get to keep it.” line that we keep hearing. Not everyone who disagrees with the President, Nancy Pelosi and the other liberal Democrats on a government-run health system is a Republican, just like not every person who disagrees with the NRA or the Pro-life movement is a Democrat.

      Universal health care simply means that everyone is insured, through whatever means are employed to get that way, and does not in any way require the creation of a single payer, government-run entity. The problem is that health insurance, BOTH private and public (yes, that includes Medicare), is presently too costly for our country to afford. This is primarily why we have so many uninsured. Why would a young and healthy adult want to subsidize the health expenses of older Americans (who largely do not live health lifestyles) when the premiums are astronomical and the odds of financially catastrophic illness for these individuals are so low? What kind of impact do you think the cost of health benefits has on our economy? If you were an employer, would you gamble on hiring a larger workforce to expand your enterprise when the costs are so high? Of course not to both. So then doesn’t it follow then that without changing the ground rules under which health care is being delivered and paid for that any mandates to provide and expand coverage would prove to be economically unsustainable and potentially ruinous to our economy?

      If you look (with your eyes wide open) on both sides of the political aisle, you will see the impact of special interests on the decision-making in Washington, often to the detriment to the country and its taxpayers. In the realm of health care, on the side of the Republicans you will see a tremendous amount of influence by “big business” in the form of the private insurers and the pharmaceutical industry. For the Democrats, it is the trial attorneys and to a lesser degree the senior citizens who hold the most influence. The result is our current system, costing twice as much per person as in other developed countries.

      A successful solution, whether in the form of a government “led” (not necessarily administered) single payer system or the insurance coop or exchange system currently in favor in the Senate Finance Committee, requires that the cost of delivering health care in the U.S. be reduced. To accomplish this end, substantive changes in the insurance market and the delivery of health care need to be made. Elimination of unnecessary consumption of goods and services requires the reconstruction of our medical tort system and efficient utilization review to discourage excessive self-referral by practitioners. A mutually-beneficial partnership between the pharmaceutical industry and the public needs to be forged to ensure the availability of new, improved and affordable medications while protecting the ability of these companies to survive (and provide jobs) in the long term. I’ll leave the changes in the insurance sector to Alan and the other qualified insurance experts who help make this blog the tremendous resource it is.

      As for the other advanced nations with universal health care, many of these systems are privately administered–in fact, these are the ones that work the best. As for the public single payer systems, Canada’s and Great Britain’s shortcomings are well documented, and now France in in a huge money crunch with its system ( I firmly believe that if we can put our political agendas aside, we can come up with a uniquely American system of health care, one which combines the efficiency and pursuit of excellence of a well-structured free market system with the liberal heart of a government that cares enough to establish and enforce a set of ground rules that ensure its citizens be cared for and not exploited by its health insurance and health care delivery systems.

    • J Williams said

      Thank you for your comment.
      One thing we know from the Bush administration and is now being highlighted in this healthcare debate is how to know when GOPs are lying. And that is when there are talking!
      The GOP won’t be happy until there is a GOP dictatorship run by themselves and/or a civil war!

  5. Amir said

    Nosedoc, I would like to respond to your comments.

    1) I don’t believe fixing medical liability is easy, I just think it’s necessary. You have to understand the difference between people in academic policy and people in government. My job is to provide the best possible solution, that is attainable, without respect to difficulty of attainment. I might add, however, that if 18/19 industrialized countries have done all the things I am suggesting, clearly they have realized that at some point such reforms are inevitable to financial and health system survival of a country and we will have to get there too.

    I agree that the trial lobby blocks malpractice reform and I think this is a major problem. We don’t have disagreement here.

    2) I think pushing all doctors in hospital-like salaried environments is not a bad idea. As I mentioned on my site, I come from a family of 13 doctors and run all my ideas by them, in addition to the fact that I have worked in hospital environments 3 times, for total time lengths of almost 2 years. I survey and run things by doctors, both inside and outside of my family and inside and outside of America, with intense regularity. My father is a physician who ran a three-office private practice for almost 40 years. Thus, please don’t give me the “I’m a doctor you know nothing and are an academic MBA” because my job is to write about and research my policy views all day and I have a bachelor’s, two master’s, and am applying in the fall for a doctorate to do just that, and at the best programs in the country for each of my graduate disciplines.

    Primary-care practitioners in socialized countries have the know-how to practice sufficient preventative care. All they need to do are the “bread and butter issues”, which even you agree they are fine with. Beyond this, they need to be micromanaged with VERY strong and stringest practice rules and a national code of diagnosis and treatment for the most common conditions that tells them what tests to order and what procedures to undertake.

    As if often true with physicians who don’t want to lose their private practice security (I can only assume you are private practice and if I’m wrong I apologize), you attack these reforms but I go back to my main question:

    If everything I am saying is so unattainable and ridiculous, then why is that all the other 18/19 industrialized countries, when compared to us have:

    -An almost inverted specialist/primary care ratio of care providers
    -Low malpractice
    -40-50% lower per-capita medical costs
    -The same drug provision and device provision needed at lower cost
    -Higher life expectancy
    -Lower infant mortality
    -Lower co-morbidities
    -Leave us in the dust as the 37th country in the world in standard of care
    -Armies of doctors who, amazingly, are still willing to practice and make less mistakes despite American physician assertions that if we move to socialized care, magically every doctor will become an idiot specialist and not know what to do or leave medicine?

    The facts speak for themselves. And it is not public health because we can econometrically show our medical care, mathematically isolated, sucks.

    • Amir said

      I understand…anything other than posts in favor of the current broken system get a thumbs down. I thought this was an open-minded site for meaningful discussion. Apologies and won’t post here again. I’ll keep my comments to my Harvard/Wharton colleagues who, obviously in the view of people on this site, are idiots despite their MDs and PhDs in economics and policy and their views that our system should more closely model Europe and Scandinavia.

      Sorry for wasting your time. Keep thinking our broken system will work and our $13 trillion debt + $500 billion deficit won’t bankrupt America and give money to special interests at the expense of the middle class having reasonable, sustainable care and social services.

      United States isn’t even top 10 in WHO/UN scale for quality of life. Enjoy the system you support.



      • Ron Masters said


        So sorry you wish to leave the debate. You make some valid points, but your read on many of the participants is incorrect, I believe.
        Most want reform, but not necessarily what is framed in the misguided legisaltive initiatives brought forth to date.
        You have offered the need for malpractice reform, to which all would agree.
        As an academic, your background and that of your family is valuable as a backdrop for your findings. Yet,regardless the number of years or interviews you have conducted the conclusions you have reached should always be subjected to the microscope of differing views.
        Our system needs change, but at what cost and how can it best be achived? Have you and/or your collegues put such a change through financial models to evalute the effect on an economy already in crisis?
        The effect on 1/6 of tne county’s mostly private sector health care spending, moving with speed of free market slowing to the crawl of goverment bureuacracy?
        Just wondering.

        • Amir said


          Let me be very clear on a few things:

          1) I DO NOT, actually ABSOLUTELY DO NOT, support ANY of the current legislation or reform objectives being articulated by either of the two major parties right now. In fact, on my website you will see an extensive critique of the Obama plan in which I give it a C-.

          2) I am not an administration sycophant, nor even a Democrat. I am not registered to a party but come from a family proscribing mostly to Socialist viewpoints, as they are executed properly in Europe and Scandinavia. I agree that those countries are not perfect either, but they, in my opinion, do a much better job of meeting a higher per-capita, median standard of living and services for society.

          For me, the health of a society is the health of the middle class. I worked on Wall Street and in banking in Goldman Sachs, in fact covering and arranging many of the biggest insurance mergers in U.S. history. My undergrad training is in finance, but I am also extensively studied in finance, economics, accounting, epidemiology, public health, statistics, public health, health policy and comparative health systems.

          I believe I am qualified from experience to say that we do a very poor job of accounting for average societal well-being in America. America is a system designed to squeeze as much out of the middle and lower classes as possible without destroying them to enable as much well-being for the top 5% as possible.

          3) People have a misguided view of social welfare. The view of the individual who sits on their ass and just gets benefits from the government is not supported by facts. 80% of people without healthcare work. 90%+ of people on welfare have made an earnest effort to look for work in the past 6 months. America is a country of people, mostly, who make an honest effort to try to make it, but, as opposed to other industrialized countries, the system is ruthlessly organized to try to make them fail.

          4) I always encourage disagreement and open debate. Many of my professional and academic colleagues are ardently conservative. It is the quality and nature of debate I can get frustrated with. Debate should be based on research, statistics and information. Debates based on emotion, anecdotal information or personal desire for selfish enrichment are not good debates.

          5) Many studies have been done on major transformations of nations in crisis. The crisis was called World War 2 and the major change was all other industrialized countries, whose systems of socialized care and other benefits such as education reform date back to the 1940s or earlier. The NHS in England, the care structure in France and the other notable examples WERE crafted during periods of crisis, because it is during periods of crisis that the biggest changes are changed.

          6) AGAIN – the proposed administration/legislative from Democrats suck and are not those changes. I describe why on my site.

          7) I have never disagreed that private —> public transition does not cause some bureaucracy. However, the question is what the goal is. For what people with for-profit orientation argue is bureaucracy, I argue the entire private insurance industry and much of the profits of the drug/device industries are total waste given to special interests that are not needed.

          If up to me and most economists I know, the private insurance industry should disappear except for provision of supplemental private insurance, a niche market. Yes, I know people working in insurance don’t like this, but it’s necessary.

          I know doctors will lose salary levels. I know corporations and affluent, special interests don’t like this.

          8) The current system is a pipe dream. When you spend double other countries per-capita, when you are 37th in medical care and when you have a country with a bankrupting level of macroeconomic debt, you can’t change the system.

          I have taken, at this point, almost 20 classes in economics. I have studied with people who won or were nominated for the Nobel Prize. I understand economics. And the economics people want to sustain with a for-profit bias do not work.

          All the other industrialized countries have shifted to socialized systems because they know they have to to continue. Below, an Op-ED I sent to the New York Times on this point:


          The Economic Sphinx’s Important Riddle
          By: Amir Satvat

          The Economic Sphinx has an important riddle for its captive audience of intellectual Oedipi:

          “What is brown in the morning, green in the afternoon and red in the evening?”

          The answer: an economy.

          Conventional economic thinking has long accepted the existence of two very broad phases in an economic life-cycle. There is, however, a third phase, the acceptance of which is lacking and very important to the survival of America and the world.

          In the “morning” of an economic life-cycle, undeveloped countries typically begin in a relatively crude, labor-intensive agrarian form. These countries are “brown” with the fruits of tilled fields and low-tech industries. Capital, if present in any form, is little utilized or for basic chore substitution. Most individuals in such societies live on low-wage self-sufficiency.

          In the “afternoon” of an economic life-cycle, countries enter a stage of development, the sub-classifications of which are numerous. However, this phase can be simplified to a “green” phase in which industrialization and capital flourish. As opposed to an agrarian phase, governmental involvement in such societies increases as capital markets, taxation and regulation are needed.

          In the history of industrialization, the governmental role in the fastest growing economies has been to provide just enough oversight to remove disorder without slowing down growth. However, of particular relevance to current conditions in the United States, I believe there is a third phase in the economic life-cycle which most do not properly consider.

          In the “evening” of an economic life-cycle, mature industrialized countries hit a steady-state of development at which GDP growth starts to stagnate and can no longer boom at previous rates, a rate reasonably pegged at sustained growth lower than 4%. Why is this the “red” phase? This is the stage in which nations that continue to thrive, in providing a quality standard of living for their whole populations, realize that an embrace of a socialist-based economic system is essential for survival.

          Most industrialized countries in this steady-state stage of growth, including Canada, the European Union, Scandinavia and Japan have realized something that Americans refuse to accept: you can only push the economic mule so far before it needs a rest.

          In the first stage of the economic cycle, capital accumulation and distribution mechanisms need little regulation so that such practices can spread across a society and lead to a middle class and a broad capital base.

          In the second stage of the economic cycle, rules and regulations are a system of seemingly paper-thin checks and balances that allow the capitalistic engine to drive growth as far as possible.

          In third stage of the economic cycle, nations need accountability to the working classes that drove their progress, not just out of a sense of moral righteousness, but also for their own survival. America should look at other, older industrialized countries for these truths and a vision of the future.

          As economies grow out of an agrarian state, rates of childbirth typically decline. The number of workers supporting each retiree decreases. Also, as every economist or financier knows, expectation for future growth decline, meaning that filling funding holes for social welfare through gains in equity becomes more difficult.

          Finally, and most importantly, as countries become more industrialized, the increasing sophistication of capital allocations and gains means that the importance and value placed on industrial workers decreases and wealth goes to the hands of the elite few.

          Other countries have realized that an economy, and the nation it is attached to, needs a red twilight if it is to receive a happy “retirement”. Steady-state industrial countries that have made a shift to a high system of taxation, nationalized healthcare, nationalized education and systems of pension and social reward have seen rewards for their actions as sustaining benefits for the elderly and working masses have created a sense of class preservation.

          As long as America believes there are only two fundamental economic life-cycles, it will continue to attempt life as a “green” stage industrialized economy and fail the Sphinx’s riddle, putting our country’s future and sustainability in jeopardy.

        • Amir said

          🙂 Please more “thumbs down” ratings. I know my comment wasn’t:

          “No matter what logic and 95% of economists agree on, the insurance industry should get whatever it wants because that is what makes sense and we should preserve an industry that is a broken model. Anything other than comments supporting private insurance gets a thumbs down”

          I think I nailed it.

          More thumbs down ratings please…I really give zero value to how you rate me 🙂



    • Nosedoc said

      Amir, I’ve done enough writing for today, so I’ll keep this brief. Most people participating on this blog, myself included, are in favor of substantive changes to our health care insurance and delivery systems. In fact, I agree with you on the vast majority of your observations and opinions on our current health care state of affairs. I even agree that mean physician incomes will go down with a repaired system under any number of scenarios, but not necessarily median incomes. And, by the way, I am a private practitioner. What gets my juices flowing is to hear you say in a fairly “as a matter of fact” way that the medical tort system needs to be fixed–this needs to be said loud and clear! It needs to be shouted, complete with the objective supporting data, that any reforms are doomed to fail without the elimination of the practice of defensive medicine. When it’s only the doctors and Republicans saying it, it’s easy for the Democrats to ignore. When non-partisan experts on the subject are saying it, and also directing attention to the amounts of PAC dollars being paid by the trial lawyers’ lobby into Democratic coffers, then maybe the public at-large will listen and start demanding these changes from their legislators. In making your recommendations, you need to acknowledge political realities and make provisions for them.

      • Amir said


        I misjudged you and I’m sorry I did.

        The fairness of what you say is reasonable and acceptable.

        As you have pointed out, I am bound to no politician, bill or platform currently or ever being proposed. I am after ideas and I give points where they are due.

        I think almost every party involved in the policy reform discussion, from academics, to lawyers, to doctors, to the AMA, to citizens, etc, are culpable in some way. I don’t see this as partisan. I agree with liberal and conservative-based concepts on how to fix the problem.

        However, as I have pointed out, with the weaknesses that do exist, I believe other countries have fundamentally socialist-oriented systems of organization and they do so with better results and less problems than those faced in America.

        Your post on needing to eliminate costs under any system is an excellent one. The systems in all these countries are bloated, but it’s all about relative bloating.

        As I have said on my site, I believe five issues are the essential starter for any reform. You will see that some are liberal, some are not, and each touches or targets different special interests. I am for what makes sense and I appreciate that you can see this.

        Those points are (verbatim from my site):

        1. Payment Structure
        The two choices in health payment structure are single-payer or multi-payer. Single-payer systems push all health funding out of one party: the government. As a result, multiple insurance companies are eliminated, except for those offering private supplementary insurance for the affluent, which serve a niche function and are of no bother to efficiency. The elimination of these multiple insurers and their wasted spending and overhead could save the American health system as much as $300 billion a year, paying for Universal Coverage for the 50 million uninsured Americans in our country by 1.5 to 2.0 times in just one fiscal year.

        Single payer also gives the government enormous leverage over drug and device companies. By serving as the only entity paying for their products, the government decide which products are reimbursable for treatment. This significantly lowers prices for consumers and discourages drug and device companies form manufacturing copycat products with insignificantly improved efficacy.

        2. Universality of Care / Coverage
        Universality of care and coverage ties in to payment structure. Ultimately, the goal of health policy is to cover every man, woman and child, something that every industrialized country other than America does. It is very hard to ensure true universality of coverage without a single payer system. This is because under multi-payer systems, payers are private and try to find reasons to exclude sick patients, which they callously term “bad risks” or people with “pre-existing conditions”.

        In insurance, the technical term for every dollar spent on care for patients is actually known as a “Medical Loss Ratio” , or “MLR”. Patients are a loss to insurance companies and that is how private insurers/payers view the general public.

        Under single payer, the government writes all checks and not only guarantees service for everybody but, also, holds back on unnecessary treatments that currently waste money in our system.

        3. Tort/Malpractice Reform
        The unwillingness of the Executive and Legislative branches of our government to work on malpractice reform is handicapping our health system. While there is no question that, to some extent, care providers order unnecessary procedures and tests to generate income, it has been studied that the supermajority of excess medical treatments are ordered due to provider fears of legal repercussion.

        The total direct and indirect effects of defense medicine on our health system have been estimated at anywhere from 5-20% of total costs.

        Whether you look at extreme examples such as Nassau County, Long Island, where OB-GYNs are strangled with malpractice bills well over $200,000, or more mainstream examples, such as doctors in community hospitals who overload on diagnostic work, the primary and secondary effects of lawsuit fears are tremendous.

        This is a hard issue to move on because of the close love between legislators, their legal colleagues and the ABA, but it is an essential part of true health reform that is, unfortunately, seemingly off the table and never mentioned by the President or those in Congress.

        4. Trust Fund / Tax Issues
        There is not enough money in the coffers to fund our current system of healthcare or the Medicare trust fund. I raise this point in this manner because, often, people reject the prospect of tax increases because they don’t want to pay for EXPANSIONS of care or MORE care. I am merely talking about our existing system. We need a 4-6% tax increase on the top 5% of income earners just to sustain our current system and for America to not go bankrupt. I actually believe, in the long-term, that Universal Healthcare will pay for itself. We do need more money for healthcare and for Universal Healthcare, but we would need that same amount of money right now, even if nothing changed. A 5% tax increase would be needed for the current system too, not just for Universal Healthcare.

        5. Primary/Specialty Care Balance
        All other industrialized countries have a primary/specialty care balance in a ratio of 3/1 respectively. In America, the care ratio is 1/3. Specialists cost more money and do not provide enough front-line support for basic preventative care and initial examinations. In socialized countries, there is a much heavier reliance on nurse practitioners, midwives, and physician’s assistants. Furthermore, a much higher ratio of primary care doctors to population are allowed to graduate. Adding care for 50 million people will require much more primary care. Again, however, even under our current system, numerous studies show that we would have better care outcomes, and much lower costs, if we loaded up on lower-paid primary care providers instead of relying on a system filled 75% with much higher-paid specialists.

        As an example of the excess costs created by a high specialist-ratio system of care providers, a New England Journal of Medicine study found that, on average, specialists earned as much as 25% more than their primary care counterparts for performing medically equivalent services that took the same amount of time and had statistically similar medical outcomes. This is wasted cost that could be eliminated.

  6. I believe that some of these protests are orchestrated events, but I also think that there is a lot of frustration among the American people. I can understand this level of frustration when you look at the track record of the people in Washington that have been making decisions. How can they tell people that they are going to get this right with so many failures behind them. Fear and frustration make it easier for these organizers to pull this off. If politicians were spending more time giving specifics (not self serving soundbites) on how this has going to benefit the majority of Americans it would be more difficult for these organizers to succeed.

  7. Amir said

    Very interest post and comments. I have written up many of these ideas on my site about health reform and I think anybody interest in this blog will find the information there very salient. Many of the ideas are things I am studying right now at The Wharton School as an MBA, although I combine thoughts as a practitioner in industry as well.

    Please do check it out!

    All ad profits go to fight ulcerative colitis!



    • Nosedoc said

      Amir, I don’t know what this plug for your own web site has to do with the topic of civility (or lack thereof) at Town Hall meetings or the proper way for constituents to express themselves to their legislators.

      However, I read some the assertions on your site. You make it sound like fixing the medical liability aspects of our health system is an easily-achieved element of the bigger picture health care reform. It is not. The Democratic Party is essentially controlled by the ATLA, the lobbying group for the trial attorneys. In 2003, there was a major push for federal tort reform that was unsuccessful, and that was with a Republican in the White House and a non-filibuster-proof Republican majority in Congress. As long as this is the case, i.e, as long as the PAC dollars in favor of maintaining our medical tort system dwarfs those in favor of reform, nothing will change. I suspect that increasing liability premiums coupled with inflation and other increases in practice overhead, accompanied by reduced revenues through a government-run, single payer system, not to mention the array of unfunded mandates (ADA, HIPAA, Red Flag rules, translator requirements, etc.) which medical practices must conform with, would push many if not all medical/surgical practitioners to the point at which the private practices close, and the practitioners, because their services are still very much in demand, will look for employment through larger institutions like hospitals and no longer function as independent contractors. This could involve unionization as well. Obtaining adequate reimbursement for medical services and paying for liability insurance then becomes the problem of the employers, which at some point would have the financial/political clout to overpower that of the attorneys. Until the liability system is fixed, defensive medicine will remain a financial drain on health care and our economy.

      MBA-types also have this notion that primary care practitioners have the know-how to provide cost-effective care. The truth is that you haven’t the slightest idea of what goes on in clinical practice. When it comes to bread and butter medical issues like hypertension and uncomplicated Type 2 diabetes management, the generalists are fine. Get out to the frontiers of their knowledge base, and things get very sketchy–there are a lot of incorrect diagnoses being made, unnecessary tests being ordered, and inappropriate treatments being employed. Sadly, phone calls to specialists for advice on patient management are rare, either because of time constraints or because there is no capacity to inquire on the part of the generalist.

      • Ron Masters said

        Thank you Doctor.

        The cost of defensive medicine on our system is most likely impossible to measure. Though as far back as the 1980’s, Joseph Califono, former Secretary of HEW (now HHS)estimated the cost of defensive medicine to be as much as 18% or the nation’s health care costs.
        Should that percentage be applied to the 2007 spending for health care of $2.1 trillion, a figure supplied by the Office of the Actuary of the CMS, a savings of $368 billion could have been realized.
        Of course not being a clinician, I’m not as intimate with the problem as you. However, I have been speaking on health insurance and health care reform for the past 22 years and malpractice reform has been at the core of the issues presented.
        Once again, thank you for the wisdom your post represents on the subject.

  8. Rick said

    Alan, you have a great blog! However, I disagree with your statement that the tactics are orchestrated. It’s obvious these people are legitimate. The most skilled Holloywood actor could not perform the way these people are. Regarding “Right”, (Which I never heard of) no firm has power of this magnitude to influence this amount of people.

    Some Democrats carped about how good these people are dressed. I see, by their dress, that these are the bill payers of this country, and not the usual type of protestor.

    • Alan said

      I agree that many in the audience are sincere and said so in the original post. That doesn’t mean there’s not political organizations supporting and supplementing this genuine expression of frustration and anger. Nor does it excuse the behavior of these individuals. Whether they pay bills or not, shutting down a meeting aimed at discussing substantive issues is wrong. Threatening elected officials is wrong. Anger does not have to be destructive, quite the contrary. It can be channelled into productive action. March in the streets. Send letters to newspapers. Hold rallies. But comparing the president to Hitler, hanging lawmakers in effigy, preventing presenters from speaking, yelling “liar” at someone saying something which which you disagree is wrong. It’s undemocratic. It undermines one’s own position and it will not get us health care reform that works.

      Personally I find this situation frightening. If America’s ability to have civil discourse crumbles, the results will be catastrophic. When George Bush became president, many on the left felt as strongly as those on the right do today that the constitution was being violated, his policies were dangerous and the country was being weakened. But debate continued. That wasn’t because they were liberals and these were conservatives. If Sarah Palin were elected in 2012 the left would be behaving like the right is today. What seems to be happening is that we as a people are more tolerant of what had been unacceptable. I don’t know if it’s the accumulation of ugly rhetoric from the Rush Limbaugh’s and Glenn Beck’s of the world, a fear of change, or the fallout of an insecure economy, but I’m amazed at the lack of outrage at the outrageous behavior of some of these folks. Yes, they are sincere. Yes, they are angry. More importantly, they are Americans. And in America we don’t stifle debate we encourage it. We engage it. And we tolerate those who disagree with us. Sadly, not all of us do anymore.

      • Rick said

        I agree with much of what you said. I also feel buried anger for how disgraceful the Democrats treated the past administration for the previous 8 years has something to do with it.

        I must say the situation is frightening, more so for me, because it appears to be coming from the people that pay the government’s bills.

      • The biggest problem here is that what President Obama’s is campaigning for is not what is outlined in the proposed legislation. This creates a huge mistrust in the voters. So much for transparency. And then you have Nancy Pelosi, the President and others saying: We will have a bill!, It will pass! So naturally, people feel frustrated and hopeless because they feel powerless, especially when it concerns the health and well being of their loved ones. Yes, it does not excuse their behavior but it would have been so much better had the President been more realistic about the ramifications of the bill instead of trying to sugar coat everything and then insisting that it will pass despite what others may do or say. He says we “need it” and the reality is that many people feel that we do not need it at this time with a failing economy. In the scriptures, we can find old age wisdom- “by small and simple things great things come to pass”. We don’t need a radical overhaul of the system. However, to implement a few small and simple changes into our health care system would be to change our course. Hence, the rudder is the smallest part of the boat but determines the direction it heads. We have elected govt. officials, insurance companies, hospitals, doctors, and the pharmaceutical companies at the table with solutions. We need to capitalize on this energy in order to change our course or we headed towards the titanic.

  9. Meg McComb said

    Why can’t anyone believe that some Americans have just had it and are expressing their true frustrations at these town hall meetings? Yes, some protesters may have been misled/manipulated by special interest groups….However, I choose to believe that in the America where I proudly live people still have freedom to let others know when they’re upset–especially when they feel that Washington bureaucrats are just pretending to listen.

  10. Ron Masters said


    Yes the debate needs some civility. However, do we not have to give some thought to what motivates those “mobs” (media words)of angry senior citizens and common Americans that become unruly. And by motivate I don’t mean the few that have been singled as being organized by either side, far right groups or on the other, SEIU and ACORN. Could it possibly a combination of the the lack of transparency of the current administration and passion that is created when anyone fears their health care is in jeopardy.

    For an administration that had described itself as one that would bring transparency to government it ha failed to just that. I won’t go into specifics but you and others will know to what I am referring.

    I submit that should civil discourse be a goal, and it should, then transparency needs to be one of the guiding principals to achieve it. It’s all about the trust. It’s said that when trust is lost, it is slow to return. Well, Washington, you are now experiencing what distrust has garnered. It’s not pretty is it?.

    On the other hand, Americans have proven to be fair if they feet they are being dealt with by a government that is open and listens. If, however, the feeling is their representatives, be they the members of Congress, the President and administration are viewed to be taking them as fools, incapable of “understanding” what is good or bad for them in any matter, frustration arises and what should be civil turns just the opposite.

    So, I say, if civil discourse is what our leaders want and IS what they will respect, without calling the valid questions from Americans “mob like” or “planted”, then our Representatives need to learn once again how to represent us.

    Mr. President, members of the administration, members of Congress and other policymakers, lead by example. Tell us all the facts, not just what you “think we will understand”. Give this issue some time, in the light of day, to bring about meaningful reform, not a rush job for some ideological or political reason. If Town Hall’s are your desired venue, then send out spokesmen that know current reforms offered and don’t tell us that is that it is too complicated to understand. The American people are more informed that ever before.

    I guess maybe it’s difficult for members of Congress and the administration to explain a health plan that is so very different than they believe they themselves will ever be enrolled in.

    If it’s yours, wouldn’t you study it more? The American people sure have.

  11. dman said

    I always find it interesting that opponents to health care reform argue that it will be the “death to all of us” or “it will restrict our choices” or “medical decisions will be made by bureaucrats”.

    It is the current unregulated capitalistic private insurance companies who are actually fulfilling their worst nightmare right now. “Death to us all” – private insurance companies are literally killing patients right now by denying lifesaving care like in the case of Cigna’s denial of Natalie Sarkisyan’s care.

    “It will restrict our choices” which is exactly what our private insurers are doing. I have private coverage myself as a medical professional through my hospital who employs me. I’m restricted to a list of doctors I can see and also to only 4 hospitals in the local Tampa Bay area and if I seek medical care outside of this my insurer will put a majority of the financial cost on me so if I want somewhat affordable medical care I’m forced into their restrictive measures.

    “Medical decisions will be made by bureaucrats” – in the private insurance market medical decisions aren’t made by myself or my doctor but rather by bureaucrats (executives and internal business analysts) from my private insurers when they decide what is covered and what is not.

    Healthcare reform would put a stop to all this and I’ve actually researched for hours on what the best way to achieve this is. Here’s my solutions –

    • Doug said

      I would rather take my chances with an insurance company any day over a bureaucrat in Washington. The “public option” will lead to a single payer system. Do not listen to me listen to the president ( ) Just look at Britain and Canada. Any questions watch John Stossel’s 20/20 report ( ).

      The federal government is running broke on Social Security, Medicare, and Medicaid. Why would we have faith that they can run approximately 20% of the US economy?

      • dman said

        We will certainly just have to agree to disagree on this. The private market has failed miserably in providing affordable access to quality care. And I would love to have a system like Canada or Britian’s. I’ve actually read about and talked to both Canadians and Britians and the exact feelings from them are they wouldn’t give up their healthcare system for the U.S. system no matter what.

    • J Williams said

      First I believe its moral to want every citizen to have health care. I believe some people are born with morals and some are not. The ones who are not, some of which go and get morals at places like churchs, law inforcement, etc.
      Second, I believe the middle class is not natural(a given) and if neglicted it will go away. Is that what we want America?
      Third, people think in different ways: linear and global, for examples. In otherwords you may have advanced degrees from ivy league universities but not have any creativity.
      I believe Americas biggest problem is unbriddled greed! For example I believe that we(America) could be running soley on solar power years ago but oil special interests killed the research long ago. Just now is it being allowed to gain a foot hold.

      Good Luck Everybody

  12. Alison said

    I agree completely and at the same time feel as if I am being run over by a train that I have no way of stopping. The feeling of powerlessness leads to wanting to speak louder to be heard. I believe there are many people who feel passionate about their views including me. I do believe we hinder ourselves my letting our actions speak louder than our messages. Point taken. I feel the frustration and understand it.

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