Excuse me, but I have a few questions…

If you’re like me, you have been over-saturated with news stories about health care reform. Many of these stories contradict each other, some contain wild exaggerations both pro and con, and some are merely spin doctoring in its purest form. How are we supposed to take all this in? Well, we can start by breaking it down into small chunks and by asking questions.

Who are the uninsured, anyway?

First, let’s look at the center of the whole debate: the uninsured in the United States. Who are they, exactly? The Census Bureau[i] can tell us: The number of people who were uninsured at least part of the year in 2007 was 45.7 million[ii]. That’s a big number. This is the crisis we keep hearing about, the growing avalanche of uninsured.

This 45.7 million represents about 15.3% of the total U.S. population. So what was the percentage back in 1992? Surely it wasn’t as high?

It was 15%. Same as now. In fact, since 1987, the percentage of uninsured in the last 20 years has fluctuated between 14% and 16%[iii].

The total number has grown, true, because our population has grown. But the percentage has remained more or less stable. In fact, the number of uninsured actually dropped from 2006 to 2007, from 15.8% to 15.3%.

So I’m not entirely convinced we have a “crisis.” I think we have a problem that needs to be looked at, but it’s a problem we’ve had for a while and not a dire crisis promising the end of the world if we don’t act right now.

And of these people who are uninsured: they are all poverty-stricken, correct? That’s why they cannot afford insurance? Not exactly.

There are approximately 116,011,000 households in the U.S.[iv] We can divide those American households into 4 income groups:

$0 – $25,000    (29,306,000 households)

24.5% of the people in this group are uninsured

$25,001 – $50,000   (30,279,000 households)

21.1% of the people in this group are uninsured

$50,001 – $75,000   (21,150,000 households)

14.5% of the people in this group are uninsured

Over $75,000      (35,276,000 households)

7.8% of the people in this group are uninsured[v]

Isn’t it a little surprising that 14.5% of the people in households earning over $50,000 are uninsured? Or that 7.8% of the people in households earning over $75,000 are uninsured? There could be many reasons for this, but the point is that the typical image of the uninsured living in dire poverty needs to be re-examined.

The people pushing hardest for universal health care on the moral ground of helping the poor aren’t giving us all the facts. I, for one, want to know if I’m going to be taxed to provide health care for not only the poor, but also the millions of uninsured living in households making more money than mine. Just what is the plan?

What about the uninsured and illegal immigrants?

We know that the percentage of uninsured in this country, over the last 20 years, has remained relatively stable at 15% (on average). But we also, in the last 20 years, have been flooded with illegal immigration.

A few things should be pointed out here:

1)      It is estimated that 65% of illegals are uninsured.[vi]

2)      We have nearly 12 million illegal immigrants in the country now.[vii]

3)      Some people estimate that illegals represent 12.5 to 25% of the uninsured population, and up to 59% of the growth in actual numbers of uninsured can be accounted by illegal immigration. [viii] [ix]

So, in other words, we have been taking a garden hose to the pool of uninsured and filling it up with millions of illegal immigrants. Yet the pool isn’t growing. It remains steady at 15% of the population. If you could wave a magic wand and remove all the illegal immigrant uninsureds, wouldn’t that percentage drop?

Of course it would. If the official number of uninsured in this country did not take into account the influx of uninsured illegal immigrants, we would find that the number of uninsured Americans would be dropping as a percentage of the total population.

Now, I’m quite aware that the bare mention of “illegal immigrants” causes a firestorm of controversy. So let’s just look at it another way. We’ll take the “illegal” part away and just examine the impact of immigration as a whole on the uninsured population.

Here are the findings:

1)      Between 1994 and 1998, immigration accounted for 43% of the growth of the uninsured.[x]

2)      Between 1998 and 2003, immigration accounted for 92% of the growth of the uninsured.[xi]

3)      Overall, between 1994 and 2006, immigration accounted for 55% of the growth of the uninsured.[xii]

So what’s the true “crisis” here? An increasing percentage of Americans who cannot afford insurance, or a health care system flooded with uninsured patients from outside the U.S?  Isn’t uncontrolled immigration the main source of the health care crisis? I’m just asking here, because I rarely hear any mention of this in the news.

I remember back in 2005 when President Bush decided to help states pay for the costs of treating uninsured illegal immigrants. The federal government divided $1 billion among the 50 states. That’s a lot of money. But it wasn’t even close to covering the costs.

For example, California received as its share $70.8 million from the federal government, but its actual costs were (at that time) over $500 million yearly[xiii]. In 2005, over 50% of the uninsured patients in Los Angeles County were illegal immigrants[xiv]. It cost each taxpayer there $1,000.00 yearly to foot the $340 million bill for the uninsured, meaning of course that the bill was double what it should have been[xv].

Now the federal government is running around and telling us taxpayers we need to cough up more money to cover the uninsured and solve the health care crisis. Well, before I’m asked to fork over more money, I want to know a little more about the uninsured and just whom we plan to cover. And that’s all I’ll say on that.

Our health care system is wasteful and inefficient?

In all the articles I read about health care reform I see references to inefficiency and waste. It is “plagued by substantial inefficiencies and waste,”[xvi] or “our doctors and hospitals are failing to provide us with care we need while delivering a staggering amount that we don’t need,”[xvii] or “..one recent study found that due to inefficiencies and the lack of clear standards, patients had just a 50-50 chance of receiving flu shots, aspirin or beta-blockers…and other treatments that were shown to improve health,”[xviii] or “America has ended up with the Hummer of health care systems: big, costly and inefficient.” [xix]

OK, I get it. Our health care system is inefficient. But the next part bothers me. That’s when these writers hold up the Mayo Clinic and Cleveland Clinic as examples of how things should be.

Writers like Patricia Barry,[xx] Shannon Brownlee,[xxi] Karen Tumulty,[xxii] Alice Park,[xxiii] and Michael Grunwald[xxiv] have all touted how wonderfully these two institutions run their business. According to them, the Mayo Clinic provides “tremendous value for ordinary care,”[xxv] the Cleveland Clinic “might just be the future of American medicine,[xxvi] and both are “a model out there for how to do things right.”[xxvii]

Even the President talks about the Mayo Clinic and the Cleveland Clinic, asking the question, “We should ask why places like the Mayo Clinic in Minnesota, the Cleveland Clinic in Ohio, and other institutions can offer the highest quality care at costs well below the national average.”[xxviii]

Well, let’s look at these two models.

The Mayo clinic, to keep costs down, has its doctors work on a fixed salary, consolidates care to avoid unnecessary duplication, and relies on what it calls “evidence-based medicine.”[xxix] This keeps costs down and allows it to charge patients less.

That is, if you are a Medicare patient. If you are on Medicare and go to the Mayo Clinic, you get cheap, top-notch care. But here’s the kicker (of the writers above only Michael Grunwald pointed this out), the Mayo Clinic loses money on Medicare patients. In fact, it lost $840 million on $1.7 billion worth of Medicare work.

So how does the Mayo Clinic make up that $840 million deficit? After all, it can’t run at a loss. Easy. It gouges its other patients, the ones with private insurance.  Here is how Michael Grunwald put it: “It [Mayo] compensated by charging private insurers a premium for the Mayo name, but they’re starting to balk.”[xxx]

Starting to balk? Are you kidding me? I would think the private insurers would be screaming bloody murder!

So let’s get this straight: the Mayo Clinic gives top-notch, cheap care to the Medicare patients, and to make up for the money it loses it overcharges the private patients. How is that a workable business model? It can’t be. Even Grunwald states: “That’s the bad news about Mayo’s success: it’s not sustainable.”[xxxi]

Well, what about the Cleveland Clinic? They also have a business model designed to keep its costs down. It works like this: Just hire healthy people. They don’t get sick as much and therefore use less health care, resulting in lower premiums to pay.

As explained by writer Alice Park, Cleveland Clinic made the decision to not hire smokers and thus reduce its insurance premiums.[xxxii] The clinic happens to be Cleveland’s largest employer, so it wasn’t a small impact. The clinic’s CEO said about the policy he implemented, “I had to fight everybody, including human resources. But this sends a message. It’s perfectly legal. It’s as much symbolic for the community as for the organization.”[xxxiii]

Sure, that’s certainly symbolic. About as symbolic as that now infamous Wal-Mart memo. Remember that? That was the 2005 memo that Susan Chambers, who was then Wal-Mart’s executive vice president for benefits, wrote discussing several “bold” moves Wal-Mart could make to “dissuade unhealthy people from coming to work at Wal-Mart.”[xxxiv]

Nice. So seriously, is this really another workable business model? Just hire the healthiest people to drive down your premium costs? What happens to the rest of us deemed too unhealthy to hire? Or worse, what if you are hired healthy, but end up getting sick? Are you targeted for lay-offs?

I mean, come on. Can you envision the job interview questions? Do you smoke? Drink? Does cancer run in your family? How overweight are you, anyway? Do you play in traffic? Yes? Can’t hire you. Next…

I guess if I ever had a chance to answer President Obama’s question, I’d answer it this way: Mr. President, the Mayo Clinic undercharges Medicare patients and makes private insurers subsidize the losses, and the Cleveland Clinic cherry-picks the healthiest employees. That is how they offer the highest quality care at costs well below the national average. Design a national health plan around those two business models and you’re good to go. Or not.

Paying for health care reform?

In this health care reform debate numbers get thrown around like handfuls of confetti. Any number you care to come up with I can counter with another. So I’m going to avoid being specific here, and work with a range.

Here’s the range: $1 to $2 trillion over 10 years.

I know that’s quite a range, but between those two numbers fall just about everyone’s estimates. What is vehemently disagreed over is just what result that kind of money will actually buy. (And by the way, just so we know, a trillion is 1,000 billion.)

But for now let’s stick with discussing the cost of health care reform. Who’s going to pay for this? We are, of course. No matter how it is presented, the bill will settle onto the taxpayers. So I want to get some idea of what I might be paying each year. Easy, right? Divide the total number of people into the cost and get the share we each pay. Just like dividing up a dinner check.

Unfortunately, it doesn’t work that way.

Here’s why. First, we have to find the number of people who pay taxes. The Census Bureau tells us there were 138,894,000 individual tax returns in 2007.[xxxv] But according to the Tax Foundation, about a third of tax filers end up paying no taxes because of low income or credits and deductions.[xxxvi] That figure came from 2004, so let’s be conservative here and only deduct 28% as non-payers. That means we have 100,000,000 taxpayers in the U.S. (isn’t that nice how I worked it out to a nice even number?).

OK, with the burden of cost shifted to 100,000,000 taxpayers, that means a $1 trillion health care reform cost comes out to $10,000 for each taxpayer spread over 10 years. A $2 billion cost comes out to $20,000 spread over 10 years. So remember:  a $1 trillion plan means you will pay $1,000.00 extra each year in taxes for ten years. A $2 billion plan means you will pay $2,000.00 extra in taxes each year for ten years.

Simple, right? I only wanted to get a basic grasp of what this reform is going to cost me. Now I have a quick way to figure it out when all these huge numbers start getting thrown around.

(Even from here I can hear the economists gnashing their teeth and screaming that the numbers are not right. They’ll want to talk about GDP and inflation and adjusted gross incomes and so on and so forth until your eyes glaze over. Whatever. These economists, in my view, are part of the problem. Put 50 economists together and see if any four agree about something.)

As I said before, I am assuming that the main burden of the health-reform cost is going to fall on us taxpayers. I don’t think I’m wrong here, but there have been other ideas tossed around. There has been talk about raising the tax on alcohol, sugary drinks, tobacco, and eliminating the tax credit for insurance premiums for businesses.[xxxvii] But the biggest proposal is to tax workers for health care benefits they receive.[xxxviii] This is the big one, and it’s almost certain to go that way. There’ll be other little revenue generators, but the bulk of health care reform cost will be strapped onto us workers.

Why? Because that is where the money is. Experts who looked into it say the Treasury Department can raise $300 billion in taxes that way.[xxxix] When John McCain was running for President, he claimed that taxing health-care benefits would raise $3.6 trillion over 10 years, more than enough to pay for even the highest estimate of health-care reform.[xl]

(Remember the formula I gave you: you just heard $3.6 trillion, so you should be thinking $3,600 in extra taxes each year for ten years).

However, even if health insurance benefits are not taxed directly, we will still get the bill in the form of an increased federal budget deficit. But the real problem will not be the projected cost estimates. As of now, lawmakers are claiming they found a way to stay under the $1 trillion ceiling.[xli] But for how long? Even if a plan passes at that level, won’t the money be mishandled, spent elsewhere, and squandered on other projects?

Of course it will. Remember the billions the states received from the tobacco lawsuits? This was no small amount of money. The 1998 settlement totaled $243 billion, payable over 25 years.[xlii] Big plans were immediately made to use the money for health care. The National Association of States Attorneys General announced on November 16, 1998, “States spend billions each year on medical care for smoking related illnesses and the industry payments, which will be made in perpetuity, (sic) will relieve taxpayers of the costs from future smoking-related illnesses.”

So how’d that go, anyway? Not well. The states just couldn’t keep their hands off the money. Instead of paying for health care and education, the money went to other projects.

For example,  New York used $700,000 of tobacco settlement funds for a golf course sprinkler system, and $24 million for a county jail; Alaska used $3.5 million to repair shipping docks; North Carolina spent $42 million to market tobacco (yes, tobacco) and to modernize the tobacco curing process; North Carolina also gave $200,000 to a horse park.[xliii]

In 2003 the states received a total of $7.9 billion from the settlement, but nearly half of that (47%) was diverted into general funds instead of paying for health care[xliv].  Overall, as of 2008, only 5% of the money has gone to tobacco prevention programs and nearly half of the states sold off their rights to future payments from the fund for a lump sum to throw against debts or to balance budgets.[xlv]

That’s a pretty dismal record. We had a quarter- trillion dollars to throw at health care and it’s being wasted. Now the government wants another trillion (or more) and says, “Trust us. We know what we’re doing.”

How well has the government run Medicare?

It’s not like the government hasn’t had experience running a national health care plan, which is what Medicare is after all. It’s limited to certain people, of course, and runs on a much smaller scale than what is being proposed now. But shouldn’t we look at how they’ve done with it? Won’t that give us a clue to how the national health care plan would be run?

Well, Medicare started out in 1965. Among other things, it primarily gave low-cost access to health care for the elderly. And naturally, the elderly took advantage of it.

In 1983, studies of the previous 16 years showed that the proportion of elderly receiving hospital care increased by 31%; the number of hospitalizations for every 1000 elderly people increased by 42%; cataract operations doubled; rates for angioplasty tripled; the percentage of elderly who saw a doctor at least once a year rose from 62% to 82%; and that the proportion of the elderly using home health agency benefits increased by 608%. [xlvi]

That was the result of Medicare. It provided low cost access to health care and of course people took advantage of it. I’m not bashing the elderly here; I carry an AARP card myself. I’m just pointing out the tendency to use a provided service increases if it is made easily accessible.

The result is that Medicare is now going broke. Just recently the trustees of the program stated that the system will be insolvent by 2017.[xlvii] This is bad news, but what’s more frightening is comments like Representative Pete Stark, D-California, who said about the report, “We have seen worse reports in years past and the Congress has always stepped in to strengthen the program’s financial footing, and we will do so again.”[xlviii]

Translation: “We’ll just raise taxes.” Thanks, Pete Stark.

I bring all this up because Medicare has been managed (or mismanaged) into the ground by the federal government and now it wants to expand into an even bigger national program. I don’t know about you, but I have a few doubts about our government handling that. More than a few, actually.

Essentially, the national plan will provide low cost access to health care to everyone in America. A giant Medicare, in other words. It’s going to bring 40-plus millions more people into the system. Won’t the use of services increase, jut like it did with Medicare? Although we are being told the cost will be $1 to $2 trillion over 10 years, won’t it actually turn out to be much, much more? Are they giving us real numbers?

If I haven’t worried you yet, or at least caused you to ask some serious questions, let me bring up a little known fact about government accounting. In the real world, accounting standards require that all financial obligations be shown, even if payments towards those obligations will be made later. So if a business has a balloon payment coming up in a few years, it has to list that on this year’s financials.

Makes sense, doesn’t it? It gives a clearer picture of what’s going on.

But the federal government doesn’t do it that way. It lists only financial obligations for the current year. Anything coming down the road is ignored. So what does this mean?

USA Today did an analysis, applying general accounting principals, and wrote back in May of 2008: “Taxpayers are on the hook for a record $57.3 trillion in federal liabilities to cover the lifetime benefits of everyone eligible for Medicare, Social Security and other government programs.”[xlix]

Are you kidding me? Do the math and you’ll discover it comes to $500,000 for each household in America. In the same article from USA Today it was noted that Medicare had an unfunded liability of $30.4 trillion.[l]

How does that happen? How does the federal government run a program like Medicare for 40 years and underfund it to the tune of $30.4 trillion? I’m just asking here; maybe somebody can give me answers.

I have a question about this, too…

What do you see when you look at the chart below? I see a huge, bloated, unworkable bureaucracy. We are being told this is the answer, but is it? Will this be efficient? How has your experience been dealing with one of these monsters?

Health Care Chart

We use too much health care?

In this health care reform debate we are constantly being told that the reason health care cost so much is because we use too much. To me, that’s like saying cars cost too much because we buy too many. It flies against the evidence I see every day.

Most new medical procedures, when they first come out, are expensive. As they are performed more frequently, the cost per procedure goes down. In 2005, the cost of an artificial hip had dropped 50% from 10 years previous.[li] Cataract surgery used to take a week; now it takes 30 minutes and costs a fraction of what it did before. And guess what? Over 1.5 million people get it done each year.[lii]

It seems to me it’s like that for everything. Remember waiting to buy something because the cost goes down as it becomes more popular? In health care, more people utilize a service as the price falls. True, the aggregate spending goes up, but that’s part of the natural process. I don’t see how that translates to “using too much.”

But this theme of using too much health care is being drummed into us. Sharon Brownless mentions it in almost all her articles, and Time writers Michael Grunwald and Karen Tumulty both take up the theme in recent Time Magazine articles appearing weeks apart. The idea is that unnecessary and wasteful care is driving up costs. Too many procedures are done that have no benefit, or are overkill.

I can go along with some of this. I can see discouraging Hypochondriac Sam from yet another MRI for that funny twinge in his elbow he felt last week.

But there is a fallacy in the “too many procedures are done” logic. Calling treatments unnecessary or wasteful is after-the-fact labeling. It’s a bit like Monday-morning quarterbacking. Besides, we don’t spend the bulk of health care on Hypochondriac Sams; we spend the majority of it on seriously ill patients, some who die anyway despite great amounts of money thrown at the illness.

Is that a waste of money then? No, some patients don’t die; in fact, the majority survive. Exactly which ones will survive, though, is something that the doctor can’t know in advance. The truth is that during the treatment process we don’t know if a particular treatment is a waste or not until we see the result. Do you want your doctor to give up on you to save a few bucks? I don’t. And you won’t either. If you ever get seriously ill you’ll want no dime left unspent if there is any hope of surviving.[liii] Your doctor can save money on the other guy, you know what I mean?

But really bothers me about this talk of using too much health care is that, if you flip the argument around, the answer is to use less to save money. How would that work?

Well, I came across an article about people wanting cataract surgery done in Canada. Remember, down here we do over 1.5 million of these surgeries each year. But in parts of Canada, to keep costs down, they ration out the surgeries.

It seems that this year, due to budget restraints, the Alberta Health Services can provide 2,000 fewer cataract surgeries than the year before.[liv] The result is that people are finding long waiting lists, up to a year, and some of the surgery centers are restricting operations to only the worst cases.[lv] Other areas of Canada are rationing health care, too. In Edmonton’s Royal Alexandra Hospital, they decided to cut back on elective surgeries by 15% to save costs.[lvi]

That’s certainly a way to cut costs. Just provide less. Is this what these writers mean when they talk about using too much health care? It seems that way to me. If that’s the case, I don’t know how we can be talking about providing health care to all and also rationing it, all at the same time. Somebody is going to be disappointed.

Can it work?

Senator Edward Kennedy released a health care plan called The Affordable Health Choices Act on June 9, 2009. To be fair, this was only a draft and everyone knew it needed work. So I won’t be overly critical with it, but I still think it is important to look at the plan as it was presented. Fortunately, the Congressional Budget Office (CBO) did an analysis of the major provisions and so I only need to draw from that.

Here is what the CBO found[lvii]:

1)      The plan would result in a net increase of the federal budget of about $1 trillion.

2)      About 39 million people would obtain health insurance through the plan’s provisions

3)      The number of people who had coverage through an employer would decline about 15 million, and the number of people who lost coverage from other sources would be about 8 million.

4)      The net decrease therefore in the number of people uninsured would only be 16 million!

So what does that mean? It means that after all was said and done, the number of uninsured in the United States would still amount to 36 or 37 million. The report also states that roughly a third of those 36-37 million would be illegal immigrants or people eligible for Medicaid but not enrolled. Obviously, the plan isn’t feasible: not enough people get covered.

Now, I won’t bash Mr. Kennedy’s plan because I understand it’s merely a working draft. It will undergo major revisions as it goes along. But if a plan that saddles us with an additional $1 trillion to the national deficit still leaves 37 million uninsured, what’s that say about the true costs here?

The point is, the costs are astronomical no matter how you look at it. We either raise taxes substantially, or run the deficit sky-high. And either way, are we really solving the problem? If immigration is driving the health care crisis, and we do nothing about getting coverage for immigrants, aren’t we just spinning our wheels?

This isn’t just an academic question. Massachusetts, which has had a state-wide health insurance plan in place for only three years, is already facing a growing deficit and just cut health insurance to 30,000 legal immigrants to save money. So what happens now in Massachusetts? To reduce the deficit will they continue to pare away at who’s covered? If any of these 30,000 legal immigrants get sick now, what happens? Who pays for it?

Weren’t the citizens of Massachusetts promised essentially what the federal government is promising all of us now? And how’s that working out?

* * *

I appreciate you bearing with me over the course of this essay. I know it’s long and quite a slog at times, but it’s an important issue. I’m not an academic, an economist, a health care expert, or connected to the media. I’m just an average guy with some questions I think need answers. If anybody out there has a few, leave a comment. Or if anybody can point out where I’m wrong in my thinking, have at it.

But do something. We had better get some hard answers before our leaders rush into something that may cripple this country for years.

David G. Urban

SUPPLEMENTAL -Many of the responses I’ve gotten touch on the same issues, so I’m adding this section to respond:

Why are you so against health care reform?

I’m not. I’m simply asking questions about what we’re being told. Things aren’t adding up, and I think we better slow down here and take a better look at what’s going on.

Why are you bashing the immigrants? You must be getting your “facts” from the Minutemen. Isn’t that just a racist right-wing scare tactic?

I’m not bashing anybody. The numbers about immigration and the uninsured come from the Census Department. They publish a report titled, “Current Population Reports, Income, Poverty, and Health Insurance Coverage in the United States.”

The reason you can’t ignore immigration is that the numbers for the uninsured include everybody here in the United State, legal or not. When you hear about the “50 million uninsured,” those numbers include not just citizens but everyone. We hear about how the uninsured are a huge drain on our resources and how a national health plan will actually save us money in the long run. Yet, every plan presented so far ignores the fact that up to 25% (or more) of the uninsured won’t be covered. Won’t this still be a huge drain on our resources?

This issue needs to be addressed. Many uninsured immigrant families are “blended,” in the sense that although the parents may be illegal, their children are citizens. If we come up with a plan, it has to solve the whole problem, not just part of it.

Your estimated numbers about how much each taxpayer will pay are too simplistic.

I know that. But we need some sort of benchmark to start with. I only wish the government would be more forthcoming about what a national plan would cost each one of us. As of now, it’s been pretty vague.

You didn’t explain why the CBO claimed the number of people who had coverage through an employer would decline by 15 million if Kennedy’s plan went through.

Because, according to the CBO, a good percentage of employers will stop offering health insurance benefits if a national health plan is available instead. And some employees with poor benefits will opt out and take the national plan.

According to the government, employers will start offering higher pay instead of expensive health benefits. But is this true? How do they know this?  My worry is this: right now my company offers excellent health benefits. If they drop it, what do I do? There is no way a national plan can compete, quality wise, with the one I have now. President Obama says we all can keep our current plans if we so choose, but what if the plan disappears?

[i] DeNavas-Walt, Carmen, Bernadette D. Proctor, and Jessica C. Smith, U.S. Census Bureau. Current Population Reports, P60-235, Income, Poverty, and Health Insurance Coverage in the United States: 2007. U.S. Government Printing Office, Washington, DC, 2008. Available online at http://www.census.gov/prod/2008pubs/p60-235.pdf

[ii] Ibid. Page 19.

[iii] Ibid. “Figure 6: Number Uninsured and Uninsured Rate: 1987-2007.” Page 20.

[iv] U.S. Census Bureau, Current Population Survey. 2007 Annual Social and Economic Supplement.  Page 1. Available online at: http://pubdb3.census.gov/macro/032007/hhinc/new06_000.htm.

[v] DeNavas-Walt, Carmen, Bernadette D. Proctor, and Jessica C. Smith, U.S. Census Bureau. Current Population Reports, P60-235, Income, Poverty, and Health Insurance Coverage in the United States: 2007. U.S. Government Printing Office, Washington, DC, 2008.  Page 23. Available online at http://www.census.gov/prod/2008pubs/p60-235.pdf

[vi] R. Cort Kirkwood. “ER Overload: A Survey of the Research Available Shows That Uninsured Illegal Immigrants Are an Imponderable Burden in Our Nation’s Hospitals, in Particular Emergency Rooms.”  The New American. 27 Nov. 2006.

[vii] Passel, Jeffrey S., and D’Vera Cohn. “A Portrait of Unauthorized Immigrants in the United States.” Pew Hispanic Center. April 4, 2009. Available online at http://pewhispanic.org/reports/report.php?ReportID=107

[viii] Williamsen, Kurt.  “Counting the Costs of Amnesty: With Many of Our Nation’s Politicians Pushing to Give Permanent Residency and Amnesty to Millions of Illegal Immigrants, Americans Should Know the Costs of Granting Amnesty.” The New American. May 29, 2006.

[ix]Kirkwood. R. Cort. “ER Overload: A Survey of the Research Available Shows That Uninsured Illegal Immigrants Are an Imponderable Burden in Our Nation’s Hospitals, in Particular Emergency Rooms.” The New American. Nov. 27, 2006.

[x] Fronstin, Paul.  “The impact of immigration on health insurance coverage in the United States 1994-2006.”  ERBI Notes. Aug 2008, Vol 29, No. 8.

[xi] Ibid

[xii] Ibid

[xiii] “US to Pay for Illegal Immigrants’ Emergency Health Care.” May 10, 2005. Available online from http://health.dailynewscentral.com/content/view/732/0

[xiv] “L.A. Emergency Rooms Full of Illegal Immigrants.” March 18, 2005. Available at  http://www.foxnews.com/story/0,2933,150750,00.html

[xv] Ibid.

[xvi] “The Economic Case for Health Care Reform.” Executive Office of the President Council of Economic Advisors. June 2, 2009. Page 2, Executive summary.

[xvii] Brownlee, S. and E. Emanuel. “5 Myths About Our Ailing Health Care System.” Washington Post. Nov. 23, 2008. B03.

[xviii] Brownlee, S. (2008). “Why Does Health Care Cost So Much?” AARP Magazine, July and August, 2008. Page 2.

[xix] Horsley, S. “The Risks and Rewards of Taxing Health Care Benefits.” Available online http://www.npr.org/templates/story/story.php?storyId=105044390

[xx] Barry, P. “The New Face of Health Care.” AARP Bulletin. Print edition, April 1, 2009. Page 2.

[xxi] Brownlee, S. “Why Does Health Care Cost So Much?” AARP Magazine. July and August, 2008. Page 5.

[xxii] Tumulty, K. “The Five Big Health Care Dilemmas.” Time Magazine. June 15, 2009. Page 27.

[xxiii] Park, A. “This Doctor Does Not Want to See You.” Time Magazine. June 22, 2009. Page 64

[xxiv] Grunwald, M. “More Data + Less Care = Lower Cost + Better Health.” Time Magazine. June 29, 2009. Page 39.

[xxv] Ibid.

[xxvi] Park, A. “This Doctor Does Not Want to See You.” Time Magazine. June 22, 2009. Page 62.

[xxvii]Brownlee, S. and E. Emanuel. “5 Myths About Our Ailing Health Care System.” Washington Post. Nov. 23, 2008. B03

[xxviii] Park, A.  President Obama qted in “This Doctor Does Not Want to See You.” Time Magazine. June 22, 2009. Page 64.

[xxix] Grunwald, M. “More Data + Less Care = Lower Cost + Better Health.” Time Magazine. June 29, 2009. Page 39.

[xxx] Grunwald, M. “More Data + Less Care = Lower Cost + Better Health.” Time Magazine. June 29, 2009. Page 40.

[xxxi] Ibid.

[xxxii] Park, A. “This Doctor Does Not Want to See You.” Time Magazine. June 22, 2009. Page 64.

[xxxiii] Ibid.

[xxxiv] Chambers, Susan. “Reviewing and Revising Wal-Mart’s Benefits Strategy.”  Memorandum to the Board of Directors. Available at http://walmartwatch.com/img/sitestream/docs/Susan_Chambers_Memo_to_Wal-Mart_Board.pdf

[xxxv] “Table 2. Number of Returns filed, by Type of Return, Fiscal Years 2006 and 2007.” Research, Analysis, and Statistics, Office of Research RAS:R

[xxxvi] Hodge, S. “Putting a Face On America’s Tax Returns: Sound Tax Reform Must Begin with a Solid Understanding of the Changing Face of American Taxpayers.” Available at http://www.taxfoundation.org/files/dba37618d9c2d2df02f24766ac4cc39d.pdf

[xxxvii] Lytle, T. “The Trillion Dollar Question: How to Pay for Health Care Reform?” AARP Bulletin Today. May 14, 2009.

[xxxviii] Ibid.

[xxxix] Ibid.

[xl] Calmes, J. and Robert Pear. “Administration is Open to Taxing Health Benefits.” New York Times. March 15, 2009.

[xli] Werner, S. and David Espo. “Senators claim $1 trillion health bill in reach.” The Associated Press. June 25, 2009.

[xlii] Gordon, Dianna.  “Tobacco Money Well Used, Not Abused: States Have Spent Billions of Dollars on Health-Related Services. Even So, They Are Being Criticized for Using Some of the Tobacco Money to Fill Budget Gaps.”  State Legislatures. Feb. 2004.

[xliii] “Where Tobacco Settlement Funds Really Went.” ABC News. July 22, 2002.

[xliv] Gordon, Dianna.  “Tobacco Money Well Used, Not Abused: States Have Spent Billions of Dollars on Health-Related Services. Even So, They Are Being Criticized for Using Some of the Tobacco Money to Fill Budget Gaps.”  State Legislatures.  Feb. 2004.

[xlv] Elliot, D. “States’ Use of Tobacco Money Varies Widely.” November 17, 2008. Available at https://www.npr.org/templates/story/story.php?storyId=97081916

[xlvi] Blumenthal, D., Schlesinger, M., and Pamela Brown Drumheller. Renewing the Promise: Medicare and Its Reform. Ed. David Blumenthal and Pamela Brown Drumheller. New York: Oxford University Press, 1988. Page 22.

[xlvii] Reichard, J. “Trustees’ Report Projects 2017 Insolvency of Medicare Hospital Fund.” May 12, 2009. Available at http://www.commonwealthfund.org/Content/Newsletters/Washington-Health-Policy-in-Review/2009/May/May-18-2009/Trustees-Report-Projects-2017-Insolvency-Of-Medicare-Hospital-Fund.aspx

[xlviii] Qted. in Reichard, J. “Trustees’ Report Projects 2017 Insolvency of Medicare Hospital Fund.” May 12, 2009

[xlix] Cauchon, D. “Taxpayers’ Bill Leaps by Trillions.” USA Today. May 18, 2008.

[l] Ibid

[li] Morris, Charles R.  “The Economics of Health Care: It’s Going to Cost a Lot More.”  Commonweal.  April 8,  2005.

[lii] Ibid

[liii] I want to credit Charles R. Morris for this line of thought. It is from his article, “The Economics of Health Care: It’s Going to Cost a Lot More.” Commonweal. April 8,  2005.

[liv] Lang, Michelle. “Wait Times Soar for Cataract Surgery in Calgary.” Calgary Herald. May 20, 2009.

[lv] Ibid

[lvi] Ibid

[lvii] Congressional Budget Office Report to Honorable Edward Kennedy. June 15, 2009. Available at http://www.cbo.gov.


7 Responses to Excuse me, but I have a few questions…

  1. Billie Jo Jannen says:

    What a fine – and not as boring as you claim – essay. As a resident of the border region and former client of hospitals that have been shut down by the weight of non-paying users of local emergency rooms, I am happy to see someone detail these impacts. The lives of my family and 100,000 of my neighbors are now over an hour away from emergency care, thanks to hospitals going bankrupt and shutting down.

    It’s worth noting that no single pay system in the world allows non-citizens to participate in their healthcare unless they pay for the privilege. How ironic that our supposedly broken system allows non-payor non-citizens full access.

    One thing I don’t see mentioned about the proposed plan is that one of the funding/saving mechanisms proposed is the “reallocation” of grant and other federal support monies currently given to hospitals and clinics to fund services for underinsured.

    I was, myself, the beneficiary of some of these programs recently. While between jobs and with no health insurance, I came down with a pneumonia that resulted in a pleurisy that was on the verge of completely collapsing my left lung. Several doctors informed me that, if I didn’t check into the hospital I was guaranteed death within days. It was freakish and terrifying.

    Ultimately, a fairly huge surgery was done and I was in the hospital for two weeks. The bills, when all was said and done, totaled over $150,000 – a staggering sum to me. I applied for Medicaire assistance, but my income, even on unemployment, was too high to qualify. I was terrified I would lose my home of 21 years to creditors.

    But I spoke with the hospital about assistance via its charity programs and, lo, I was able to get the bill discounted to a sum I am capable of paying off over two years. These are the monies that are being taken away from the hospitals, according to Obama’s press conference just before he left for his recent overseas junket.

    From my point of view, this type of program is working for middle class people like me who would otherwise fall into the cracks. And it’s a type of program that does not come between doctor and patient, does not result in healthcare rationing, and does not impose additional layers of government regulation on medical providers. But it will fall to the axe under the current proposals.

    Speaking as a middle class person who is more than happy to pay her own way, I think that is a damned shame.

    • David Urban says:

      Billy Jo, thank you for contributing to this thread. You make excellent points also. I think if more people took the time to research this whole issue there would be much less of a rush to do this. Right now, the current hysteria is leading us into a hastily crafted plan that will make things worse, not better. I can’t remember if I mentioned this already somewhere else, but I called Rep. Bob Filner’s office to ask questions and even they admitted they had no idea what was going on with the bill so far. No one in the office had read it. As written, the house bill clearly states that private insurance will not be an option for somebody seeking health insurance after the bill is made law. I haven’t heard President O’Bama address this point yet; perhaps tonight on TV he will. Personally, I don’t see how limiting my choices improves my life. Anyway, thanks again for responding.

      David Urban

  2. Ken Zuercher says:

    While I agree with some of your points, here I disagree:
    Most new medical procedures, when they first come out, are expensive. As they are performed more frequently, the cost per procedure goes down. In 2005, the cost of an artificial hip had dropped 50% from 10 years previous.[li] Cataract surgery used to take a week; now it takes 30 minutes and costs a fraction of what it did before. And guess what? Over 1.5 million people get it done each year.[lii]

    It seems to me it’s like that for everything. Remember waiting to buy something because the cost goes down as it becomes more popular? In health care, more people utilize a service as the price falls. True, the aggregate spending goes up, but that’s part of the natural process. I don’t see how that translates to “using too much.”

    ***Most of our truly costly procedures haven’t dropped. Especially Heart bypasses and Cancer treatment. Sure cataract treatment and others haven’t held prices.
    From my personal experiences, I spent a month in a hospital in 1996 having a stem cell treatment for Stage 4 Non-Hogkins Lymphoma. The total cost was $100K. I am truly grateful for it’s availability and am alive because of it.
    Six years later i had a small recurrence involving Stage 1, one node involvement. The treatment was outpatient, radiation and chemo and cost…$100K! The cost was primarily the drugs. A newer drug treatment was $20k each time and some extra drugs(for example Nulasta is $7000 for a shot!)
    the doctors made considerably less than the treatment six years prior. The radiation was quite reasonable, conforming to your point but the pharmacological costs are nothing short of profiteering on a grand scale. It is this sort of thing that runs up the costs.
    I draw the line on regulation when I have a choice as to whether to use the products involved. I had to have the treatment or die. We all need to heat our homes, eat meals, etc. We have no choice and to profiteer on someone elses bad fortune is just plain immoral

    • David Urban says:

      Ken, you make some good points and raise some more valid questions. (And congratulations on surviving cancer so far! I’m a survivor also. Isn’t it great to be alive?!).

      I agree we need reform. My worries are that a hastily crafted plan won’t achieve it. The Congressional Budget Office Chief Elmendorfer just stated he believes the latest house bill will raise costs, not lower them. This should be a major red flag; whatever we do, the plan has to be sustainable. We just cannot run up a huge bill now to pass on to our descendents later.

      As far as some of the medical costs, I agree we have to look at it. During my own cancer treatment I couldn’t believe the bills for the drugs. Certainly we can improve in this area.

  3. Tina McClain says:

    Excellent essay.

    I will be forwarding it to everyone I know. So glad you pointed out the porblem we have with immigration. FINALLY!!

    I have a few more questions for you.

    When it comes to controlling costs- why haven’t I heard medical malpractice reform mentioned? With physician insurance premiums soaring as a result of the unbelievable high number of malpractice claims and frivolous lawsuits; physicians in private practice have had to turn to “contracting” with hospitals, or becoming paid employees- with the benefit of having the hosptial cover their malpractice premiums.

    In order to offset this cost- don’t hospitals simply charge more for services given to the insured?

    Has anyome proposed legislation to discourage medical malpractice claims?? Like allowing a physician or drug company “monday morning quarterbacking” protection under the law- or providing a concrete way for lawyers to be held liable for accepting frivilous lawsuits in the first place…actually hold lawyers to the same malpractice standards we hold our physicians to??

    Would love to hear your thoughts.

    • David Urban says:

      Thanks Tina,

      You make some outstanding points. Essentially, you are asking: where is the “reform” in this health care reform package?

      I don’t see it either. And we are not alone. Just yesterday the Congressional Budget Office Director Douglas Elmendorf stated:

      “In the legislation that has been reported, we do not see the sort of fundamental changes that would be necessary to reduce the trajectory of federal health spending by a significant amount. And on the contrary, the legislation significantly expands the federal responsibility for health care costs.”

      The common man translation to his statement is: this plan blows.

      Now, Elmendorf used to be a senior fellow in the Economic Studies program at the Brookings Institution, served on the White House’s Council of Economic Advisers and also as deputy assistant secretary for economic policy at the Treasury Department, served as an assistant director for the Division of Research and Statistics at the Federal Reserve Board, and earned his Ph.D at Harvard, where he also taught.

      If he is saying that this new plan is making things worse, I think we should be listening.

      I called my local congressman’s office, and asked a few questions of one of his aides (I won’t say who because he at first thought I was the press. When I told him I was just a regular citizen, he agreed to talk off the record). He said right now everything is so confusing no one can make heads or tails of it. The latest house bill is over 1,000 pages long, and no one at the office had even read it. I wasn’t exactly reassured over this.

      I don’t know, Tina, the more questions we ask the worse it sounds. Thanks for the comment about the illegal immigration issue. I knew as I researched it I would be slammed as a “racist,” a “bigot,” or “xenophobic.” I’ve had to delete some comments that got pretty nasty. Apparently, one can’t honestly look at an issue and raise relevant questions anymore without being personally attacked.

      But I’m not backing down. My question on that issue still stands: if all these plans only affect legal residents, that still leaves 10,000,000 illegal residents without insurance (or more). And this means the health care system still has to absorb the costs of all the emergency health care benefits we give away (which are the most expensive of treatments), and thus the costs keep getting driven higher and higher. This isn’t sustainable.

      I haven’t heard a single politician address this issue at length. Not one.

      Anyway, Tina, thank you for your comment. Please pass along this essay to others. As long-winded and boring as it is, I think it raises some good points.

      Dave Urban

  4. Liz Rudolph says:

    Great article. Helps me easily understand the actual dollars the government is wanting to spend on this project……………which is outrageous!

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