Friday, July 17, 2009

The Big Health Care Extravaganza Post

I've been formulating what it would take to truly reform health care in this country for a while now, ever since my last specific post on the subject (and the related ones where any mention of the subject was the equivalent of dropping the word abortion into the debate). And now that the ABC-sponsored infomercial by President Obama succeeded in boring the shit out of the paltry few who watched (I didn't, because I don't watch network crap), it's time for me to unveil my big plan.

Now as with any plan condensed into the space of a blog post, if i miss a specific or am a little lean on detail, I'll catch it in the comments (unless I really hose it). Plus, some of the details, by the nature of my plan, have to take care of themselves.

First of all, my assumptions:

1. No matter what, there will be people that will not get the proper medical care, and will die. This happens now, and it will happen under any reform, as people are dum.

2. The debate is not whether we need a public option, or more private ones, or more or less regulations, or any small change bullshit. The debate is whether the government or the private sector is best equipped to handle health care in America. Right now we have the worst aspects of both.

3. The problem is not accessibility of services, but the exorbitant cost of said services.

4. My goal in this is to create the fairest, most flexible, and best health care system in the world. And my approach is to keep it free from the control of as many people as possible (except doctor and patient, of course).

And so....

The Illustrious (and Plaid) Patrick M Health Care Reform Plan

(applause/eye roll)


1. Tort reform - As with most highly paid and therefore litigiously lucrative professions, much of a doctor's overhead is in malpractice insurance and CYA medicine. And since most of the procedures are covered by insurance, why not just order them all? Taking away much of the liability for educated guesses, and for the inherent risks that come with cutting and pouring chemicals into the human body is the first step in shrinking the costs. And capping most malpractice awards (except in cases of gross negligence, where a little cya procedure would have saved their ass) also affects the cost of malpractice insurance (lower the payouts, and you lower the cost).

2. Insurance Competition
- Our insurance market is so burdened by so many regulations, limitations, and piles of bullshit that it's no wonder they do everything in their power to pinch every penny (as they're trying to rake in their last dime before the government pinches them). This has led to them pulling some vile practices (rescission) in the pursuit of the last dollar. So there are three things that we can do to fix the current insurance mess:
  • Reduce all barriers to selling insurance, keeping only regulations that ensure transparency and protect the rights of all parties. This would include access to the medical records of the patients they insure, so that everything is clearly on the table. It would also create the opportunities for insurers that
  • Make insurance something paid with pre-tax dollars for the individual. And make it 100% portable, attached to the individual.
  • Create a streamlined method to legislate disputes when insurance companies deny coverage (except in cases of fraud).
  • Start treating insurance as insurance, not a payment plan for health care. When a routine medical check is paid for by someone else, it ain't insurance.
The point of this is to make insurance become something that people have for emergencies, that rewards or punishes behavior, and is not the go-to source for payment. Most importantly, it will mean that prices will go down as people want their money to work for them.

3. Non-Naughty Nurses - Doctors, for all their expertise in treating illnesses and diagnosing symptoms, are often complete fucking idiots when healing people. This is not to belittle what they do, but often, most of a patient's contact with medical staff is through nurses, from the lowly shit wiper to the haughty head nurse (complete with kneepads (kidding)). And they can tell very quickly what the hell is going on in most cases. So why are we waiting for an hour for some moron with the right alphabet soup to get our routine shit looked at?

In some cases, we have the Certified Nurse Practitioner (like the one my kids see for their wellchecks). Or the Certified Nurse Midwife (she caught my first when he fell out, was there for most of the second). These are nurses with a little more training and experts in their fields, often taking the place of the doctor for the most part (the doctor is the consulting expert). For most things, people don't need the burden (and price) of a real doctor. So why do we see them?

Expanding caregiving responsibilities to the people most competent to do so (and having the doctors just do the cool shit they went to medical school for) would be the fastest way to both cut wait times (a reason I ditched my son's first doctor) and the cost of getting your shit looked at.

4. End-of-Life Care -In this area, I'm going to get a little grief because I'm a believer in dying with dignity rather than being kept alive as a human vegetable. In fact, since I lost one grandfather to Alzheimer's, I know how I want to be treated if I get the disease. When I reach the point I no longer recognize people and places and can no longer function effectively, I want to be taken on a road trip. Anything tho accelerate my decline so I die quickly.

Now this is not to say we should start snuffing the old (despite it working for one planet in Star Trek: TNG). However, when a person reaches the point they can no longer function, we need to find a point at which we can let go, and help them to let go. I don't have any specific legislative ideas, because this is a matter of personal faith and relationships. But the need to prolong the aged for years after they become miserable is futile.

5. P-p-p-p-p-pilllllssss -One thing I saw early on sitting at the doctor's office with my newborn son was the result of the doctors I mentioned just trying to solve problems rather than treating people. There were old people in there with BAGS OF MEDICATION. Now I've always been the type of person who tries not to pop a pill unless it's absolutely necessary. The occasional antibiotic when fighting an infection. Maybe a vitamin (well, for the kids, I haven't touched my horse pills in months). A few pills to stave off the bitch-headaches that sometimes blast me (or that time when I had the abscessed tooth and was smashing aspirin on my gums).

But we may not have had a "crisis" that required a prescription drug program if we weren't addicted to the idea of solving shit with pills. I had one grandmother who fought this tendency (mainly because the doctors kept diagnosing more shit (when she was 87 and due to die 2 years later)) and another who appears to be as almost messed up by the medication designed to "fix" shit as by the problems that got her to the doctor in the first place.

And this trend of doctors popping prescriptions so we can pop pills is also very much the thing that helps exacerbate the abuse of the prescription drugs, affecting people from Rush Limbaugh to on-the-street junkies, to the now-late Michael Jackson (who likely was killed (directly or indirectly) by his prescriptions).

Again, it comes back to healing people and not just trying to fix problems. And fixing problems caused by pills by using pills IS a problem.

6. Grandfather Clauses - One of the sources of our current debt is the expanding costs of Medicare and Medicaid. So these are going away. However, there are two problems with that. First people are paying in for this shit. Second, there are lots of people currently receiving the programs (full disclosure, my kids are both receiving medical through Medicaid).

So it's grandfather time. Anyone currently in a program may stay within that program until they drop out or die. We create a 1-year window for Medicaid and a 5-year Window for Medicare. Then we start shutting the programs down. That leaves us with....

7. Insuring the Uninsurable and Irresponsible, AKA The Safety Net -That leaves us with the people who can't get insurance or fail to do so and need help. In any system, as I said, there will be people that aren't served by the system. They fall into four categories.
  • Senior citizens - Those who didn't do what they needed to prepare for their retirement, who missed the deadline for Medicare above, and will need care. I'm inclined to say we should create a program similar to Medicare in the sense that it covers our seniors, but structured much differently than our current mess. Also, the eligible age will be based on current life expectancy, not some arbitrary age set by Congress that means the average person gets 15-20 years on the program. And preferably, this will be something administered at the state level.
  • The poor - There will be people who, even with the inequities of the current system eliminated by market forces, simply cannot afford basic care. And we as a society have a moral obligation (not a legal one) to help our fellow man. This requires that we find ways to help. The establishment and enhancement of free clinics is the key here. They can be supported by donations, by the free time of doctors who would otherwise be writing off non-payments. I don't have the particulars, but from someone who's seen the power of philanthropy, I know we can do this.
  • The chronically ill - There are people who have diseases that will plague them until they are dead. There are people who have diseases that take their time to kill. And there are people who cost a lot of money to keep alive. I'll be honest when I say there's no easy answer here. Part of it will be though the generosity of people (speaking of which, someone like Jakari could use some of that). Part of it may come from the government (I may oppose this on principle, but I'm willing to compromise. Because like any moral society, there are times where we have to do the right thing. This may be one of those times.
  • Addicts and the self-destructive - Okay, here's where I draw the line for helping people. Now I do believe in trying to find ways to help people beat addiction (and there's a public role in this). And sometimes, when someone comes into the emergency room, doctors are going to fix first and ask questions later. But there comes a time when someone who is intent on doing things that will kill them should be told, simply, no more. We're not going to give you help to survive your latest binge. We're not going to patch up your latest hole from a shooting. And you knew your behavior was killing you and you kept doing the stupidest things imaginable. Now if you've got the cash to pay for it, or insurance that will still cover your dumb ass (and since you're in this category, you don't), then we'll keep going. but you chose your poison, and we're not going to eat more money just to continue your useless existence. Die. Is that harsh? Yes. But we're denying coverage to people who chose to mess themselves up.
Okay, there's my best shot at fixing health care. I can say it beats the debacle that is coming from Washington. So what did I miss?

17 comments:

rockync said...

No amount of reform is going to be workable until (I can't believe I'm saying this) we go BACK to the state of healthcare when I first became a nurse. Back then healthcare was a sacred trust and NONPROFIT. Costs were kept down because all monies were kept in healthcare, not some greedy investor pocket.
That is when our healthcare system really started to fail.

dmarks said...

Ah. You didn't include lots of money for roads and other pet pork projects unrelated to health care. That's what the bill in Congress does.

Rocky: What changed? Were all hospitals nonprofit then and they aren't now? Or were drug companies like Merck formerly nonprofit?

TRUTH 101 said...

I enjoyed especially the irony of your "poor plan." Freee clinics supported by donations of money and free time by dictors. Dmarks jumps me about "spending other people's hard earned money." Now Patrick wants to donate doctor's valuble free time. Very generous of you Patrick. How about going with my single payer plan that even the poor have a financial contribution to.

rockync said...

dmarks - yes, all the hospitals, nursing homes, etc were all nonprofit. What this meant was better salaries and better staff to patient ratio. It also meant adequate supplies and more money toward quality of life activities. The whole system was a cooperative effort and the drug companies essentially had only one choir to sing to. That helped limit how far the drug companies could go.
Our current health care system was engineered to be one big screwjob for the American people.
Drug companies charge exorberant prices for essential medications and treatments, insurance companies deny claims and drop sick clients with no fear of retribution. Hospitals are understaffed and many of them have dismal track records.
Yep, this is one great system we have here...

Time said...

Tort reform is only 2% of costs (CBO) numbers. That's why legislators won't pass it. It won't help a bit and it causes a big argument.

All people should have to have on file a statement of death. A living will, if you like, but a simple statement filed with the government. By the time people become mentally unable to speak for themselves, it's to late.

Any cosmetic treatment is not allowed. No penis enlargers, no face lifts, no tummy tucks, etc., etc........If you fat, diet. If your ugly, live with it. If your penis won't work, take a hot shower, or buy a sex toy. Glasses, fine, but why tinted contacts? Why contacts at all? Drug treatment coverage, maybe once.

The cost of our "vanity" medical care, could probably pay for insurance coverage for all.

Why free care at hospitals? If they can't pay now, fine, but will they be broke the rest of their lives? Bill it and collect it over the years. Attach IRS refunds, paychecks, etc. If they die before they pay it, well that's at least an excuse.

Let doctors trade their school debt, for free care where needed.

Deductibles should be on a usage scale.The more you use services, the higher your deductible.

Producers of medicines need to make a profit. Why do insurance companies need to make a profit on top of the profit the medicine producers make?

Just rambling

Jennifer said...

Ok....Where to start? For the most part I agree with a lot of your programs and ideas.

Tort Reform....I know Time has the figures regarding the CBO but I still think it is important. It is being abused and until we stop it, we are going to pay the price one way or another.

Insurance Competition.....If I am taking this right...is this like a personal account rather than money going to the insurance companies.

Nurses.....This is a great idea. Half the time I bring my kids or myself, the nurses do more than the doctor himself.

End of life care....My take on it is this. If my kidneys and heart are failing and I am diagnosed with 4th stage lung cancer, then let me go in peace. Johnny's grandmother was very old and was in poor health. She got diagnosed with lung cancer and got treatment. She couldn't get off the couch and she barely moved. As hard as it may be, in that case, you should just live out whatever life you have in peace without all the effects of chemo.

Pills....Could not agree with you more! I have anxiety and they have thrown more pills down my throat than I thought was humanly possible. I was young and stupid, almost 15 years ago and if I knew then, what I knew now, I would have told then where they could stick those pills!!

Insuring the insurable.....this is where things get a bit difficult.

Senior Citizens and disablities (You didn't mention them so I am putting them in this category.) need some kind of program but medicaid and medicare have lived out their usefullness.

The poor...we are back to the same argument that has gone on time and time again. Although it's not the governments responsibility, something needs to be done. I actually really liked Times suggestion that doctors pay off their debts by volunteering free care.

I'm not quite as "harsh" as you are regarding the addicts and self destructive but I see your point. How many times do you have to bail them out with other's money to have then just screw up again.

Not too bad Patrick!!

Time....you speak about vanity, but those things you mentioned aren't covered, at least in any plan that I have ever seen. I've just heard about viagra being taken off the covered drug list.

Satyavati devi dasi said...

I continue as of late to be in no mood to get in a fight with you but I will point out two things.

One. Rocky is absolutely right. The minute profits become the point, the patient suffers. Medicine is supposed to be a mission, not a business. To make this work we have to go all the way back to medical education and either reduce tuition costs or subsidize education, because it's the phenomenal student loan amounts that push physicians away from looking for the biggest dollar. But the point remains that when you work for profit, patient care is what suffers.

The second point is this. People need to be educated about end of life decisions and encouraged to write living wills, establish HCPOAs and so on. People need to put this stuff in writing and families need to stop being so fucking selfish and follow what Grandma wishes. Also, we need to get over our collective fear of "overmedicating" for pain in the case of chronic, incurable, terminal illnesses.

Your utter lack of understanding of addiction as a disease process in its own right leads me to not even want to broach this subject with you.

That will do it for now.

Anonymous said...

Another way to help the insurance mess is to uncouple insurance from employers. Let each of us be the customer and get our own plans, and the employer can just pay us the money as salary.

Employers (ie, HR folks who could not care less, except for total cost, maybe) now stay in our lives only about 3-5 years. They should not be our health insurance gatekeepers.

Patrick M said...

Rocky: To a degree, you are right in that we need to go back to before. Psychologically, that's what my plan is all about.

101: Unlike the single-screwer insanity, mine has lots of stuff that is not controlled by a single entity. And I'm not donating the time of doctors. That's a tradeoff they would be willing to make (I expect) to avoid having to deal with writeoffs and billing headaches. That comes from the time when healthcare was, to quote Rocky, "a sacred trust and NONPROFIT."

Time: Even if I take the 2% as a fact without verification, I'm also dealing with the psychological effects of the current medical thought (CYA).

As for the rest, there are some good ideas there, including clearing some debt for volunteer work. It would probably be less expensive than Medicare.

Jenn: To be honest, my harsh take on addicts and destructive people would mean, in essence, the death of a family member of at least one of the people who has routinely commented here. It's hard to devise a plan when you know it will kill someone.

Saty: I agree with your first point and most of your second.

As for overmedicating, I have no problem with making the dying comfortable. I'm speaking about the idea that keeping the human body on meds to "fix" a myriad of problems, including psychological (They'd have pumped Ritalin in me if it had been around) is not always the best thing (and yes, there are times that it is appropriate).

As for addiction, in addition to what I wrote above, if the first couple brushes with death don't convince the addict to stop, there has to be a damned consequence. I'm not saying let every addict die the first time they show up in the emergency room. But sometimes, the only thing that's going to get them to stop is to die. I know I'm passing, in essence, a death sentence on people for sometimes innocent and sometimes foolish choices that have trapped them in a cycle that is hell to climb out of.

So broach away. Would you continue spending limited public funds to keep someone who's spiking their veins or popping oxys and is trying to die for the 10th time, or spend some on last-ditched coerced rehab and some on a chronically ill infant (and you know which infant I'm referring to)?

Anon: That's my point: when other people are responsible for our health care, it won't be as efficient.

Time said...

Patrick M,

Your idea of a circle of free clinics staffed by doctors and nurses who want to clear their school debts (something I mentioned), is a good answer. I have no idea how large a circle of clinics that would be, or fill the need.

I'm all for medical tort reform, sign me up.

The numbers I used are from the CBO and can be found by googling "medical tort reform."

What I'm not for is the mistaken idea given by Republican leaders for 20 years, that tort reform is some kind of magic bullet of cost savings for medical costs, it is not.

Yet, President Bush and other top leaders of the Republican party have for years offered up tort reform as a huge monetary savings for the system. I find that misleading, not to mention why they did not pass that kind of legislation when they held the majority in the Congress.

Republicans have not offered up serious alternatives to the administrations health care plan. Rep. Bahynor(SP) gave the Republicans official alternative health care plan weeks ago. It was a 4 page document with no figures and no plan. He did at the time blast the Presidents plan???

There are many other plans out there, none of which either side has given any support to. Only the Presidents current plan (which I do not like) has any kind of majority support.

It's negligent that the Republicans have not offered up any serious plan to this serious problem. That is not responsible for elected officials.

The most publicly accepted plan would be one compromised between the two parties. The Republicans are simply sitting on the sidelines allowing the Democrats to own the issue. Serious opposition offers ideas, not just criticism.

Their position basically accepts the status quo, which I find unacceptable.

President Obama will use his majority vote to push his legislation through and we will be stuck with it.

Yes, I am upset with the Republicans for playing politics with this issue and offering up no serious ideas.

Satyavati devi dasi said...

We're not going to patch up your latest hole from a shooting. And you knew your behavior was killing you and you kept doing the stupidest things imaginable.

Really. Addicts and the self-destructive? You're taking on a lot of God's ground with that one. Do you plan on including cigarette smokers? How about diabetics who keep on eating M&Ms? How about people with heart disease who continue to eat at KFC five nights a week? They knew their cholesterol was too high, dammit, and yet they just had to have another biscuit. I guess you'd choose to not give them CPR when they went into arrest?

Or are you just referring to junkies, crackheads, drunks, and whoever else you deem to be socially redundant?

Are you also going to deny care to someone with a mental illness who has recurrent suicide attempts? That latest 'hole from a shooting'? Does that include a shot incurred during a drug deal gone wrong?

This is tricky ground you choose to tread here. You're "denying coverage to people who chose to mess themselves up".

So Grandma won't be getting dialysis after her kidneys fail from her diabetes, because it's her own damn fault for eating too many Krispy Kremes.

Uncle Cletus won't be able to get any breathing treatments for his emphysema because he should have known better than to smoke.

Cousin Jethro doesn't deserve high blood pressure medicine-you know he puts salt on everything he eats.

Right.

You're going to decide who's "worthy" of healthcare.

Malthusianism. Again.

Patrick M said...

Rocky: There is no silver bullet in reforming health care. Because the changes necessary to really fix the system require both a government component, a private component, a rebalancing of individual rights (the tort reform), and a change in our culture.

As for the GOP's failure to come up with answers, it's one that continually frustrates me. Their idea of reform seems to be either to tweak the system a little or to talk about the "free market" and not really do anything. Although, looking at the Democrat plan, I'm thinking the broken system we have now may be (ick) better. That's depressing.

Saty: Well, when there are X amount of resources, three patients with no cash or insurance (a premature infant of a single mother, an AIDS patient, and someone whose been in hospitals every year or so for the past decade because they keep ODing on their shit of choice), and X will only get two of them treatment, then I'll get as Malthusian as I have to.

I'm not going to try to pick the nit on how self-destructive someone has to be to be denied government support. But with limited funds, someone will have to make that decision.

You're going to decide who's "worthy" of healthcare.

Not me. Whatever bureaucrat in Washington (or each state, preferably) is charges with supplying the limited government health care for those that have no other option. That's their job: to dispense health care based solely on their assigned budget.

And you wonder why I don't want ALL OF US under a system where the government decides on health care? Because that's the problem inherent in a single payer, government controlled, nationalized, or socialist health care plan!

dmarks said...

Patrick M. has a great point. The plan in Congress limits, rations, and takes away health care.

Patrick also said: "Although, looking at the Democrat plan, I'm thinking the broken system we have now may be (ick) better. That's depressing."

Well, the health care system now works for a vast majority of Americans. Surely it would be better to leave that in place than to replace it with the Obama plan, which trashes the entire system.

dmarks said...

Rocky: Remember, "better salaries" are a problem in that they increase the cost of health care.

And I am familiar with "nonprofit" hospitals where people are making out like bandits (millionaires). Kind of tarnishes the idea of non-profit when people are getting filthy rich off it even when, technically, "profits" are not being made.

Toad734 said...

Not all these are terrible points on their own but I don't recall hearing anything about prevention (which could reduce the drug overdoses, obesity, etc.)Note that there isn't as much money is prevention so thus less profit. More sick people=bigger profits.

Nothing about the redundancy in the industry (under a single payer you could eliminate 30% of overhead administrative costs overnight).

Nothing about the fact that 30% of the poor population in this country happen to be children under the age of 18. Children or childrens as you may prefer, are not irresponsible for not having health coverage. Another good percentage of the poor in this country are the elderly such as my grandmother.

Nothing about the fact that Canada with universal coverage spends 9.7% of their GDP on health care for everyone yet we spend 16% of our GDP (and a much larger GDP) on a health care system which leaves millions uninsured/covered and Canada has both a higher infant mortality rate and a longer life expectancy rate, as does every other western nation that has national healthcare.

Nothing in here to address why Americans pay 50% for prescription drugs than the rest of the world including those countries with universal healthcare who can monitor and set limits to prices.

You did note that health care and health insurance has become too expensive and I would like to add that over half of all family bankrupcies are due to medical bills. That is a huge problem and a huge drain on the economy.I would also like to let you know that our for profit health care system in the US is the most expensive in the world...and most profitable. Do you want your kids health determined by profit margins?

If you are for letting people die who were "irresponsible" don't ever let me hear you call yourself prolife again.

You act as if doctors are sometimes negligent and can destroy people's lives. If some asshole is allowed to sue Obama for his birth certificate, I think we should be able to sue a doctor who gives your kid the wrong amount of medication and kills them. Not that the system isn't abused but you can't take the right away.

And who would you rather trust with running a health care system: The CEO of Enron, Bear Stearns, AIG (AKA the same people who thought it was a good idea to give loans to the homeless and count debt as profit because in our free market they were allowed to do so) etc. or an organization which can get a letter/package from L.A. to NYC in 3 days for $.48?? Who do you think is more effecient?

Patrick M said...

Toad: First of all, I did leave prevention out, probably because I don't really think in those terms (I'm not even sure who I'd put down for a doctor if I needed to fill something out).

However, I do have an answer: The way you create a desire for preventative care in America (as we don't usually go for a doctor until we're half-dead) is through insurance policies that severely cut rates for people who meet certain criteria (screenings, checkups, good BMI, etc). And many of those people just need the high-end coverage only, rather than medical coverage for a case of the sniffles.

And I did cover the elderly and the children (mine are part of your statistic). There will be ways to get them cared for.

Strangely, in bringing up the Canada example, you leave out the number of Canadians (and others) that seek help in this country when they can't get to a doctor in a timely fashion. And strangely, they're reversing some of the stupidity they passed (you can now pay for a doctor's services in Canada if you choose. And half of what you bring up is culturally driven.

Nothing in here to address why Americans pay 50% for prescription drugs than the rest of the world including those countries with universal healthcare who can monitor and set limits to prices.

2 points. First, if we had to pay more out-of pocket for those drugs, sales (and then the price) would go down. Second, part of our markup is to make up for the price fixing of other countries.

As for my pro-lifitude, don't confuse any statement where I say my philosophy is generally pro-life with being an assembly-line pro-lifer. My goal is to save as many lives as possible with limited funds. So yes, someone who keeps sucking off the system after many chances to get it right should be allowed to die. And if that idea hits close to home, it's not something that was out of my mind when I wrote it.


Now as for tort reform, it's a matter of correcting the system to protect doctors from abuse. On the other hand, when a doctor fucks up (see the boy pictured above for an example), then they should pay big. But part of the expense of health care is in CYA medicine, as well as every other aspect of life.

And who would you rather trust with running a health care system?

No one. First, the responsibility of managing health care should fall to the individual. Second, freeing insurance companies from idiotic regulations and limitations on how they can offer coverage is critical. However, clear oversight and regulation of a government charged with watchdog duty (and nothing more) for the rights of each individual and corporation is the capstone.

In short, no one group can be fully trusted. And the more diffuse the power is, the closer we are to really having control over health care.

Satyavati devi dasi said...

I keep having to go back to the bare facts that outcomes (which are, despite what you may think, THE POINT) in our system are worse than in every other industrialized nation on the planet (who all have single payer systems or close to it) and in many areas worse or on a par to developing nations.

I am not sure what it takes for you to realize this. Our preventable death rates-deaths caused by nosocomial infections, procedural errors, med errors...ie, things that can be PREVENTED during intervention... are the highest around. Our infant mortality rates are outrageous. We suck, people. Why do we suck? Because the system is not driven towards providing good care. The system is driven towards making money. This means we cut where ever we think we can get away with it. We use cheaper, lower quality supplies, and less of them. We cut staff to bare bones and work them crazy hours, encouraging fatigue-related mistakes and accidents. We use old equipment that is not always safe. We roll patients over and discharge so quickly that care isn't complete. Because we're not worried about curing the patient-we're worried about making money.

Any system that has X resources uses triage to allocate those resources. Triage means prioritization. Now, you, the patient, may not agree with where I've placed you on my priority list. This is because you don't know, and don't give a shit, about any other patient I have to deal with. In macro terms, this means that if someone in Canada or elsewhere isn't happy with the fact that someone needs treatment more urgently than they do, they can (if they can afford it) bring their happy asses to America and buy their way to the front of the line. In America, we view this as 'Canadians aren't getting the treatment they need'. In reality, it's that a patient isn't happy with the fact that someone is sicker and in more need than they are. That's the fact, gloss it as you like. If you have a headache and I have someone with difficulty breathing, your headache, no matter how urgent you believe it is, is going to wait. No matter how angry it makes you, no matter how pissed off you get, no matter how you spout off about the 'lousy treatment' you're getting, the fact remains that someone who cannot breathe is a more urgent priority than your headache and is going to be treated first.

The American public is deluded about our own healthcare system and those of other countries. We need to look at what REALLY matters: the patient's outcome. Nothing else should come before that. And the fact of the matter is that we have piss-poor outcomes compared to other nations, who pay a fraction of what we do for healthcare.