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Posted by: thepinetree on 05/10/2017 12:41 PM Updated by: thepinetree on 05/11/2017 10:03 AM
Expires: 01/01/2022 12:00 AM

Sickness Unto Death: An American Dilemma. Part One ~ By John MacWillie, Ph.D.

Murphys, CA...Introduction: The United States is alone among industrialized nations in using wealth as a gatekeeper for access to health care. The wealthier you are, the more and better health care you get. The national debate that is now taking place focuses on whether every individual, irrespective of their income, should have access to great health care.

This is a series of eight articles on a single theme to be released once a week.  Copyright license granted under  

The United States is alone among industrialized nations in using wealth as a gatekeeper for access to health care. The wealthier you are, the more and better health care you get. The issue isn't about efficiency (keeping costs down) or efficacy (performance), it is about whether you have the financial wherewithal to be able to see a doctor, have surgery, visit a mental health professional, or afford prescriptions. The national debate that is now taking place focuses on whether every individual, irrespective of their income, should have access to great health care.

From Medicare to Obamacare

Before 1965 and the creation of Medicare and Medicaid, if you were elderly or very poor, the answer was definitively no. In 2003, President George W Bush signed legislation to expand coverage to include prescription drugs. But the working poor, those working for small companies, individuals with pre-existing conditions, students, and those seeking employment -- a population in the tens of millions -- were still not covered by these programs. The Affordable Care Act (ACA) of 2010, more popularly known as Obamacare, sought to address these concerns by mandating increased coverage for those with pre-existing coverage and a host of other changes.


The House of Representatives recently voted by the narrowest of margins (217-213) to radically alter Obamacare. While the primary associations of doctors, nurses, hospitals, and mental health professionals have been quick to criticize what is becoming known as Trumpcare, most Americans are confused by the bewildering debate and changes in insurance plans. Over the next several months, while the Senate and the Congressional Budget Office weigh in on what House Republicans have adopted, it is time to consider why coming up with a good health care system is so contentious.

The Republican plan, known as the American Health Care Act (AHCA), would provide tax credits in lieu of subsidies for insurance premiums, eliminate Federal mandates for insurance coverage, establish high risk insurance pools for those with pre-existing conditions, provide limited underwriting of these pools for a short period of time, and authorize health care savings plans. In its original form, the AHCA flamed out when the non-partisan Congressional Budget Office (CBO) forecasted that 24 million people would lose health coverage by 2024. (CBO March 13, 2017). That does not include the 28 million citizens without insurance today. Even with this projection, the most conservative wing of the Republican party known as the Freedom Caucus rebelled against any protection for citizens with pre-existing conditions. Because the House rushed the adoption of the latest version of the AHCA, we will have to wait for a revised CBO analysis. But, even an early reading of the bill reveals that the numbers of those who will lose their health insurance will be substantially higher. The AHCA is opposed by the American Medical Association, The American Hospital Association, and the Catholic Health Association. Republican Senate leaders have already indicated they will ignore the House bill and write their own.

California's Single Payer Proposal

In California, legislators are moving forward with an alternative to all of these programs with a proposal to create a single payer health care system for all residents of California. (CA Senate Bill 562).

The Great Question

The difference in these programs and proposals mirror the divisive debate in America on how (and whether) everyone in our society can (or should) have the opportunity to live longer, healthier, and satisfying lives without creating a burdensome regulatory environment and bureaucracy to administer this opportunity.

What We Need to Know

The challenge of health care governance for policy-makers and politicians, as well as the general public, arises from: a.) a lack of knowledge about how the health care system works; b.) the lack of consensus over goals and objectives for health care; and c.) fundamental differences in what role the government should play in health care delivery. For something so vital to all Americans, these are big problems.

How Little We Know

First of all, most of us do not appreciate just how complicated health care is and how little we know about its cost and performance. Consider the fact that the United States spends $600 billion for defense (armed forces, civilians, equipment, operations), while, at the same time, we spend nearly 8x more -- $4.6 trillion -- for health care services (doctors, hospitals, drugs, long-term care). Ironically, there is more publicly available information about the fire and flight control problems of the Pentagon's F-35 Joint Strike Force Fighter than about the effectiveness of cancer treatments.

Healthcare is a Question of Ethics

Second, the goals and objectives of health care services are not only economic (how much) and political (who controls) questions, but emotional and ethical ones as well. Consider the decision process about a patient with catastrophic anoxic brain injury (i.e., persistent vegetative state). Whether the doctor (for reasons of viability), the patient's family (for hope), the government (for policy), or the insurance company (for cost containment) makes the decision to terminate life support, it is still an ethical choice. This decision matrix complicates many, if not most, health care related decisions.

Who Makes the Decisions

Third, this leads to the question of who makes this kind of decision. Most people, if asked, would assert it should be the patient or his or her family. But in many cases, the final decision is made by those paying for the care: the hospital, insurance company, or the government. From its inception until the end of 2016, half of the country opposed Obamacare largely around concerns about the insertion of the Federal government into healthcare decision-making. By the beginning of 2017, twenty-five million Americans had been given access to health insurance through Medicaid expansion, insurance subsidies, or direct purchase and the latest Gallup poll now shows that 55% of Americans support Obamacare, while 41% oppose it. (Gallup April 4, 2017). Opinions shift relative to perceived value.

In the Coming Weeks

In this series of columns over the next month, I will examine why health care, as policy and as practice is so complicated, why we as Americans are sicker and die earlier than residents of other countries, why our health care is so expensive, why the answers to these questions have a particularly grave importance for rural America, why the system that Obamacare tried to fix was so broken, and finally, the political question of whether health care is a right or responsibility.

[To be continued next week]

The copyright for this series of articles is held by John MacWillie and is licensed for distribution without royalties for non-commercial use under a Creative Commons License with the restriction that the content is copied in-whole and sole attribution for authorship is prominently displayed consistent with the title of individual article(s) or the entire series.

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No Subject
Posted on: 2017-05-10 13:01:14   By: Anonymous
As long as they remove the mandate and figure out some way to pay for it then that is progress.

[Reply ]

    Posted on: 2017-05-10 14:42:01   By: Anonymous
      Edited By: thepinetree
    On: 2017-05-10 15:26:44

    [Reply ]

    Posted on: 2017-05-10 15:29:28   By: Anonymous
    Agreed it's a freedom issue. That's the line in the sand. Forcing people to buy something makes it a non-starter for many.

    You can choose to not drive. You shouldn't be forced to buy something just because you are breathing.

    [Reply ]

      Posted on: 2017-05-10 16:02:02   By: Anonymous
      "Freedom issue?" How, exactly?
      The word freedom, implicity, means you are making a choice.
      No one chooses get sick.
      How about this? People who pay for health coverage receive the treatment they've paid into the system to receive.
      Those who used their "freedom" to not buy coverage will be turned out at the hospital curb.

      [Reply ]

        Posted on: 2017-05-10 16:23:14   By: Anonymous
        Well if they choose that then they choose that.

        [Reply ]

          Posted on: 2017-05-10 17:45:06   By: Anonymous
          But they won't. They'll show up at the ER needing care, and hospitals (by law) will have to treat them.
          And those costs will be piled on to the premiums of people who were responsible enough to buy insurance.
          See how that works?

          [Reply ]

            Posted on: 2017-05-10 18:07:21   By: Anonymous
            Before many hospitals and organizations were public about it and counted on it as part of their community outreach and public benefit. Straight right off against expenses and they could fundraise etc to provide indigent or community care.

            Now it just seems to be buried

            [Reply ]

              Posted on: 2017-05-10 18:15:24   By: Anonymous
              The problem with some of this is many of the backers of Obamacare etc. Have no faith in their friends or communities. People will help local hospitals and organizations provide core community benefits without forcing taxes on people or extorting money from them.

              Remember the old story about the sun and the wind arguing about who could get a man to remove his coat first? The wind blew, forced and practically knocked the man down. All he did was keep his coat wrapped tighter.

              The sun came out the man smiled and voluntarily removed his coat. It is human nature. You can raise more money for community healthcare through donations and community fundraising that by government extortion.

              People are generous, people will help care for their neighbors if you allow them to. Look at the millions that are now raised by gofundme and more from even strangers.

              It is not a binary question. Without government run healthcare it does not mean people will automatically die. We have replaced human kindness with institutional bureaucracy.

              [Reply ]

                Posted on: 2017-05-10 18:19:34   By: Anonymous
                Most people would pay a reasonable cash payment for a routine office visit. The problem is the costs are all inflated and skewed by third party payer that common sense is out the window and in some cases it is against the law to pay a Dr. directly for services. And then you wonder why the system is broken and costs are out of control

                [Reply ]

                Posted on: 2017-05-11 11:14:14   By: Anonymous
                I'm glad there are charities that help people with health care costs but it is not possible for the whole nation to rely on that. Some communities are too poor to do it, some are too large and impersonal to have any assurance everyone would be supported (e.g., NYC), and, in the end, there would not be nearly enough money.

                In the end there are only two ways to make sure everyone has access to health care. One is to have it be a government benefit, supported by everyone's taxes. It would mean a large tax increase but it would be offset by not needing to buy health insurance or even for businesses to provide insurance if we opted for the full socialistic solution. The other is some version of Obamacare where there is an individual mandate to have insurance, thus assuring that the insured pool includes lots of healthy people along with the sick. Insurance can't work if only sick people buy insurance.

                Trump and Republican promises to reduce premiums, expand coverage and make everyone's health care "great" is just ludicrous. Obamacare already limits insurance company profits so there is no way to improve coverage AND lower premiums. Doing both those things at the same time requires adding MORE money to the system, but Trumpcare pulls money out by removing the Obamacare taxes on the rich AND by cutting $80 billion/year out of Medicaid. You don't need to be an economist to realize you can't get more coverage or better coverage by taking $ billions out of the system.

                [Reply ]

                Re: Neighbors will pay for neighbors
                Posted on: 2017-05-15 15:00:07   By: Anonymous
                I'm curious where you live. Do you have neighbors who actually offer to cover the expenses of Alzheimer patients? Cancer patients? Those needing long-term care facilities? If so, I'm ready to move to your community.

                In the rural community where I live, there are so many people poor and out of work there is no way neighbors, regardless of how generous and kind hearted they might be, could afford to help all of them, not even one of them. If the poor get sick here, they simply stay sick. If the illness is terminal, they simply die.

                So is healthcare a right? Should only those with $s in the bank who can afford insurance be the ones who get treatment? Should the treatment you receive be governed by how much you can afford to pay? I'm looking forward to reading the upcoming articles on this topic. And I'm hopeful that I don't get sick and have to depend on Trumpcare.

                [Reply ]

              Posted on: 2017-05-10 18:17:22   By: Anonymous
              It's not buried. They very openly inflate charges to insured patients insurance plans to offset the costs of the uninsured.
              Everyone uses healthcare. Everyone should have to pay their fair share.

              [Reply ]

                Posted on: 2017-05-10 18:25:18   By: Anonymous
                What if Walmart did that for everything? What if you went shopping and you never knew how much anything cost?

                How about an old fashioned model of $100 cash for reasonable length office visits etc. Many providers could keep a small office with 20 - 25 patients per day.

                [Reply ]

                Posted on: 2017-05-10 18:28:21   By: Anonymous
                The system is rigged to punish those who would like to pay as they go. They want to force third party payer where 20 - 40% of every healthcare dollar is wasted chasing procedures around and between billing departments.

                [Reply ]

        Posted on: 2017-05-10 18:35:17   By: Anonymous
        tort reform and open pricing would do wonders. Third payer has made $400 dollar hammers and toilet seats in the military look like bargains.

        One thing that never seems to discussed is that why tort reform dies is that the lawyers all want deep pockets to go after.

        [Reply ]

No Subject
Posted on: 2017-05-10 13:06:06   By: Anonymous
John MacWillie: I see you are a PhD but please tell us a bit more about your background and expertise in the US health care system. I'm assuming you are planning more than an extended opinion piece, and I'd like to know what expertise you bring to the discussion.

[Reply ]

Fake News Alert!!
Posted on: 2017-05-10 13:47:07   By: Anonymous
You claim "The United States is alone among industrialized nations in using wealth as a gatekeeper for access to health care."??
I gotta call BS on your claim.

For decades before Obamacare upset quality healthcare in this nation, citizens from Canada and various European nations came to the USA for premium healthcare procedures because they were tired of waiting on lists in failed socialized medical care plans.
That cost them serious money, despite the exchange rate.

You may not like the way the barnyard's being run, but don't fling around your barn-carpeting.
You just sound like one more whining liberal shill. Get over it!

President Trump is Making America Great Again.

[Reply ]

    Re: Fake News Alert!!
    Posted on: 2017-05-10 14:42:27   By: Anonymous
      Edited By: thepinetree
    On: 2017-05-10 15:26:14

    [Reply ]

      Re: Fake News Alert!!
      Posted on: 2017-05-10 14:50:12   By: Anonymous

      [Reply ]

    Re: Fake News Alert!!
    Posted on: 2017-05-10 15:36:44   By: Anonymous
    You are an idiot if you think this lying, raciest egomaniac
    will help you and me
    Hillbillies are brainwashed, I really wonder if they actually have one though

    [Reply ]

      Re: Fake News Alert!!
      Posted on: 2017-05-10 17:06:15   By: Anonymous
      Hillbillies?? HILLBILLIES??!!
      You nosepickin, dirtbank levee dwelling flatlander!
      Go back to the valley you left because it was destroyed by liberal progressives.

      [Reply ]

        Re: Fake News Alert!!
        Posted on: 2017-05-10 17:13:19   By: Anonymous
        I have lived and worked here, for many years you ignorant uninformed F--k,
        Instead of spending you day being the dumbs-t hillbilly you are go get job and save the welfare for someone that needs it
        Again the statement from some Trump supporter that doesn't get it

        [Reply ]

          Re: Fake News Alert!!
          Posted on: 2017-05-10 23:14:08   By: Anonymous

          [Reply ]

            Re: Fake News Alert!!
            Posted on: 2017-05-11 00:16:48   By: Anonymous
            Thank you for that barely literate comment. Maybe we need somebody to investigate why our education system turns out people with 3rd grade level skills.

            [Reply ]

              Re: Fake News Alert!!
              Posted on: 2017-05-11 16:21:46   By: Anonymous
              Yeah, you can always tell a liberal democrat by their display of ignorance and hate.

              [Reply ]

    Re: Fake News Alert!!
    Posted on: 2017-05-15 15:08:11   By: Anonymous
    To each his own. You are entitled to an opinion. Others are also entitled to an opinion. If you don't agree with the article, then write your own series using the same categories as the author.

    I personally find this first article well thought out and thought provoking. He is raising solid questions and issues. We don't know the logistics of our health care system. Even Trump admitted that he had no idea how complex is the issue of health care in the US.

    The author has not criticized either the ACA or the AHCA. He's simply stated what has occurred, and identified areas of consideration. If you can't be open-minded enough to recognize we need to think about the issues versus blindly accept whatever the federal government throws at us, then I feel for you. This should not be a political establishment issue, but it seems people like you want to make it one.

    [Reply ]

No Subject
Posted on: 2017-05-10 14:58:02   By: Anonymous
Whether access to healthcare is a human right or not is ones individual belief. What is not up for debate, is the overall cost of healthcare. 99% of people get screwed on healthcare in this country. The entire system from the ground up has to be changed for healthcare to be affordable. A lot of wealthy people are going to loose a lot of money, but it has to happen to benefit us all in the long run. And Trumpcare is absolutely no where close to the answer.

[Reply ]

    Posted on: 2017-05-10 16:15:07   By: Anonymous
    Its close to the answer of rich people not losing money
    The new bill is set up to help the rich only
    What a surprise!!!

    [Reply ]

      Posted on: 2017-05-10 20:27:31   By: Anonymous

      [Reply ]

        Posted on: 2017-05-11 11:08:36   By: Anonymous

        [Reply ]

          Posted on: 2017-05-11 22:14:14   By: Anonymous
          We'd all save healthcare dollars if John Hamilton stopped eating so much and packing it on his FAT ASS!

          [Reply ]

No Subject
Posted on: 2017-05-11 22:27:03   By: Anonymous
I have auto insurance, home insurance, dental insurance, vision insurance, none of these are run by the government, please explain why the government has to run my health care?

[Reply ]

    Posted on: 2017-05-12 08:19:48   By: Anonymous
    No explanation , the Post Office is a good example . Big government , big problems.

    [Reply ]

    Posted on: 2017-05-12 13:15:07   By: Anonymous
    Just wait till the government tries to manage your well water.....I thirst....

    [Reply ]

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