The problems of medical care in the United States

As the question of what to do about Obamacare heats up we're going to hear a lot about medical care in our country. I'm going to do a few posts on the subject. As usual I have some controversial opinions but I can't be accused of being uninformed since I know the system well from the inside and from many aspects. Early in my career I spent almost 10 years working in a county clinic in California, seeing indigent patients. Then there were 36 years in solo private practice. Along the way there were stints as a doctor in the army and in the VA system. I even was Scranton's city doctor for a year or two. At present I'm spending some time in the free clinic at the U of S seeing "undocumented" patients. 

I received my training in the pre-Medicare days and observed the transition to the program between my internship and first year of residency. So I've witnessed the full extent of the slow and steady impact of government invasion of our medical care.

The critics of our system say that we're spending twice as much on medical care as the other advanced countries but not getting as much in return. I disagree with the assessment of what we're getting but you'll get no argument from me about the present state of medical care in our country. Medical prices are way too high generally and the way they impact different segments of the population is totally irrational. Medical care delivery has become ridiculously complex and is restrained by our system from serving the public efficiently. 

Some say that the solution is to let the government take over. That is a bizarre idea. To paraphrase the sainted Ronald Reagan, the government is not the solution to the problem, it is the problem. Most people don't realize that government at one level or another already pays for 65% of medical care in our country as opposed to 75% in Canada. Government control is not a way to save money or improve efficiency. 

In the last few years we have been watching the dismantling of small independent medical practice at an accelerating rate. It is now down in the 35% range. Solo medical practitioners are almost a thing of the past. One recent commentary by a health care planner points to the natural trend toward consolidation in other areas of our economy. But what's going on in medicine is not a natural phenomenon. It is rather the result of a grand experiment by the federal agency that controls medical care in our country, the CMS. And it is a tragedy, not so much for doctors, who will get along, but for patient care. I read an article recently encouraging doctors to face their computer screen toward the patient and glance over the top occasionally to maintain eye contact. How pathetic!

Public/private partnership. How the government works.

By almost any measure our economy continues to stagnate, eight years after the bursting of the housing bubble. GDP is 1-2%, labor participation rate is at an all time low, average income is declining and the Federal Reserve has been laboring mightily to keep things afloat by zero interest rates and flooding the money supply.

The keystone of Mrs Clinton's plan to address our troubled economy is to build a "public/private partnership which will make the biggest investment in good-paying jobs since World War II". Public/private partnership -  fine sounding words but what exactly do they mean? I think the idea here is that the really smart people in government know what the public needs and the big business guys know how to make and do things so getting the two together would make everything hunky-dory. However, it sounds to me like something we already have a lot of, what many critics are calling crony capitalism.

What exactly is this government thing that we speak of in the abstract. Leaving aside the judiciary, it's pretty much just a collection of politicians and bureaucrats, and just like you and I each of them are trying to make out as best they can and live as pleasantly as possible. And if you follow the money they're doing pretty well considering that 5 of the 10 richest counties in the U.S. are collected in the Washington, DC area.

These government people refer to themselves as public servants, but just what do these servants of ours do for us and how have they gotten so much wealthier than their masters. Well they do have meetings, give speeches and run agencies so they must have salaries and benefits for that like everybody else but that would hardly make you so much richer than the rest of us. Of course their company is pretty generous seeing that it prints and borrows money without a lot of fuss and has a very efficient collection agency. But the real key to their success is the other thing they do, passing a lot of laws and regulations, most of them having to do with collecting money and doling it out again. And that's where the "public/private partnership" comes in. Controlling tax laws, mandatory regulations and handing out government contracts makes you really popular with the big boys and is the key to figuring out why it costs a hundred million dollars to run for a job that pays a couple of hundred thousand.

Perhaps my cynical view of the federal government comes from watching its steady destruction through the years, now accelerating, of medical practice.  On the other hand what with the pervasive video cameras and hackers it's getting to be difficult to keep secrets in this modern era so that my attitude seems more justified every day.  Perhaps I shouldn't just accuse Mrs. Clinton since both parties are up to their necks in this muck. But she and Mr. Clinton seem to be world class experts at this game and will do everything they can to keep it going. Mr. Trump is a bit of an unknown quantity but he's got some good friends advising him, doesn't have a lot of political obligations and seems like the best chance we've had for a shakeup in a long time.