If the current healthcare debate in America could be measured in aggregate blood pressure readings, the results might put cardiac specialists on high alert.
Reminiscent of the volatile civil rights era and Vietnam War protests, the healthcare debate has split America into extremely contentious factions.
Democrat-sponsored town hall meetings erupt in verbal free-for-alls. Marchers on Washington carry signs depicting President Obama in full Nazi regalia.
Conservative pundits bash their liberal counterparts with the liberals giving as good as they get.
Whether limited to dinner conversations or Denver-area synagogues over the High Holidays, the various scenarios of healthcare reform are played and replayed.
Who deserves coverage? Who pays? Will reforms help or worsen the situation? Do we need more government in our lives, or less? What about the role of insurance companies in bringing down costs? Who is ultimately responsible for health care the government or the private sector?
The proposed healthcare bill seeks to expand coverage to all Americans who lack coverage, employ a new system of federal subsidies for lower-income individuals and families, and establish an insurance exchange in which coverage would have federally guaranteed benefits.
It would also prohibit insurance companies from denying policies based on pre-existing conditions and limit higher premiums based on age.
Implementing the reforms will cost an estimated $900 billion over a 10-year period.
The Intermountain Jewish News held a recent roundtable on the current status of US healthcare and the proposed reforms.
Participants were:
Dr. Gilad Gordon, Harvard-trained physician, expert in healthcare economics, now a consultant- researcher in biotech sector as president of Orra Group;
Dr. Floyd Russak, Harvard- trained medical director of the East-West Health Centers, Colorado Medical Society board member;
Rich Sokol, Yale economics graduate, managing partner of Lakeview Investment Group, conservative activist;
Dan Kopelman, president, Jewish Republicans of Colorado, former policy analyst for Cong. Tom Tancredo, conservative columnist; and
Linda Weiss, mother of the late Aaron Weiss, who lived with AIDS for 21 years.
Armed with statistics, opinions, convictions and predictions, this multi-faceted group engaged in an informed debate that was both direct and considerate.
One IJN staffer, who encountered the group in the hallway after the session concluded, remarked on the lack of emotional fireworks.
Now we take it outside to the parking lot! one participant joked.
Here, in edited form, are transcripts of the IJNs healthcare roundtable.
IJN: The majority of Americans seem to agree that some form of healthcare reform is necessary. What do you think we need to do if anything?
Rich Sokol: How much time do we have?
(Laughter.)
Dr. Gilad Gordon: Let me get on my bandwagon. The key issue is reforming health insurance companies. Let me be specific. When you take a 30,000-foot view of the American healthcare system, where do the dollars go? Forty percent goes to administration, and that to me is really the crux of the issue.
Twenty percent of the money given to insurance companies stays with the companies. And not all of the 20% is profit. It goes toward quality insurance programs, salaries, other aspects.
Does it provide much in the way of healthcare benefits? As a doctor I would argue that this amount is minimal. And all my friends who are physicians spend another 20% of their dollars trying to collect money from the insurance companies.
I saw my ophthalmologist recently. Hes in a group of four ophthalmologists. The practice employs six people to work solely on insurance. This means that for every 10-minute patient visit, somebody spends 15 minutes attempting to collect from the insurance companies.
More time is spent on collecting money than seeing the patient. This accounts for 40% of healthcare dollars.
Unlike everywhere else, where there is tremendous productivity due to computerized systems at the administrative level, the insurance companies work hard not to have an efficient system.
When I talk to insurance companies about this, their comment to me is, Live on the float. We dont want an efficient system because it eliminates our ability to make as much money.
We have to reform that 40% administrative cost. A lot of people are employed (in administration). It would take a big economic toll. Still, whatever system is put in place must address that overhead more than anything else.
Sokol: Its easy to demonize the insurance companies. Nobody loves their insurance companies. I just saw a statistic that said if you took the profits of all the nasty, greedy insurance companies, they would pay for four days of health care. Four days! Their profits are not the problem.
Dr. Gordon: I wasnt talking about profits. I was talking about administrative costs.
Sokol: Obama is trying to inject more government into the healthcare system. Granted, theres a role for that regarding the indigent.
But lets look how Medicare and Medicaid factor into cost. I recently read a study that says Medicare and Medicaid have actually done a worse job over the last 30 years when compared to healthcare costs as a whole.
People will tell you that Medicare does nothing about fraud prevention or (studying) best medical outcomes. In my mind, they are broken systems. They are government run.
To think that the government can improve the situation by getting more involved, when their track record has been horrible, is insane.
Dr. Floyd Russak: I think Medicare does an excellent job in fraud prevention. A lot of people have been caught trying to defraud patients. In fact, most doctors are already spending too much time on fraud prevention. We have to prove that weve done everything we say we’ve done, which is a little stressful.
Health insurance companies do waste a lot of money. The amount of time doctors spend on meeting insurance guidelines is sort of a game we all have to play. If you put in this code, youll get paid. If not, you dont get paid. You have to sit down and figure out how to code everything.
Dr. Gordon: There is no uniform insurance form. Each company has its own form. They dont want to use the same form.
Dan Kopelman: The insurance companies want to earn as much of a profit as they can which makes them as efficient as possible. Its a little bit silly and disingenuous to say that they intentionally want a complex paper system.
What they would like to have are reimbursement levels that are so well defined that they know exactly how much to pay a medical professional for any given procedure.
Dr. Gordon: They dont want you to have an easy time collecting a payment.
Kopelman: You know those two- and three-inch books that list the codes for every procedure? The government expanded them, and thats what insurance companies have to use.
Sokol: I think were getting off track here.
Linda Weiss: Im in a totally different position than all of you. My son Aaron died of AIDS. We adopted him when he was two-months old. Then we found out his birth mother was HIV positive. They told us he would die before he reached the age of five, and that there was no need to apply for Medicaid because he would be dead before it went into effect.
But we fought like hell to get the coverage. Later he developed severe kidney issues that made him eligible for Medicare. Had he not been on those two systems . . .
We had private insurance. Were middle class. Thats tough enough, because I have medical issues. But without Medicare and Medicaid, we wouldnt have been able to keep him or keep him alive.
So while youre discussing forms and logistical problems, I can talk from the personal side. (Without government mandated healthcare assistance), my son would have been discounted and dead by the time he was five.
But he lived to the age of 21 because he could go to doctors and hospitals where we received the best care. Of course, I fought for that too.
Maybe the healthcare system needs reform. Maybe it needs to be different. But it needs to be there and not just for the lower classes and the poor.
When a person develops a medical condition like my sons, there has to be a fallback position. The medicines were fantastically expensive. We never could have afforded them.
Sokol: You were a hero.
Weiss: He was a wonderful child.
Kopelman: Certainly its hard to find anyone who disagrees that something must happen with our healthcare system the system itself, not just insurance.
The role of insurance companies that has come to the forefront of the current debate, and claims of profit and overhead, are easily and readily manipulated by both sides.
Ignoring all the infrastructure costs and all the other costs involved when a private entity, whether for profit or not-for-profit, establishes a business and has to insure people, is disingenuous. Regulation is inflicted on the private sector every time.
When Medicare says, were not going to allow physicians to treat patients gratis or we will take away your ability to treat Medicare patients, thats regulatory. That says that there are not going to be any costs eaten by the physician that can be attributed to Medicare.
On the other hand, a law is created that says anyone going into a medical office who has a co-pay must pay that co-pay before leaving the office, thats the governments way of balancing things out.
But it sure doesnt make for a cooperative effort between an insurance company or even a doctors office and the patient. So there are tradeoffs.
When I was in DC, HIPAA (the Health Insurance Portability Act enacted by Congress in 1996) was going into effect. I spent several hours arguing and yelling because part of the regulations said that a nurse couldnt have a discussion with another nurse about a patient unless they were in a soundproof booth!
Weiss: Its called an elevator.
(Laughter.)
Kopelman: Its regulatory overhead that adds to cost and limits the ability of physicians to do their job. Regulatory overhead is crushing health care.
The other thing thats looming, and being completely ignored, is tort reform. Doctors are forced to practice a huge amount of defensive medicine. The concern is, will this patient Im treating now sue me later?
Governmental involvement is the real issue. Its overtaking everything. Charitable institutions filled the void in the past. Now its become too complicated and inefficient and ineffective. Thats where we need healthcare reform.
Dr. Russak: The burden on physicians and hospitals comes not as much from government regulation as health insurance bureaucracy. None of us really like HIPAA. Its a poorly written bill.
You wont find any doctor anywhere who says, I spend 15 minutes out of every hour dealing with HIPAA regulations. To comply with HIPAA in the doctors office, you basically have to turn the chart around so no one can see the patients name, you cant talk about patients in the elevator and a few other things.
Thats nothing compared to worrying several hours a day about how were going to deal with the insurance companies.
I would argue that a major reason that health insurance companies contribute to the high cost of healthcare is by delaying payments, or not making payments, to doctors and hospitals. Thats the game we play.
IJN: Within the framework of Obamas healthcare proposals contained in the Baucus bill, whats the single most important issue you feel should be passed or defeated?
Sokol: Gilad, you spoke about looking at the real costs. I think were getting too bogged down in intricacies that wont make a big difference.
The incentives in our current system are entirely wrong, on both the doctor and patients side. Anything we do that tries to patch the problem isnt going to work. Patching is just going to create another hole.
There are two huge problems with our system.
First, there are the incentives affecting doctors. Doctors get paid for the number of treatments they provide. They are not paid according to a diagnosis code. If someone presents with a bad shoulder, doctors are paid only if they treat it. They have every incentive to treat. The more tests they order, the more money they collect.
The second problem is also connected to treatment. Doctors dont want to get sued. The more tests they order, the less they are liable. Doctors have every economic and legal incentive to treat as much as they can.
Now most doctors are good people. They may try to put this out of their minds, but in reality its always there. Until we change that, the system will remain broken.
Dr. Russak: So far I agree 100%. It sounds like youre quoting one of my lectures.
Sokol: I take back everything I just said!
(Laughter.)
Dr. Russak: When you practice in an academic setting, the first thing your supervisor asks you is, Why didnt you order an MRI or why havent you done a CAT scan? So yes, you are encouraged to perform more tests.
Sokol: Lets look at consumers who use medical services. Most of us are paying up front through our insurance company. It costs me next to nothing to get a procedure done or go to the emergency room. Ive already paid my insurance company or my employer has paid my premium.
If I have a little ache or pain, Im going to the doctor because, in my mind, its free. And because I dont have to pay, Im going to use it a lot.
Its like anything else. As one of my friends said, If my electricity is paid for, I leave my lights on. If Im paying for my electricity, I leave them off. The same is true of medical care.
The incentive for doctors is to prescribe a lot of tests, and the incentive for consumers is to request a lot of tests.
Dr. Gordon: I think there are two areas where you want to pay for health care up front: early childhood care, because you dont want a mother holding back from her child; and vaccinations. Otherwise, I agree that the incentive system is wrong.
Dr. Russak: I dont find that patient requests for tests are a huge part of the cost. Generally, patients dont come to me and say, I want an MRI. Well, whats wrong? Oh, nothing. I just want an MRI.
(Laughter.)
Kopelman: Why is there no mandate on the table for catastrophic coverage only? There is no reason that first-dollar prepaid medical coverage (the current plan) should be mandated. However, there may be one reason to have catastrophic coverage bankruptcy.
If theres going to be some sort of mandate for everyone who is alive and living in the US legally or not, I dont even care its catastrophic coverage.
Sokol: I thought we were on the same side!
(Laughter.)
Dr. Russak: As more and more insurance companies move toward $1,500-$5,000 deductibles, people are going to delay care.
If you want to design a system that wont be cost effective in the future, design a system where a person says, Im having chest pain, maybe its just heartburn, I dont really want to go to the doctor and pay $300 for a test, lets wait and see.
Then he has a heart attack. And when hes better he says, Great, I got to use up $3,500 of my deductible! when he could have gone to a doctor first and prevented the heart attack.
I believe mandated insurance is essential. Of course, eventually well have to establish cost controls. I also think the insurance companies are willing to give up the pre-existing illness clause if everyone is covered.
As physicians, we all have horror stories. Say a patient comes in and hes having a heart attack. Hes rushed to the hospital, he survives, does very well, and there is no permanent damage to the heart.
Then the insurance company says, We discovered that you had chest pain from a broken rib you suffered two years ago, so we excluded chest pain as symptom of a heart attack.
Were very sorry, we know youve been paying $1,200 a month for health insurance as an individual, but we are not covering you this time. Now the patient is responsible for the $45,000 in medical bills that just saved his life.
(Silence.)
IJN: What in your personal experience as a doctor, patient, family member or friend has most influenced your opinion of healthcare in America?
Weiss: You know my story. Ive also lived under socialized medicine. Ive had experience on both sides. And my brother lives in Canada. Were constantly talking about the positives and negatives in the Canadian system.
Dr. Gordon: My father was diagnosed with pancreatic cancer and did extremely well. He lived for two and a half years, long enough to see my sons Bar Mitzvah. Through his eyes, I saw both the greatness and horribleness of the American healthcare system.
The greatness was that because of my connections I found a wonderful doctor at Penn who operated within two weeks of my fathers diagnosis.
The flip side was that my parents secondary insurance denied their claim. We ended up fighting this for years. The out of pocket expenses probably reached between $50,000 and $100,000. I finally said, We have to let this go. Luckily, we could afford it.
Sokol: At the end of the day, I dont think health insurance should be any different than auto insurance. I dont use my car insurance to pay for routine maintenance or oil changes. Its the same with health insurance.
But I think everyone in America should have catastrophic coverage. We have a great healthcare system if you can access it and afford it.
IJN: Does Judaism inform your approach to the healthcare debate?
Sokol: Theres a tendency in this debate to characterize conservatives and anyone else opposed to free health care as bad, evil, terrible people and that not covering everything for everyone contradicts Jewish ethics. I believe nothing could be further from the truth.
We need a healthcare system thats sustainable and doesnt bankrupt us. The current path that were on will bankrupt us and well all lose. Yes, we want to provide as much health care to as many people in the most cost effective manner possible.
But to say the government should cover and pay for everyone will lead to disaster. Tikkun olam also means being fiscally responsible.
Dr. Gordon: Medicine has always been a major part of Judaism, whether it pertains to tradition or my son the doctor.
(Laughter.)
Part of that tradition is trying to extend and improve the quality of life. And it really means improving the quality of life not only for the individual but also for the society.
The heart of this debate is determining what this really means to us. Are we talking about the current generation? Future generations? Finances? Improving health also is a crucial aspect of Judaism. The debate here is more about how you accomplish this for both the individual and society.
Kopelman: Tzedakah comes from individuals, not the government. We should get back to that. I dont think my position is any different for health care. Certainly, Hashem helps those who help themselves. The issue of responsibility is still up to the individual.
We just went through a holiday where we prayed to be sealed in the Book of Life. To some extent, I think this debate, while interesting, is really about returning to personal responsibility.
Dr. Russak: Im not a Jewish scholar. But Judaism is not only concerned with the individual. It is equally concerned about the community. I believe Jews were among the first people to realize that the public health of the community is very important.
[He turns to Rich Sokol.]
And I would also argue that the health of a human being is far more important than the health of a car.
Weiss: Even though each of us in an individual, we always consider ourselves part of a community. Our concern for the well being of our community is reflected in burial societies, loan societies and kupat cholim.
Its an intrinsic part of Judaism to strive for the best in ourselves, for our fellow Jews and for the society in which we live.
Why should it be any different with health care?
IJN: Why do you feel the issue of health care is so emotionally volatile?
Dr. Gordon: Its personal. It concerns yourself, your spouse, your children, your parents.
This hits home.
