Sunday, September 13, 2009

Bottom-Up, Incremental, Not Top-Down, Total Reform

Talk prepared for presentation at the Acton Public Library, Old Saybrook, CT, September 13, 2008, no given because of mix-up in scheduling

There are, it may surprise you to know, more public libraries than MacDonalds. No other civilization, ever, has had anything comparable to our public library system. Free to the public. You walk through the portals of the public library, and you are walking through the portals of freedom.

David McCullough, Historian

I am here tonight to discuss my book Obama, Doctors, and Health Reform.

I wish to thank Jan Crozier, head librarian here at the Acton Library, for setting up this meeting and for reviewing my book for a library association. I am a library junkie. I am deeply grateful for the services you offer here – access to books, computers, magazines, newspapers, videos, DVDs, meeting rooms, and, of course, ubiquitous courteous librarians, always available at our beck and call.

A Running Start

Let me start by saying, as a physician, I support incremental health reform, expanding coverage for the uninsured, and lowering costs. I am, however, dubious about the practicality of top-down total reform that pays for most care, dictates the terms of payment, interferes with the details of the patient-doctor encounter, pays doctors and hospitals at Medicare rates, which are 20% less than the private sector, and tries to completely overhaul 1/6 of the economy. I realize I am making a moral choice, but I do not think we can afford it right now.

Respectful But Skeptical

My book is respectful but skeptical of Obamacare. It begins by saying President Obama has overreached and over-interpreted his mandate. He has bitten off more than he can digest. It predicts the President will get 1/3 of what he wants. It ends with a toast and prayer for President Obama.


My message is ACDF. Government cannot, all at once, Absorb, Control, Dominate, and Finance the financial, automobile, energy, education, and health care industries.

That is not the American Way, as demonstrated by the town hall demonstrations of August and the taxpayer marches on Washington. In President Obama's eight months in office, if you position the U.S. on the capitalist-socialist scale as measured by the percentage of total government money spent compared to Gross Domestic Product, the U.S. has moved from 9th to 3rd among Western nations – from 36.4% to 49.6%, just behind Sweden at 57.0% and France at 54.6%. Grassroots America is concerned we are accumulating debt we can never repay.

That is why the town halls and marches on Washington are important. It is a case of a moral obligation to cover all against a fear of government domination with an encroachment on personal freedoms. It is uncertainty where this country is going, and 60% think we are going in the wrong direction.

To me reform is essential and overdue, but reform should be incremental. It should include, among other things, tort reform with caps on damages, prompt payment, and expert panels to decide what to pay; shopping across state lines for the best plan, similar to the federal health employee benefit plans now available to Congressman and Senators; and bare bones coverage with lower premiums for the young, the healthy, those making $50,000 or more now dissuaded from being insured because of unaffordable premiums; and insurance reforms, such as not excluding people for pre-existing illness or cancelling policies because of high costs.

My biggest fears are limited access to care because of the doctor shortage and expanded coverage, mediocre care, and uncontrollable costs.


I wish to acknowledge the presence of my wife, Loretta, a nurse who graduated from the Massachusetts General School of Nursing, and who deep insight into the problems of doctors and their patients.

I wish to also acknowledge the example set by son. From attending Spencer's poetry readings, I have learned two things: The importance in context and brevity. Spencer by the way, is a nationally known poet, who is candidate for the Episcopalian priesthood at Yale Divinity School.

Spencer’s influence brings to mind this poem,

Seek brevity.
With a touch of levity.
In short, be terse.
For nothing is worse.
Than verbal longevity.

I invite questions after I end my remarks, which will take about 10 -12 minutes.


I am a retired pathologist. Since I retired, I have diversified into writing 10 books and composing a daily blog, medinnovationblog.blogspot. com., which now has 977 entries. The Physicians’ Foundation, a non-profit organization representing 650,000 doctors helped finance the book. I have been interviewed on Royal Dutch TV and CNN about the book.

I have lived in Old Saybrook for 14 years with Loretta and Paris, a French bulldog of impeccable heritage. I love my wife, my dog, this town, and my friends. I meet 2 or 3 times a week at the Rivermart convenience store on Main Street with a dozen or so townpeople to discuss domestic and foreign affairs.

I worked for 6 months to write this 304 page book, which has been out for a month and which can be obtained at,, and, or by ordering through your local book store.

The book represents a doctor point of view and is biased. It is respectful but skeptical of President Obama’s plan for reform. As George Orwell, who has been on my mind lately because of his warnings about Big Brother watching you, every writer, whether he admits it or not, has a political bias which sooner or later shows through.

My bias? I am an unabashed cheerleader for doctors, and I think our input into the reform process has been too limited. I am not a big fan of big government which underpays doctors by 20% on average, threatens to cut their income each year through a SGR (sustainable growth rate formula), and just a month ago arbitrary cut cardiologists’ and radiologists’ fees by up to 50%. It takes 15 years to make a doctor, takes a big slice out or your working years, and often puts your $200,000 in debt before you start practice. And after all of that is said and done, you must deliver the reform, whatever it is.

Unifying Themes

My book has two great unifying themes - one, that the next big health care crisis will be lack of access to doctors as 78 million baby boomers become eligible for Medicare in 2011 and as we expand coverage to the uninsured ; and two, that exploding costs and mounting federal will result in rationing of care, particularly for Medicare recipients. That may be why only 31% of those over 65 approve of President Obama’s handling of health reform.

For what may involve as we evolve towards universal coverage, let’s look at the neighboring state of Massachuetts. Patrick Deval, governor of Massachusetts, who remarked of his state’s universal health plan, now 3 years old, “Universal coverage without universal access is meaningless.” The Massachusetts experiment indicates that without enough doctors to cover the 46 million uninsured Obama proposes to cover, we are likely to have limited access and rationing. Both will first take the form of long waiting times to see a doctor, now 60 days in Boston, twice that of other comparable u.S. cities, and will feature increased costs, already 30% above the national average in Massachusetts.

Let’s also examine the frequently heard statement that the system is “broken.” Mark Twain, who spent much of his working life time in Hartford. When asked about what he thought about Richard Wagner’s music, Twain quipped, “It’s not as bad as it sounds.” Likewise, I do not think President Obama’s characterization that the American health care system is as “broken” as he makes it sound.

In the last 5 months, I have had a heart attack, treated with stents at Yale, and cataract surgery, treated as the Constitution Eye Center in Waterford. In each case, the treatment was superb, and was, of course, covered by Medicare and supplement Blue Cross Coverage. I am fortunate in having insurance, like nearly 230 million insured Americans, and I am satisfied with the care I receive.

Obstacles to Reform

As I say in my book, I see four obstacles to Obamacare.

One, the American Culture, which distrusts Big Government which cherishes individualism, choice, and freedom and which demands choice and prompt access to the best American medicine has to offer. Incidently, the Whord Health Organization recently said the U.S., despite its high costs, ranked number one in the world, in patient “responsiveness.”

Two, Complexity. It is a tough if not impossible job to instantly superimpose a largely government-run system on our current employer-based system on an inefficient public system, in which Medicare and Medicaid costs are rising 30% faster than in private plans, no matter what you hear to the contrary.

Three, Costs. How are we going to pay for expanding coverage for 46 million uninsured without not adding “one dime” to the deficit, which has already doubled in the first 8 months of the Obama presidency. How are we going to cut $500 billion out of Medicare with 78 million babyboomers coming on board in 2011?

Four, Consequences. Dismantling or to use that appalling phrase, “overhauling” the system will have employment consequences. Collectively, health care, with 13 to 14 million employees, is the largest single employer of Americans and constitutes the only growing employment. sector Those health care sector include doctors’ offices, hospitals, home care, and yes, health plans and the agents who sell these plans and the health resource people who administer them.

President Obama Will Get Something

In spite of these obstacles, I predict President Obama will get something, probably about 1/3 of what he wants, including coverage of some of the uninsured, cancellation of current health plan polices of not covering those with pre-existing illnesses or cutting off of coverage for those with high costs, and other things, and things like shopping across state lines and lower premiums for the young. He will not get a public option or individual or employment mandates. For these accomplishments, he should get credit and can declare victory.
Thank you for listening. I now invite questions.


steve said...

I agree with the future shortage issue. The rationing point is a bit complex.

steve said...

Grr, hit wrong button. Anyway, how do we resolve Medicare does not pay doctors enough, and often hospitals for that matter, with Medicare going broke? Who do you think is going to successfully address Medicare costs and how? Bottom-Up sounds good, but I do not see how this works in practice. Private insurance has shown no ability/willingness to hold down costs.

BTW, I enjoyed the interview with Dr. Cooper. Penn grad '85 here. Since graduation I have spent time in the military, moonlighted quite a bit and now work at several places in PA. My experience and what I have seen of physician behavior is a bit different than his. I see guys who own MRIs and PT services making self referrals. I see the consultants coming in to make sure we don't :leave money on the table." Yes, most docs remain good guys, but there is a lot more bad behavior, questionable behavior, than he has seen.