Rapunzel - Given your background and subsequent knowledge, you are the best person I know to answer questions about candidates' Health Care plans.

DISCLAIMER: I am not trying to start a debate on whose health care plan is the best for our country. Just trying to understand what ONE particular candidate is offering.

It appears to me that Hilary's plan would force the poor to purchase health care plans. Thus, in theory, eliminating some of the costs/problems associated with uninsured care. But it may also create a financial burden on the poor people that REALLY can't afford it in the first place? If so, why are Latino people standing behind her? Wouldn't they be disproportionately affected? What am I missing????

and PS When did they become Latino anyway, wouldn't that just refer to the people from Latin America?

I'll do my best to answer your question in a simple and straightforward way.

First, a glossary of terms:

Congressional Health Plan -- every candidate has used this term, and it's a bit misleading in my opinion. The real name for this plan is FEP, or Federal Employees Program. The FEP program is an administrative services only (ASO) that is contracted out to various health insurance companies throughout the country. It's usually administered by a Blue. It uses a Blue's network, but has it's own fee schedule (maximum amount it will pay a provider for a given service).

When I worked with BCBSGA, the FEP unit was the dregs. They paid their claims processors and customer service and managers less that the regular employees, they had the hand me down computers and copiers, and just generally felt like you'd stepped into the scene of the suicides in Beetlejuice. The only people who worked there were very new hires who immediately moved on to other departments if they were any good, or the people who were burnt out, bitter, and not particularly good at their jobs and were therefore willing to work for less.

When I worked with physicians and hospitals, the FEP patient was always the bain of our existence. Because the physician group/hospital is contracted with BCBS (*or whichever administrator) and they write into contracts that you will accept federal program patients, you must see them. However, you know that you will be paid only about 70% of your contracted BCBS* rate. It's also very likely that the claim will be processed incorrectly, and no amount of appealing will ever get it corrected. Just as likely, the claim will just be denied or multiple services will be bundled into one service (ie, a surgery will be bundled with the pre-op exam and instead of a $60 reimbursement and a $430 reimbursement, you'll be paid $60 and told to write off $430 because the surgery is part of the pre-op. The best practices learn to simply not bill for the pre-op, which means many services are never even billed. I believe that for this reason many of the cost savings calculated for such plans is very misleading.

This goes on because in a given market, the FEP carrier(s) are always the largest insurers. A physician or hospital cannot compete financially if they don't accept the insurance of a huge number of people. Also, the FEP population is generally a very small percentage of the patient base so it's not a huge burden to most providers. Further, I would venture to guess that members of Congress never experience problems like this. I'm willing to bet that members of Congress and their families, as well as other high-ranking Washington officials, have a special dedicated unit of the best and brightest working their claims and handling service.

Universal Healthcare -- The idea that healthcare is an unalienable right of American citizens, and that it is the responsibility of the federal government to provide healthcare to all Americans.

Single Payor Healthcare -- A subset of supporters of universal healthcare support a single payor (government) healthcare. Advocates of single payor healthcare believe everyone should be entitled to the same quality of healthcare, and that only way to achieve fairness in the system is move to a government controlled healthcare system that sets prices and removes insurance companies from the process. However, most SP proposals actually contract the services out as ASO to insurance companies, so they would still be a part of the process.

(I'm going to go ahead and post this in case we lose power -- it's storming.)

I appreciate your posting the response in segments. As it will take me a while to process this post before moving on!

If we look at both the Obama and Clinton plans, their goals are remarkably similar. Both support legislation that would forbid insurance companies to deny coverage based on a pre-existing conditions, both support the expansion of SCHIP. Both aim to offer a program that will insure all Americans, though Obama admits that his program will probably only cover 98% while Clinton insists her plan will achieve 100% coverage. So, the differences between the candidates come down to how they define "universal", and the mechanism they intend to use to achieve universal healthcare, as they define it.

The Clinton Plan
Hillary Clinton claims to define "universal" as 100% of the American people, and states that only a plan that aims for 100% coverage is acceptable. She plans to achieve universal care through the use of mandates. Mandates require the purchase of health insurance or penalize those who choose to go without health insurance. Mrs. Clinton has refused to specify what the penalties would be. In order to achieve 100% enrollment, people would be automatically enrolled upon in interaction with a healthcare provider or goverment services. To guarantee premiums would be paid, she stated last week that the government may have to "go after people's paychecks." She says that those who cannot afford to get health insurance on their own will be enrolled in the Congressional Health Plan, and the government will subsidize their premiums. The Clinton plan does not offer specifics on how they will determine who can afford to pay premiums, or who will not require assistance. Her plan does say that the burden of premiums will be limited to a percentage of income, but does not give a number. However, if you look at statements from her top health policy advisers, you will see that the number most often used as a top-out is 10% of income. So, for someone making $36,000 the premium would be capped at $300 a month. For a family of four earning $80,000, that extra $667 dollars a month might constitute a very heavy burden once the mortgage, car note, utilities, food, clothing, and retirement and college savings are all paid. The Massachusetts plan upon which the Clinton plan is modeled does includes a waiver for those for whom the premiums represent too much of a burden, and about 20% of the uninsured remain uninsured as a result.

So, the Clinton plan chooses mandates as an instrument to achieve the stated goal of 100% coverage, knowing that the model has resulted in only 80% coverage in the only place where it has ever been tried.

I'll talk about the Obama plan after I run to the store and make dinner.

The Obama Plan

Barack Obama’s plan is an opt-in plan. His mechanisms to achieve universality include cost reducing measures as well as the creation of a National Health Insurance Exchange to make it easy for Americans to find and compare health plans, and simplify enrollment. He would also offer The Congressional Health Plan as one option for those who need to purchase their own health insurance. In developing the healthcare plan, he started with the supposition that most people don’t insurance because they can’t afford it, not because they are gaming the system. Sen. Obama acknowledges that some people may choose not to insure, but his plan makes insurance affordable and available to anyone who wants it.

Like the Clinton plan, the Obama plan would open up the Congressional Health Plan. But through the Exchange, private health plans would also be encouraged to offer plans with similar benefits so that the market plays a role in controlling costs. He will also offer income-based subsidies for those who cannot afford premiums, but his subsidies could be applied to the Congressional/FEP plan or to a private plan available through the Exchange. Sen. Obama has stated that his first order of business would be to guarantee eligibility and open access to the Congressional/FEP plan. He would then take aim at bringing down costs. He has promised comprehensive reform to rein in costs, and says that the talks regarding the policy and legislative measures to do that will be public and transparent, and promises to televise the discussions on C-Span. Some of the measures specified:

Quality and Transparency

Require full transparency about quality and costs. Obama will require hospitals and providers to collect and publicly report measures of health care costs and quality, including data on preventable medical errors, nurse staffing ratios, hospital-acquired infections, and disparities in care. (For more on why this is important, see

)

Lowering Costs Associated with Prescription Drugs

• Comparative effectiveness research. Obama will establish an independent institute to guide reviews and research on comparative effectiveness, so that Americans and their doctors will have the accurate and objective information they need to make the best decisions for their health and well-being.
• Lower prescription drug costs. The second-fastest growing type of health expenses is prescription drugs. Pharmaceutical companies are selling the exact same drugs in Europe and Canada but charging Americans more than double the price. Obama will allow Americans to buy their medicines from other developed countries if the drugs are safe and prices are lower outside the U.S. Obama will also repeal the ban that prevents the government from negotiating with drug companies, which could result in savings as high as $30 billion. Finally, Obama will work to increase the use of generic drugs in Medicare, Medicaid, and FEHBP and prohibit big name drug companies from keeping generics out of markets.

Regulation of the Insurance Industry

• Health plans will also be required to disclose the percentage of premiums that go to patient care as opposed to administrative costs.
• The insurance business today is dominated by a small group of large companies that has been gobbling up their rivals. There have been over 400 health care mergers in the last 10 years, and just two companies dominate a full third of the national market. These changes were supposed to make the industry more efficient, but instead premiums have skyrocketed by over 87 percent.

Of course, anytime any of these reform issues come up in the debate, Hillary Clinton says, “me, too!” She doesn’t detail specifics of what she would do on her website, but the bullet points above (and more) are on his website -- which is interesting when you consider so many people accuse him of offering beautiful speeches but no specifics. I find way more detail in his plan. Clinton will not pledge to make the discussions public and broadcast them on C-Span. But, the fundamental difference in the plans boils down to mandates. Clinton has them, Obama does not.

Obama does not have mandates, and so the Clinton camp has attacked him because they say without mandates we can’t achieve 100% coverage. Obama considers 98% coverage, but 100% of the people having access to affordable coverage, universal coverage.

Rapunzel,

One of the things that I understand is driving health insurance so high in Florida is the constant insertion of mandated coverages for people. Every mandate tends to increase costs, and these seem to be things that some people may want to choose not to cover because they know that they would never affect them. Do I assume that this federalization of health care would do away with these mandated coverages? Or are these programs going to be coverage for everything? I have getting a big education in health care insurance at the moment, I am having some issues with my mother and my daughter that are both going to be very expensive. It is interesting to see how the billing is going to play out vs what the insurance company pays.

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Thanks Punzy for the summary with your explanations in layman terms.
I understood the plan, but even now have a better grasp of it.

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Okay, guys...I still have outlines of a compare and contrast of the plans and some thought on the Latino question. I will then answer specific questions, I promise. I'm actually learning a lot, too. I wanted to not write this off the top of my head, so I've been doing research and reading everything from Krugman to Cutler to make sure I'm being fair.

Just look to Canada, England, Germany, etc to see what we're in for if universal health care happens. Sounds great on paper, but in reality it ain't so great...

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Thanks Rapunzel for all the research. I'm still undecided and the insurance question is one of the 'Major' factors that will help me decide who gets my vote.

Singinchicken has a good point. For those that can afford private healthcare plans and are forced to go to a universal plan, it is a real negative.

Lil Seaside worked in Londo a few years ago, got an upper respiratory infection and like to have died (figuratively) before she got to see an MD. When she got there, it was cheap, but what if it had been serious?

Hear lots of horror stories from Canada too.

I guess if it was simple, the issue would have been resolved long ago.

At the same time, we do have a form of universal healthcare coverage: The emergency room and indigent care, and we all know how that works!

Thanks for the great post!

I don't understand how they are allowed to sell at different prices, but I'm guessing it has something to do w/ all of the lobbyists and campaign contributions.

The bigger the company, the more $ spent on admin. Giant corporations never benefit the general public.

How much of the market does the company have to control before it becomes an anti-trust issue?

__________________
The enemy is ignorance.

Citizens Against Government Waste Media Director Leslie Paige is scheduled to appear on “CBS Evening News with Katie Couric” tomorrow, Friday, February 8, at 6:30 p.m. EST. Leslie will be discussing improper payments in the Medicare system and the Recovery Audit Contractor Program's success in recouping hundreds of millions of dollars in overpayments from hospitals and other healthcare providers in California, Florida, and New York.


Program Details:

Date: Friday, February 8, 2008
Time: 6:30 p.m. EST
Guest: CAGW Media Director Leslie K. Paige
Topic: Improper payments in the Medicare program
Program: "CBS Evening News with Katie Couric"
Network: CBS

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YOU ROCK PUNZY!! This was more than I could have hoped for! But I'm still reading/digesting it. I may be back with questions!

Comparison and Contrast of the Plans


“Two possible reasons why people don’t have health coverage are usually given. One is that the uninsured are gaming the system. The other is that they can’t afford it and don’t know where to get it. Most of the literature suggests that the explanation is mostly the latter. That means the single biggest thing we can do to help the uninsured is to make coverage affordable and accessible.” -David Cutler, Professor of Applied Economics at Harvard and Senior Health Policy Advisor to the Obama Campaign.

Gaming the System
Paul Krugman best articulated the argument for mandates in a recent op-ed piece in the NY Times. He states, "under the Obama plan, as it now stands, healthy people could choose not to buy insurance — then sign up for it if they developed health problems later. Insurance companies couldn’t turn them away, because Mr. Obama’s plan, like those of his rivals, requires that insurers offer the same policy to everyone. As a result, people who did the right thing and bought insurance when they were healthy would end up subsidizing those who didn’t sign up for insurance until or unless they needed medical care." This is a good point that is repeatedly made by supporters of the Clinton plan. Under the Obama plan it would be possible to wait until you are sick to enroll. This would indeed be a burden on the system if a huge number of people failed to get insurance and only had an initial contact with the health care system once they had a catastrophic illness.

I have always dismissed this concern to some extent because I believe most people will have to initially utilize healthcare for something emergent but not extremely expensive, and because I believe most people find going uninsured to be a source of tremendous anxiety. First, the first encounter is much more likely to result from a sprained ankle or a bad case of the flu than an initial diagnosis of cancer. The vast majority of the uninsured are young and healthy. If they are not paying, they are not utilizing the system. As an example, I went without health insurance for a few months after Katrina. I had an accident on a Vespa -- I hit a iron fence and banged my head badly, hurt my knee, and thought my arm was broken. I didn't go to the emergency room, I went and took some Tylenol, cleaned my knee carefully, and iced my arm for 24 hours. If I'd gone to the emergency room, that one encounter would have cost more than my yearly premiums, because I'd have had to have lots of x-rays and a cat scan and an observation admission to the hospital. If my arm had been broken and I'd had no choice but to go, I would have been guilty of gaming the system once, but then I'd be enrolled and I've not had another emergent need for healthcare in two years. Of course, when I was on the ground trapped under that Vespa my head was ringing and I wasn't clear what had happened I had one thought -- I don't have insurance. It was that thought that I had every time I got behind the wheel of my car, every time I went jogging. Every time I had a headache or a small pain in my lower left belly, that anxiety would feel like a boulder on my chest. I know that if I'd had access to an affordable policy, I would have not hesitated for a moment. I imagine most people going without insurance feel the same way.

However, as Krugman states, the removal of pre-existing exclusions would take away the motivation of the sword hanging over the head of the uninsured. Clearly, that would have to be addressed, and there would have to be a penalty for those who wait until they are sick to enroll in a program. Obama has mentioned a penalty such as fines of the equivalent of six months premiums (the current pre-existing waiting period), some people have suggested taxing the value of the first three months' utilization as income. Clearly, this problem will have to be addressed when legislation is drafted but can be overcome without resorting to mandates to be effective.

Free Markets -- Good or Bad?
Paul Krugman recently criticized the Obama plan, "castigating" Obama, saying "he’s echoing right-wing talking points on health care." The Clinton campaign says his plan endorses "Reaganomics" over universal coverage. I think most Americans prefer a system with choice and will respond favorably to a plan that lowers the barriers of cost and access to health insurance whether private or public. Cutler sums it up this way, “the mandate argument is: You must buy something – but I’m not going to tell you what it is, how much it will cost, or where you’re going to get it.” The supporters of mandates advocate requiring proof of health insurance be submitted with income tax returns, and that the uninsured be automatically enrolled in the Congressional Health Plan. Opponents of mandates argue that you can automatically enroll people in health plans, but if they aren't affordable people won't pay the premiums. The pro-mandate analysts admit there will have to be fines and penalties, and many (including Clinton) have mentioned that it may be necessary to garnish people's wages to assure compliance. That amounts to a regressive tax, but by a different name.

A further point of contrast in the plans -- the Obama utilizes the market and competition through the insurance exchange while the Clinton plan focuses solely on adding people to the Congressional Health Plan. It is important to utilize the market to insure that those who are entering the system have access not just to health care, but to good quality, cost effective health care. Some of you may remember my theory of the three tier system (here -- )
We have to ask ourselves, if we want universal healthcare, which tier do we plan to add people to? Which tier is going to justify asking (or forcing) them to pay 10% of their income? The Obama plan seeks to add people to the second tier, while I believe the Clinton plan expands the third tier.

Finally, I encourage everyone to look at the plans themselves.

http://www.barackobama.com/issues/healthcare/
http://www.hillaryclinton.com/featur...n/summary.aspx

The plans may be very similar with the exception of mandates, but the approaches could not be more different. The Clinton plan approaches the problems of health care as though they are all a matter of policy easily fixed with more legislation. The Obama plan specifies many areas to be targeted for reform. The Clinton plans sees the health system as one in need of a little tweaking, while the Obama plan aims to fix many of the fundamental flaws that are creating excessive profits in some parts of the healthcare system, while starving other of funds. The Obama plan makes cost and access the first priority, while the Clinton plan makes access and mandatory enrollment the priority. Which brings us back to the question -- when Americans say they want "universal healthcare," how do they define universal?

Next post -- The foreseeable consequences of the two plans.

To be honest, I'm not sure why Latino people are so strongly behind her.

As for how the plan will affect them, I don't know many poor people who have 10% of their income to spare. For someone making $8 an hour, $130 a month is still a lot of money. Perhaps they assume that the 10% of income rule won't apply across the board, and that they will benefit from subsidies. If so, that is certainly reading between the lines of her plan.

To be honest, I think most poor or uninsured people, Latino or otherwise, just hear "universal" and "everyone will be covered" and don't really ask for the details.

Most new immigrant groups generally look to community leaders to help them determine which candidate will be most beneficial for their group. The Irish, Germans, and Italians all did it and now the newest wave of immigrants is doing the same thing. If you moved to Mexico tomorrow, would you support the PRI or PAN? Here, the Clintons have benefited from their experience with national campaigns and her long-standing front-runner status. She received pledges of support from Latino leaders way before anyone considered Obama a viable candidate.

As for when they became Latinos, I think that goes back to identity-based politics of the 60’s. Obama’s plan is his plan for the American people. Hillary Clinton’s website has a link from the healthcare plan to this page http://www.hillaryclinton.com/files/...pactreport.pdf which describes how her plan effects Latinos. The whole “Latinos won’t vote for a black person” talking point coming out of her campaign is such a throwback. It’s an outmoded way of dividing and conquering the electorate, and just one of the many tactics born out of late 1960’s campus liberalism that I am so sick of.

Or did you mean Latinos instead of Hispanics? Maybe some Spanish people took exception with that label?

I finally found the FEP image!

U.S. ranks lowest in patient satisfaction


Businessweek created a slideshow depicting the best countries for healthcare. According to Businessweek:

Among seven nations surveyed, the U.S. ranks lowest in patient satisfaction with overall medical care

30% of U.S. respondents said that they had to pay more than $1000 in out-of-pocket medical costs last year, while 1/3 of those surveyed from the U.S. said that the healthcare system needs to be completely revamped.

Top countries
1. Australia
National spending per capita: $3, 128
Percentage of National GDP: 9.5%
Healthcare System needs to be rebuilt completely: 18% think so

2. Canada
National spending per capita: $3, 326
Percentage of National GDP: 9.8%
Healthcare System needs to be rebuilt completely: 12% think so

3. Germany
National spending per capita: $3, 287
Percentage of National GDP: 10.7%
Healthcare System needs to be rebuilt completely: 27% think so

4. Netherlands
National spending per capita: $3, 094
Percentage of National GDP: 9.2%
Healthcare System needs to be rebuilt completely: 9% think so

5. New Zealand
National spending per capita: $2, 343
Percentage of National GDP: 9.0%
Healthcare System needs to be rebuilt completely: 17% think so

6. England
National spending per capita: $2, 724
Percentage of National GDP: 8.3%
Healthcare System needs to be rebuilt completely: 15% think so

7. United States
National spending per capita: $6,697
Percentage of National GDP: 16%
Healthcare System needs to be rebuilt completely: 34% think so


As a physician, I favor universal health care.

Try getting insurance if you're a diabetic.

Currently the uninsured tend to use the emergency department for their primary care, which is unbelievably expensive. Often a condition is allowed to progress until it's more expensive to fix. We end up paying for their care anyway.

Eliminating for-profit insurance companies and having a single-payer system would save a huge amount of money. I can just see the lobbyists letting this happen.

Often exaggerated stories of delays in elective procedures in Canada and England are cited, but for the most part citizens are happier with their medical systems than we are.

If my income is less, so be it.

pmed8- thanks for this. I was wondering if there was information on the dissatisfaction of Americans with our current healthcare system, or lack thereof. For every "anecdote" about a Canadian getting screwed, I hear 3 about people in the US.

I agree with your support for universal care, and I think that the provision that gets rid of denial of coverage for pre-existing conditions that both Democratic candidates support is a good thing.

However, I have to ask why a single payor system is preferable to a market based system with regulation and oversight? As a physician, do you feel the implementation of CMS' regional-based relative value scale has helped or hindered your practice? Do you find it an effective way to foster quality care?

I practice Emergency Medicine, so I can't offer an opinion on the CMS scale.

As far as market-based care, if you look at the above statistics we spend about twice as much per capita as the other countries listed with little or no improvement in quality.

I know that my internist friends in private practice spend 50-60% of their gross on overhead. They need two employees to do the byzantine coding and billing. They spend an inordinate amount of time on documentation or on the phone with HMO's. The HMO's feel that 15 minutes is the most you should spend with a patient, including paperwork.

I see patients who have to change doctors every time their employer gets a new insurance plan. Yesterday five patients (out of 24) asked if I could be their primary care doctor.

As far as quality assurance, the hospitals tend to have more to do with it than the insurance companies, at least in my experience.

There is no doubt massive reform is needed, and I could write for days about the waste and inefficiency and how that needs a complete overhaul. I just do not think migrating everyone to the FEP system will make anything better for anyone. Ask your internist friends (or their billing people) how they enjoy working with FEP v. the average HMO.

I just believe deeply in markets and consumer choice. I can't think of one example where a single provider has resulted in the best value or service.

It's like saying Mediacom's single cable provider service is the best way to provide value and quality to South Walton, when it's really all about access and graft.

This is from an article in the Washington Monthly in March of 1999. I believe it's still pertinent.

Medicare has been able to beat the private sector at cost containment because Medicare has very low overhead costs (Medicare spends a mere 2 percent of its revenues on overhead versus at least 13 to 15 percent for private-sector insurers), and because Medicare reimburses doctors and hospitals at rates below those paid by private-sector insurers. Medicare's overhead is much lower than the private sector's because it does not pay for marketing, utilization review (jargon for unsolicited insurance company advice to doctors about how to take care of patients), obscene salaries, and myriad costs associated with influencing public policy. Moreover, Medicare does not have to make a profit for stockholders.

Yet it's also important to note the cost-control techniques Medicare does not use. Traditional Medicare does not use the techniques so beloved by the private sector that now threaten quality of care--restricting the freedom to choose one's doctor, overturning physician-patient decisions, and exposing doctors to financial incentives to deny care.

The real problem with Medicare is not that it is inefficient but that it relies so heavily on regressive taxes. Medicare's method of financing hospital services--payroll taxes on working people--is regressive and increasingly insufficient as the ratio of retirees to workers rises. The problem with Medicare's method of financing physician services is that a fourth of the financing comes from monthly premiums paid by Medicare enrollees. These premiums are even more regressive than the payroll tax. The upcoming Medicare debate should include a discussion about whether to abandon payroll taxes and premiums in favor of a progressive, general tax.

Thanks so much for taking the time Rapunzel. This is good info.

__________________
"You are your choices"
www.lifeonshore.com
http://bobbyjblog.com

Well, the Netherlands and Germany come to mind. We spend twice as much per capita and they have excellent health care.

Please also refer back to the above article.

In my experience, the most common complaint about "choice" is that patients have to change doctors when they've found someone they like.

They usually don't have a choice if they have insurance through their employers.

Well, I worked with breast cancer patients from all over the world. I've seen how those systems work. I'm sure you've heard the statistic that 80% of health care dollars are spent by 20% of the people. Well, Germany, the Netherlands, and other countries with socialized medicine work great for the 80% of the people that are just seeking basic healthcare. It's when people are really sick that those systems begin to show cracks.

In countries with socialized healthcare, medical decisions are made with a cost/benefit analysis -- they aim to use their dollars (or Euros I should say) to do the greatest good for the greatest number. I can think of ten women off the top of my head who were patients from Europe, Canada, and Israel (plus one from California) that went on to develop metastatic disease. They had lung, bone, or spine tumors that were not likely to be cured by further treatment, and so they died. If they had been Americans (but not from California, Kansas, or Missouri) at least a couple of them would still be alive today.

Further, I believe our system has subsidized the rest of the world to a huge extent and far as medical innovation is concerned.

Your example of musical providers is a great example of one of the very broken parts of our current system. It's not a very good example of free markets, however. One of the fundamental flaws of our current system is the lack of consumer driven healthcare decisions. Your patients had no say in which healthplan they bought, it was decided for them by an employer group. The employer group looks only at price, not the quality of the network or access to providers. In a perfect world, I'd support HCSA and high-deductible indemnity insurance but I think that would require a revolution. I know a great deal of reform is needed, but I really don't think the government is going to be able to administer the entire healthcare system and do a good job.

I guess we'll just have to agree to disagree on this.

The US does have a greater 5-year survival rate for breast cancer, but 30-day acute myocardial infarction case-fatality rates are below 7% in Denmark, Iceland, and Switzerland, compared with almost 15% in the United States. Incidence of major amputations among diabetic patients in Finland, Australia, and Canada is less than 10 per 10 000 compared with 56 per 10 000 in the United States. And Australia, Canada, England, and New Zealand all have a better 5-year kidney transplantation survival rate than the United States.

Don't you think that has much to do with the difference in patient population and lifestyles in those populations? Further, do you not believe US rates would be greatly improved if more people had access to healthcare, regardless of whether it was single payor or free market in nature?

I'm just firmly convinced that the healthcare delivered by our system to privately insured Americans is the best in the world, and we should try to find ways to expand access to that care by taking resources that are going to excessive profits for corporate hospitals and pharmaceutical companies or compliance with outdated accreditation and legislation and re-channeling those resources into expanded coverage.

No doubt our rates would be improved by universal health care and healthier lifestyles.

Very few hospitals make any profit, especially those with a high percentage of indigent patients.

In 2005 United Health Care's CEO William McGuire made $124.8 million, Aetna's CEO $22.2 million, Wellpoint's CEO $25 million, and Cigna's CEO $13.3 million.

Add to that what they pay lobbyists.

I was just thinking, if we encouraged smoking, heavy drinking and unprotected sex, we could reduce average life expectancy and save Social Security!

Very few hospitals make any profit at all? Are they giving you free Kool Aid in the cafeteria during your shift, Doctor?

Granted, I should have added insurance companies that are creating an oligopoly in the industry and monopolizing markets to that list.

Jeffrey C. Barbakow
Tenet Healthcare
$22,785 per hour, $116.4 million for 2002
Doesn't include new stock options with potential value of $72.4 million
--from USA Today, and the most recent number I could find after a good long search.