Single Payer Monte

(Judging from my email, the previous article was poorly understood even though I tried to break things down to the most fundamental level possible. I used little, easy-to-read words and I even made mention of dogs biting scrotums for crying out loud. Let me take another crack at it for the sake of those of you who need to have things explained a few times. -PB)

Universal Access, Tatooed Ladies, and the Dreaded “R” Word

Let us consider how the typical uninsured patient accesses health care. Arriving at the Emergency Department after a brief stop at the tatoo parlor for the finishing touches on a modest tiger motif around her left breast, our patient stubs out her cigarette, throws the scanty remains of her super-sized Big Mac meal into a nearby trash can, and with her three disheveled children in tow waddles to the triage desk where she presents for some common complication of her smoking and her non-insulin dependent diabetes. After a brief assessment by the triage nurse, she is directed to a row of grimy plastic chairs where she and her three children, Kristal, Alexa, and Deshawn will spend the next six hours watching The Fresh Prince of Bel Air while eating stale chips from the vending machines.

While there is no shortage of health care in our patient’s city it is still, like every other good or service, scarce meaning that there is not enough of it to completely meet the demand at the price that people are willing to pay. In our patient’s case, she is unwilling (and unable) to pay anything at all for this scarce service. From her perspective, health care is tightly rationed and although she is going to eventually receive top-notch care, she will end up spending eight good hours (at least) of otherwise productive time essentially standing in line for a few minutes of the Emergency Physician’s time. That’s how the poor pay for their rationed health care, with time and inconvenience.

The key concept to keep in the back of your mind (with the scrotum biting dog) is that every good or service is rationed in some way or another. In a free market system, it is the invisible hand of the market, the collective wisdom of millions of buyers and sellers deciding what something is worth, that sets the price and determines access. If you have, for example, the money for insurance and your copay you can generally make an appointment with your doctor and avoid the plastic chairs and stale chips. We also, however, live in a society that provides government funded charity as our finer impulses compel us to provide medical care (along with other goods and services) to the poor. But as this kind of charity work doesn’t pay very well, with the exception of a zealot or two the enthusiasm to provide it is not strong.

Which explains the plastic chairs, the chips, and the wait.

Now imagine our tatooed lady along with every other uninsured person in the United States waking up to find themselves the beneficiaries of a health insurance policy paid for by Uncle “Single Payer” Sam. A year later and they will still be sitting in the same plastic chairs in the Emergency department because the government cannot provide access to additional services that don’t exist. Unfortunately, not only does a single payer system do nothing to increase the supply of the service it purports to provide but the benevolant teeth of the government dog biting the important parts (the money, for those of you not following along) will limit the financial incentive to produce more of the service.

In a rational system, an increase in demand would be met by an increase in production (spurred by an increase in price) to meet the demand. The production of health care, however, is relatively inelastic. Doctors, midlevels, and nurses can only see so many patients. I don’t know too many doctors, for instance, who have a shortage of patients. To the contrary, the number one complaint of most health care providors is the need to run patients in and out like cattle to make a living.

There is a some elasticity in supply but not much. For the right price, most health care providers will see more patients, the key being that the incentive to stay at the clinic another three hours or work on Saturday has to outweigh the desire for leisure. Still, as it takes a minimum of seven years to train a doctor, three to train a Physician Assistant and somewhere in between for a nurse practioner, unless we want to have motivated junior college graduates as primary care providers the ability to increase the production of health care will always be limited.

Unfortunately, when the government controls the price of anything for which it must pay, the overwhelming tendency is to decrease the price even at a time when to meet increased demand the correct play is to increase the price to encourage the producers. Money itself is a scarce resource to a government and must also be rationed, usually in a way that panders to one constituency or another. (Governments cannot create money, although some have tried with disasterous economic consequences.)

In the quasi-single payer system of Medicaid and Medicare we have today, the goverment fixes the price at such a low level that those who decide to let the dog into their practice have to run a high volume business. If the last vestige of restraint was removed from the government to at least pretend to meet a reasonable market price, the bid price for health care would fall so low that any available excess production capacity would be held back from the market in the ancient tradition of all producers in the face of price fixing, to be sold for the real price to those who can afford it. In this case this would be the same people who have health insurance now, except in a Single Payer world this would be through supplemental insurance or its functional equivalent. That is until the government that promised not to get involved in any other way but providing insurance outlaws this practice.

Does our tatooed patient care about any of this? Probably not. She doesn’t pay a dime now. She won’t pay a dime in the future. The care will still be rationed and she will still sit on plastic chairs waiting…except now she’ll have a lot more company.

45 thoughts on “Single Payer Monte

  1. (Ho ho, very funny– now you’re generalizing again, ridiculing “tattoed, waddling ladies” who eat Big Macs and bring their “disheveled children to the ER”. Whatever. Hey, I could care less if you detest your patients, okay?

    But why don’t we get down and dirty, cut the bullshit, and call it like it really is, okay?

    Here it is: Many of you doctors don’t want universal health care because it will be much more difficult for you to make your high salaries.

    The drug companies won’t be happy either.

    And everybody knows it.

  2. This is really low. That little caricature of the poor woman really couldn’t have been more full of sneering contempt unless you had taken the extra step of implying that she was a whore.

    The scrotum-biting dog? You had me with that, but now you’ve lost any credibility you might have garnered from the analogy.

    And, once again, you seem to forget that this woman — the prototypical underclass — would likely be covered under DSHS or Medicaid or something like that. The REAL uninsured are those who work crappy-ass jobs that either don’t offer insurance or offer insurance which is unaffordable given the subsistence-level wages. Hard-working Americans getting fucked by the system. They’re not as easy to treat with such palpable contempt, so you ignore them and paint a straw-man (woman) as the detestible and unworthy befeiciary of government largesse.

    Again, single-payor has drawbacks. But argue the point honestly.

  3. Where have I said that I am not concerned about physician’s salaries? There is no bullshit involved and none needs to be cut through. Socialized medicine is wrong on many levels, after all. I think, as usual, you have missed the point of my ariticle and read it through the prism of your own prejudices without giving condideration to what I have to say.

  4. Shadowfax, this in in no way a caricature. Don’t you know that there is nothing in my blog that isn’t drawn from real life? The sight of an incredibly obeses mother leading her brood of little ones into the department is a common one.

    If the mother is covered by Medicaid, what is she doing in the ED for her routine health care?

    You guessed it. It is a combination of irresponsibility and the shortage of physicians who will take medicaid. Do you kind of see my point about the difference between insurance, access, and use?

  5. If someone expects me to help pay for their health care, then I can equally expect them to be sensible, responsible, contributing citizens to the best of their ability.

    However, we all know that people will take what’s free and give nothing in return. Many are not sensible, responsible, contributing citizens.

    People being what they are, those of us who ARE sensible, hard-working, and responsible are obligated only to take care of ourselves and our own.

    When everybody is willing to give back as much or more as they receive from society, single payor will work the way it’s supposed to.

  6. I think the point that the detractors are missing is the whole scarcity argument. They have probably never seen a supply curve in their lives. At the lower fixed price that the government is willing to pay there is less medical care available because there are fewer providers willing to work for such a low price because the cost of providing care (read: malpractice insurance+cost of education+overhead+actual treatment+living expenses) is so high.

    The root cause for high physician salaries is not GREED (certain specialties excluded). Lay-people can’t comprehend that physicians are approximately $250K+ IN DEBT after their training, which can nearly TRIPLE over the course of a 20 year repayment period. Physicians will spend a minimum of 11 years in school and residency before earning a salary that is capable of repaying loans before hell freezes over. Hopefully the lay-public can understand that we’re up to our asses in debt, we’ve given up our 20’s and 30’s to studying and we deserve to be compensated for that.

    To put a face on it, I’m 23 and a first year med student, $60K in debt, about $180k away from finishing up school and about 6 years away from job where I can make enough money to pay back my student loans. Kids I graduated college with are making $60-120k in other fields, starting their families and generally living life. I’ve got 6 more years of being a slave to the requirements of my aspirations of helping people, a couple years until I give my girlfriend the best wedding I can afford on a $40k resident’s income and 30-some odd years to pay off $240k of loans at 6.8% interest. It’s like buying a house that I’ll never get to live in or see or even imagine. I’d have better prospects of getting rich by dumping that $250k into the next huge Powerball jackpot. But do I regret my decision? Not yet.

    The image of physician in the public eye needs to be revamped from the selfish, all-powerful, super-human to reality: we’re people, we make mistakes, we sacrifice decades of our youth, our families, our interests and our very LIVES to keep thousands of people healthy over the course of our career. We expect nothing more than a wage proportional to our sacrifices and a little bit of respect for making them. Does any other profession demand as much? Perhaps the military, police force and fire fighting…but few others. Be reasonable before you ignorantly attack us, we’re not the monsters you make us out to be.

    Demand for health care certainly isn’t going away any time soon without a huge improvement in the delivery of preventative care and reasonable limits to end of life care. Therefore, we need to address a way of increasing the supply of providers at all levels. A good place to start would be by making the education accessible without having to pay it off for the rest of your natural life, therefore lowering one of driving forces behind high wages while simultaneously increasing the number of providers.

    Use your heads folks, the majority of us are in this field to help you and your family and friends…there are certainly much easier ways to make money.

    Panda, thanks for keeping it real.

  7. In response to a previous post, I agree that it is contemptable that doctors should want to make good salaries. I mean, afterall, they only put in 11-15 years of grueling post-high school education and incur hundreds of thousands of dollars of debt to get where they are. What an easy life. Bastards.

    I am so sick and freaking tired of liberal socialist “punish achievement” bullcrap. If you people would spend half the time working to better yourselves that you spend on whining about how unfair life is and how unfair it is that some people have more money than you, you’d probably be millionaires by now.

    Hell, you know what, while we’re at it let’s stop giving differing grades in school. “Single payer system” – everyone gets straight A’s regardless of the work they put in or their intelligence level because it’s not fair to punish folks who aren’t as smart. They’re getting screwed by the system. Sure, you may get doctors and engineers who can barely tie their shoes, but at least everyone will have a “fair crack”. And why don’t we have a single payer housing system too? The government can buldoze everything current, build 200 million row houses and we’ll all live in equal conditions. And we may as well go to a single payer food system. Just walk into your grocery store and take whatever you want and as much of it as you want, whenever you want.

    The American Dream 1776 – Work hard, dream big, and you can succeed!

    The American Dream 2007 – Bitch about how someone working hard and dreaming big has made good things happen for them, and you can succeed at making them pay for all your entitlements!

  8. To the people who dog on Panda, sneer at his depiction of patients, or complain that doctors could stand to be paid a little less:

    Shut The Fuck Up.

    Considering medical education costs at the bare minimum 8-10 years and $150,000, I hardly think physicians making six digits is ludicrous.

    The depiction of the patient was too contemptuous? How else should the morbidly-obese, smokers, fast food junkies, drug abusers, or the myriad of other patients who inflict their medical conditions on themselves be depicted? Until you see an 800-pound person with COPD from smoking for 30 years (don’t forget raccoon eyes from crack) having a medal pinned on their enormous chest by the president for representing the pinnacle of human achievement, quit trying to sugercoat the fact that those who bring the problem on themselves not only are at fault for the problem, but since they could have prevented it they will inevitably be looked at with disdain. If you saw someone stick his hand in a beartrap, just because he could, would you cry out in sorrow for him or think he’s a dumbass? My point exactly.

    If anything, the people who require the disdain and contempt by the masses are you fools (including the nurses, anonymous pussies, etc. who were offended by this post) who bitch when the obvious is pointed out. You’re wasting oxygen that could have gone to someone with enough intelligence to be labeled human.

  9. I’m with you Panda and associates. Enough entitlements. I don’t mind (to much) taking care of the kids. However, I am sick and tired of entitlements. I am sick and tired of grown men and women saying(to paraphrase) gimmie, gimmie, more, mine, whine, whine. And when denied unreasonable demands, followed by your mean, racist, don’t know what your doing and lets not forget *^$&#@&% and I’m going to sue your a$%. When they have worked as hard as me and mine to EARN what you want then you can choose what you want to spend your money on,. And if you choose ETOH, cigarettes and/or the drug of the day instead of food, shelter and medical care for you and yours. I just hope(optimist that I am) that we can influence your kids(you know the ones you put on the corner with your “product”) to achieve more than you did. The only thing I will gladly fund is birth control.

  10. I love the smell of betadine in the morning…

    To the “holier than thou” crowd defending Panda’s ridiculing attitude towards his patients, and to those unrealistic types who continue to “blame the victim” for having bad health due “their own fault”: One day it’s gonna be you on the other side of the guerney, pal, and then we’ll see who wishes they had a compassionate and understanding doctor.

    And to those who say “Shut the Fuck Up” to people who dare to call it like it is: I can see your anger, which makes me think I hit a nerve–so all I can say to you is: party on dudes!

    I don’t hold any hostile feelings to people whose opinions differ from me, but I do find it amusing that so much anger is generated by the statements I make. (Which makes me think that people just don’t like hearing the truth—it’s just too uncomfortable, eh?)

  11. Great posts, Panda.

    Unfortunately, nurses and the like will always prefer big government solutions like ‘single payer’, not matter what reality and economics dictate.

  12. What’s wrong with reimbursement being comissurate with training and responsibility? Should physicians, with all the years of mandatory schooling, debt, slave labor during residency, etc. make the same as you, who didn’t have to go through all that just to work? In other fields, when the people who sacrificed the most and have the most responsibility get paid the most, it’s called “normal.” For some reason, the same situation in medicine is called “greed” by many.
    How many people in fields outside medicine that people still need would support “single payer” takeover of their industry? Single payer groceries (we all need food). Housing (and shelter too)? Automobiles (gotta get to work)?
    The people who don’t think the practice of medicine would radically change under a single payer system are fooling themselves. The government would be holding the purse strings and calling the shots as to what gets paid for and what doesn’t. Instead of the proverbial 24 year old insurance company paper pusher making your decisions for you, you’d have the 24 year old government paper pusher doing the same thing. Managed care by a different, bigger company with a monopoly.

  13. Panda,

    I think the fundamental mistake you’re making (and that which is causing so much confusion) is that you’re assuming that medical students are familiar with terms such as “elasticity,” “supply and demand,” “scarcity,” “productivity (at least in an economic sense),” amongst others that one would have to be familiar with something besides photosynthesis and protein metabolism to understand.

    Awesome post though.

  14. No shit. As I said, I don’t have a degree in economics but part of my curriculum as an engineering student was both micro- and macro-economics. They need to make this sort of thing mandatory for pre-meds.

  15. Folks: If the government controls reimbursement, then it controls the entire game. Under single payer, insurance companies can pay out $3k for a surgery that costs $3k, but if the government only pays $1k, then the insurance company has to change it pay scale or it goes out of business. Then the hospital has to change the services it provides to cut costs. Maybe they don’t do stents anymore. Maybe they stop taking medicaid. Maybe they fire staff. The result is loss of services, fewer people served, and longer waits.

    The government will always be motivated to cut costs. As it is fed by taxes, separate from market forces, its only motivation is to get re-elected. Re-election comes by making good press, and it always good press to reduce costs. It also sounds good to pay money to hospitals, but these will be relatively small payouts that sound great on the evening news, but affect only a (vocal) minority at the expense of many. Pediatric chemotherapy might be 100% covered by the government, but insulin won’t.

    Currently we have mostly good care for most of the people. Moving to single payer system would make poor care available for everyone. It doesn’t reduce costs associated with a service; rather, it simply eliminates the possibility of providing a service in the first place. Note that it doesn’t address the problem of how people approach health care or caring for themselves.

    On ‘impressing morality onto patients’: People make decisions based on perceived risks and benefits. It’s human to diminish possible future drastic consequences when faced with immediate gains.

    (cost of terrible event X) x (likelihood event X will happen) / (how far away in time event X is away) = perceived risk.

    Unless a patient realizes that this is the way we all make choices, preventative care will always lose out to Big Macs and cigs. That’s the patient’s choice, and that’s OK. It’s a free country. Panda’s point is that it’s not right for me to take $10 out of my neighbor’s pocket to pay for the consequences of my lifetime of poor decisions.

    Lastly, to hell with econ – just teach people the idea of a mass or energy balance – you cannot get out more than you put in.

  16. Panda,

    I thought your post raises some interesting issues and concerns. I used to be much more liberal (much like the Bohemian Road Nurse) and would have argued that everyone should be covered. However, I am beginning to have a better understanding of the big picture, economics etc. and am coming to the realization that a single payor system would spell disaster for healthcare in the USA.

    To BRN, Panda writes very descriptively and the accounts of his patients are often incredibly accurate. It seems like these types of patients are in every town throughout America. Do not confuse brutal honesty in description with poor compassion in treatment. I would venture a guess that Panda is very good at his job and gives out a great measure of compassion to go along with the truth.

  17. The fact that PandaBear is getting so many comments and hits on his site, when his may be the dumbest and most bigotted defense of the status quo I’ve ever seen–not to mention factually challenged at several points–makes me very depressed about the general level of education in medical schools.

    But I note he’s an ex-Marine. Perhaps the quality and service in that organization is dreadful too? After all, that’s a socialized organization as well, all provided for by a single payer. I didn’t realize that the Marine Corps was so terrible at what it does, but apparently it must be so if PandaBear says so.

  18. Matthew,

    You seem great at ad hominem arguments for a consultant (who produces nothing).

    Why not try to make a case instead?

    What exactly is factually incorrect?

  19. Well said, Matthew Holt. You’ve really stimulated the discussion by eluding to PB’s “factually challenged” points and calling him names.

  20. Matthew,

    Someone I’m not surprised about your comments. After all they come from consultant who makes money off trying to tell everyone how bad the system is.

    But, we can all smear each other quite easily. How about playing the ball instead of the player?

    What is factually incorrect?

  21. Matthew, don’t be a condescending ass. I don’t know you and you don’t know me but as I have five (some would say six) years of college, two years of graduate school, a medical degree and two years of residency training (not to mention a Professional Engineering license in Civil Engineering) let’s drop the idea that you are somehow smarter than a salty old Marine dog like me. I at least have a fundamental grasp of the realities of economics, something a surprising number of policy wonks do not.

    For my part, I’m sure you are a very intelligent fellow, probably even better edumafuckingcated than little old me but you’re not talking to some 19-year-old political activist on fire to stick it to The Man who buys what you’re selling without hesitation.

    What the Marine Corps, the payment for which is a legitimate function of government, has to do with providing free health care to the masses escapes even my agile brain. It is most cerainly not a socialized system because free-loading and slacking are definitely not allowed, can get you your ass kicked, and if that don’t larn’ ya’ you can get dishonorably discharged. And you can get out when your contract is up. Think of it as “fee for service,” as in “You pay me and I’ll kick down doors.”

    You must be thinking about the Air Force.

    Pray to what country are we going to discharge all of our patient-slackers and assorted free-loaders?

  22. Bohemian Road Nurse:

    People such as yourself are far too predictable in the sense that you try vainly to prove your viewpoint as correct by pretending to not care. Want to know the ironic part? If you didn’t care, and were comfortable with your viewpoint to begin with, you wouldn’t be posting a comment and trying to prove your point in the first place. If you, or anyone else, inflicts a medical condition or injury on yourself through preventable means, then it’s your own god damn fault; it’s as simple as that.

    Hopefully in the future the world will stop babying people like yourself who are too immature to take responsibility for your actions, but since society tends to give in to people like you (since your kind doesn’t stop crying until it gets its way), I don’t see that trend reversing anytime soon. And when you find yourself on the gourney for a preventable illness or injury, you can try to blame every “cynical, uncaring” doctor in the world out there for your problems but at the end of the day, you’re the idiot who put yourself there.

  23. Hey y’all:

    I NEVER said that I cared one way or the other about what salaries doctors make. I don’t think they’re “greedy” at all for desiring high salaries. I think they deserve them, because I agree that hard work and struggling to succeed should subsequently end up with a rewarding salary and standard of living.


    My POINT is this:
    I think it’s “shadows and mirrors” for many doctors like Panda to cruelly insult and ridicule patients by calling them “fat, drunk, careless, and stupid” while complaining about being forced to take care of said patients. I think that these doctors are taking their anger of the system out on the hapless patients.

    To Sex Panther:
    I’m not “confusing brutal honesty” with “poor compassion in treatment”. Let’s call it like it is: it’s not brutal honesty. It’s cruel and just plain mean to talk about patients that way. And it’s just plain unprofessional. Doctors are supposed to “DO NO HARM”—and I truly believe that character assasination is just as bad as physical harm.

    And to “Mike”, who said:

    “Unfortunately, nurses and the like will always prefer big government solutions like ’single payer’, not matter what reality and economics dictate…”

    My friend, you are generalizing about nurses, which obviously means that you know nothing about nurses. You have NO CLUE as to what we “prefer”. By the way, who are “the like” you refer to?) I never said I “preferred big government solutions or any type of solution. What I have said is that I hope someone can figure out a VIABLE and ACCEPTABLE solution. Read my comments more carefully, instead of generalizing about nurses, and you might figure out where I’m coming from.

    And yes, to whoever called me a liberal up there. (Although I’ve always voted Republican.) If liberal means that I stand up and defend the weak, then call me a liberal. Those people that doctors like Panda casually write off as “fat, drunk, careless and stupid” need someone to defend them. They are part of this country and deserve respect and love. I have been a nurse in a variety of settings and I can tell you that I would treat a convicted murderer with the same amount of respect and dignity that I would a prince. I love the human race–good, bad and ugly.

    And heck, I’m no saint myself–so who am I to judge? This country was FOUNDED on accepting the poor, tired, and weak (or something to that effect).

  24. For the record, I like treating fat, stupid, lazy, drunk, and other colorful patients which is why I went into Emergency Medicine. You know, for the freak show. This is not to say that I don’t also like treating my regular-folks patients who come in as result of bad luck or for semi-routine medical care which they otherwise couldn’t afford but if we didn’t have the occasional 600 pounder beaten up by her lesbian girlfriend because she cheated on her with a guy, well, let’s just say the magic would be be gone.

    Where else can a guy like me make civil conversation with crack whores?


  25. The country was not founded on accepting the tired, the poor, and the weak and then giving them handouts. I must have missed that part about “yearning to obtain welfare.”

  26. I say let the chips fall where they may. Anyone read Atlas Shrugged? that’s the type of ending I expect to this story.

  27. was waiting for the “atlas shrugged” tie-in. it has occured to me too. don’t we want to encourage our best and brightest who have an interest to go into medicine? take away the rewards and see what happens. it’s already happening in the more demanding specialties like cardio-thoracic surgery, neurosurgery, and pediatric surgery. do we really need more lawyers or bankers? we certainly need some but last time i checked there’s no law or banking crisis right now. i’m all for altruism but it wears pretty thin the first night of your internship.

  28. Hey Panda:

    How come you get to call names (you called “Matthew” a “condescending ass”) and another guy up there calls me an idiot, but when I do it (which didn’t even contain a cussword) you delete my comment? That ain’t fair, doc…

    Also, Panda: You are quite witty and funny– and your subsequent comments cause me to believe that you just might have a heart inside you despite your blustering, since you admitted that you like your “fat, drunk, stupid and careless” patients. Okay, I’ll get off your case. (I will admit that I’ve been testy due to a rough week–I had to fire my secretary and also one of my close friends for poor job performance and it was painful.)

    As to Tim Thompson up there:

    Your comments really aren’t witty enough, as Panda’s are, to provoke me to grace you with a reply. But I’m going to make an exception in your case, if only to educate you since you really sound rather…uh…uneducated. (And with very poor insight to boot.) So here goes:

    Where on earth did you get the idea that I’m “predictable” and “pretend not to care” in order to “prove my viewpoint”?

    Do you need a flashlight and a road map up in your brain?

    Because you obviously have no clue as to my “point”, my “predictability”, or anything else about me, heh! If you read my blog and comments on other people’s blogs, you’d know I’m definitely not predictable.

    And I won’t bother explaining my “point” because, as bikers say (and I’m a biker chick) “if I had to explain it, you wouldn’t understand.” (Another HEH!)

    The world has never “babied” me, and I don’t “cry until I get my way”. I am simply an outspoken person who enjoys debate with intelligent people. (You are not in their company…)

    And I don’t “blame” doctors for anything. I happen to LOVE doctors! And since I am a very hardworking, no-nonsense nurse, I usually enjoy very good working relationships with them. In fact, I spoil them rotten whether they deserve it or not. Ask any ER doc I’ve worked with.

    And the odds of me getting a “preventable” illness, as you call it, are pretty good, because I am a recovering alcoholic and I may have done some internal damage that will rear its ugly head when I get older, who knows. But if and when that happens, and I’m laying on the guerney, I will look deeply into my doctor’s eyes and say: “Please… help me”.

  29. It always amazes me to hear people say doctors are ‘greedy’ or that they don’t ‘deserve’ very high salaries. But what is most amazing is that you never hear the whiners brag about their willingness to work for next to nothing, just out of the goodness of their hearts.

    Like, the Burger King flipper refusing order payment from the welfare momma driving through with her carload of disheveled, sleepy kids. He COULD tell the company he works for to just take the cost of the poor woman’s order out of his wages, right? But he probably won’t, because he has bills to pay. He may even be paying for night school so that he can someday get a better-paying job. (You can substitute teachers, business consultants, construction workers, computer programmers or any other kind of worker for Burger King flipper)

    I’ve been poor and sometimes very poor while raising my kids. We didn’t eat fast food nor shop at the little 24-hour stores — cost too much, better food could be bought more cheaply and cooked at home. Being poor is often boring, often depressing and worrisome, but it never robs anyone of their dignity or courage or honesty. And every handout from the government steals exactly those things from the poor, just as the money to pay for them was stolen from the pockets of all workers. (By the way, my family sure didn’t stay poor.)

    Everyone wanting doctors to be paid less please line up to hand over your earnings or provide your services for free to the poor including the working poor. Lead by example, fellas.

  30. BRN, you called our colleague, Dr. Flea, a name. I didn’t insult Matthew, I just asked him not to be a condescending ass. A simple request. I’ll be more vigilant to make sure no one calls you names.

  31. Mr Holt:

    I have been reading your website and posts on various sites for some time now. Your disdain for MDs is clear and was likely predicated by a denial letter from a medical school admissions committee at some point in your Ivy education (Ive seen you belittle “less respected” schools in the past as well).

    It always amazes me how a person like you, who has absolutey no direct knowledge of patient care (except in your personal medical history) or ANY component of medicine not harbored from books and Dartmouth studies, seems to have all the answers. Unbelievable.

    Your as closed minded as the people you routinely reprimand, and that’s sad.

  32. Great post, and interesting comments. Your descriptions and your grasp of the economics are wonderful. I am going to link to you, and I thank you.

  33. GREAT POST!!

    It really sucks that scarcity exists, and everyone can’t have everything. The fact that it sucks however, will never make singing Kumbaya fix it. Just because we want everyone to have universal coverage won’t make it affordable. To those who scream about physician salaries and drug company profits, what do you think keeps people in practice and produces new drugs? We are about the only country on earth that doesn’t have a physician shortage because of this. We do however, have shortages of people who will take government payments. See any connection?

  34. PB, so you say this:

    What the Marine Corps, the payment for which is a legitimate function of government, has to do with providing free health care to the masses escapes even my agile brain. It is most cerainly not a socialized system because free-loading and slacking are definitely not allowed, can get you your ass kicked, and if that don’t larn’ ya’ you can get dishonorably discharged. And you can get out when your contract is up. Think of it as “fee for service,” as in “You pay me and I’ll kick down doors.”

    You must be thinking about the Air Force.

    OK, so you do admit that government funded and supplied services–which is I’m afraid what the marine corps, the air force et al are–can be done well. But apparently if they’re done well they not “socialized”. Well I’m glad that my superior “educametion” included a logic class, because in that class you get taught that things are what they are because of their characteristics not by what they’re called.

    And in fact you say that providing such organizations is a legitimate function of government. But you somehow think that this can’t apply to health care even though in the vast majority of the world including the US. Even though almost none of them are are single payer–again despite what people call them.

    And who do you think is paying for the heart surgery for 90 years olds over here that your commenters think they can’t get in France, not to mention more than $100K a year in subsidy to the residency that you’re going through. Yes that would be the taxpayer too.

    Unfortunately if you ever talked to people who purchase health care, whether in the private or public sector, you’ll find that they are very envious of those poor foreigners because they have to pay nearly twice as much for essentially the same thing with no clear differential in value. this is common among observers of health care across the political spectrum–look at Cato, look at PNHP. The only place where this understanding appears not to have touched down is on this blog.

    Oh, and you are despicably rude about your patients in addition. Given that your chosen profession requires compassion and understanding as a major part of the role of healing, may I suggest you head back to the marine corps where your attitude may be more suited to the task at hand.

  35. Matthew, you do know that as a Resident, I only make around $39,000 per year, right (and work around 70 hours a week for it as well)? The government may pay the hospital an average of $110,000 per resident per year but I only see my little bit of it.

    In fact, I would prefer not to get this stipend if instead the hospital had to bid for my services on the free market. Let’s put it this way, I have pulled overnight call about fifty times this year. To cover “gaps” in the call schedule that result when there simply isn’t enough cheap resident labor to fill every slot, the hospital pays upper level resident moonlighters eighty bucks an hour which is obviously the market price.

    The fact that I work for ten bucks an hour is a function of the way the system is set up to make residents the modern equivalent of indentured servants.

    So let’s run the numbers. Suppose a call night is 12 hours (it’s more, but let’s just say, of which I work the entire time with no sleep and then have to work until one PM the next day). That’s about 1000 bucks a night. I usually have eight call night a month (sometimes more) which is $8000 per month or nearly triple my current stipend.

    This doesn’t even take into account the productive work I do during the day (on most rotations although I’ll grant you that on some I am useless) for which the hospital, through the attending physicans, bills.

    So keep your stinking government money. If you think I am a big fan of the way medical training is funded you obviously have not read my blog or maybe I haven’t been clear enough. Or did you think I’m clapping my hands for joy to get taco jockey wages for a physicians work load and responsibility?

    Man. That is a real pet peeve of mine. Do not get me started on it because I will never shut up.

    As for my patients, how many patients have you seen, how much compassion have you demonstrated, and who have you healed? In fact, when was the last time you either talked to or touched a wino, a crack whore, a vagrant or a bum? Or when did you stick your hand, protected only by a thin latex glove, into the chest cavity of an HIV positive gang-banger to cross-clamp his aorta before he bled to death, feeling the jagged edges of his broken ribs brushing the back of your glove and knowing that a sudden move, a jab, or torn glove could seal your fate (maybe not today but eventually)? Or when did you peel the urine-soaked socks off of a diabetic drunk to examine his feet for ulcers and other non-healing lesions? When? Never?

    Then while I will take criticism form Bohemian Road Nurse, you, my friend have nothing to say on this matter. I help more people in one day at my job than you have probably helped in your entire life, seeing as your stock-in-trade is nothing but hot air and position papers.


  36. “Unfortunately, when the government controls the price of anything for which it must pay, the overwhelming tendency is to decrease the price even at a time when to meet increased demand the correct play is to increase the price to encourage the producers.”

    And that right thurr is one of the things that scares me the most about going into medicine. I hope it doesn’t become a reality.

    Great posts, as always, Panda. I’m not sure what caricature people are referring to, because “caricature” implies that it’s an exaggeration or distortion, but I’ve personally met the woman you’ve described.

  37. Miami med:

    I thought we do have a physician shortage? ( At the very least, there definitely is a substantial shortage of physicians in rural areas.

    Panda Bear:

    Out of curiosity, which of these do you think comes first?
    – the Federal government reducing reimbursements for Medicaid?
    – increases in the costs of treatments (pharmaceuticals, biotechnology, etc.)?
    – private practices limiting the number of Medicaid patients they see?
    – Medicaid patients, having difficulty finding physicians that take their coverage, showing up in EDs looking for nonurgent care?
    – Medicaid patients neglecting preventive measures and primary care?

    Of course, there might not be a distinguishable cause-effect relationship between any of these. (I’m pretty new to this topic and have been trying to read up on it extensively.) I would guess that all of these things I mentioned above proceed simultaneously, and that no solution “fixing” just one of these will solve these interrelated problems of the uninsured, health care access, sky-high health care costs, reduced reimbursements, etc. If you could propose a plan to address these problems, what would it be, and where would the direct interventions be?

  38. I have no plan. There is no solution, at least not one that has a chance of being implemented. The electorate want everything and they want someone else to pay for it and there is no reasoning with the mob.

    I believe the point of my articles was to show how “Single Payer” isn’t much of a plan either, not to propose how things would run in the Pandaverse. I don’t doubt we’re going to implement something foolish like it and ten years from now the system will still be in crisis and the same people will want even more money thrown at it.

    In fact, I am too humble to propose a plan except to say that personal responsibility, in the long run, would be a better play than any system yet proposed. That is, people should buy their own major medical insurance, pay for their own routine health care costs like they do their groceries, expect to borrow money like they do for cars if they can’t pay their hospital bills out of pocket, take responsibilty for their lifestyles, stop expecting that we can spend a million bucks to stretch their lifespan by a year or two, and stop viewing medical care as a right or something that just springs, de novo, from the soil.

    But it ain’t going to happen.

  39. Matthew is British. He dreams of the day that he can enslave the US population under the same type of single-payer healthcare nightmare that he left behind in the UK. Unfortunately, unlike him, his British compatriots are still suffering under the crushing weight of a faceless government run single-payer system. Additionally, as a consultant, he hopes to handsomely profit from the implementation of such a draconian system in the US.

  40. great post! not only did you spark an extensive conversation here on your blog but it also started conversations at my home. Thanks for bringing all of this up.
    As an aspiring medical student, I’m afraid for the future of the medical system. One thing I don’t understand is how people don’t see medical care as a bussiness just like any other service. Without this mentality, people just expect medical care to be provided for free even though it still IS a bussiness.
    Thanks for the post

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