Money Driven Medicine by Maggie Mahar

book jacketMoney Driven Medicine: The Real Reason Health Care Costs so Much by Maggie Mahar (2006)

Obviously this book is out of date but it does discuss some of the continual issues that plague the US medical and insurance industries under the great invisible hand of the “free” market rules of supply and demand that result in our citizens paying more and more and having inflated medical prices and drug prices forcing people to choose between food and healthcare.

The fundamental reality is that it is NOT APPROPRIATE to apply the “laws” of supply and demand to healthcare.

Taxpayers pay for massive drug research and yet the drugs that come to “market” are literally given to for-profit companies without them complying with the other parts of the statutes that gave them first and exclusive rights to RX profits. Big Pharma has absolutely no obligation to reveal anything about their cost plus overhead plus reasonable profit that results in price setting. What the market will bear was what I was told when questioning a pharmaceutical rep about the way they set their price for a particular drug ($1,700 cash on the table for one month). “That’s ridiculous.” was my response.

These meds cost half or less in other countries of course, that is one of the kickers. And they specifically passed a law at the behest of drug companies to prevent re-importation of the very same drugs from Canada or elsewhere, making it criminal even. Then there are all the shenanigans Big Pharma gets up to so their patents get extended and generics can’t get a share of the market or drugs that are being used successfully without concern in Europe can’t make it through our FDA process here for decades for some reason.

Competition will lower prices! Well, no. Competition trends to little guys being eaten up by big bullies, having their patents parked and eliminating competition so they have a monopoly. Do you really want your heart surgery done by a doctor advertising on a billboard that he will beat any price anyone else offers? For profit is not an acceptable model for healthcare, drugs, or durable medical goods.

Unlimited profit is not good for any product actually, and I would like to see some reasonable profit caps on goods that would enable more people to buy them (driving the economy) while preserving up to 25% profit for corporations or similar. There should be no case where a lifesaving drug costs $1,500 a pop when the actual cost to make the drug/delivery system is $10.

A hospital should not force you to buy your prescriptions one at a time while you are in the hospital from their pharmacy, which is always going to be considered out-of-network by insurance companies even if you walked in off the street and purchased the same prescription the pharmacy would be in network. Plus you get to pay “overhead” for the pill to be brought to you in the hospital room. Thus a bottle of pain pills might have cost you $2.65 for 30 but as an outpatient out-of-network, the same med, one single pill, will cost you $20.25. And you needed bother to try to get reimbursement from the drug insurance plan you have because they only cover the cost of the pill, not the overhead, so the pill might cost $1.00 and that means your out-of-network cost share is 20 cents and they will give you a check for 80 cents, but you have to eat the “overhead” of nearly $20.00 because it is not medicine and it is not hospitalization cost that would be covered under part B Medicare. If you are an inpatient, the cost of meds would be covered but you have to be receiving ACTIVE medical care for 3 days to be considered in-patient.

Oh the rules they come up with, like co-pays and deductibles so that we the people don’t “waste” money going to the doctor or hospital, essentially a rationing system that results in worse consequences for 90% of people. Medical costs are, I believe, the number 1 cause of bankruptcy today.

This attitude, that people will waste resources given half a chance stems from the elites’ beliefs about the deserving and undeserving poor and lack of trust that people are capable of good judgement without a nanny state. Kind of like women can’t be trusted to make their own reproductive choices (conservatives think old white men are better suited to make that decision). The massive amount of salary waste just to keep the insurance companies viable and pay multiple millions to their overrated CEOs and other managers rather than on medical care makes this concern represented by her remark that, “Some blame CONSUMERS for wanting TOO MUCH HEALTH CARE (particularly when they are spending other people’s [!!!!] money.  [Missing the whole concept of large pool of people to share the costs, like highways and the electrical grid.] She continues:

Others denounce drugmakers, insurers, doctors, and hospitals for charging too much; government for interfering too much; and trial lawyers for stiffing the pot. In recent years each group has taken a turn as the villain in the play. But the truth has less to do with the individual actors, and more to do with the larger economic forces that determine the rules of the game.

Put simply, over the past 25 years, power in our health care system has shifted from the physician to the corporation. A professional, the physician pledged to put his patients’ interests ahead of his own financial interests. The corporation, by contrast is legally bound [not really, another lie that has been repeated as if it is true] to put its shareholders’ interests first. Thus, many decisions about how to allocate health care dollars have become marketing decisions. Drugmakers, device makers, and insurers decide which products to develop based not on what patients need, but on what their marketers tell them will sell — and produce higher profit. “There is a saint in the drug industry,” one Wall Street analyst notes. “A pill you take once is good; a pill you take every day is better.”

Even not-for-profit hospitals are expected to keep an eye on the bottom line when deciding whether to invest health care dollars in a new heart pavilion, valet parking, or palliative care for the dying. “Is there a business case for palliative care?” hospital administrators ask. (preface)

Part of what makes me crazy about being a health care CONSUMER is that I cannot know what something will cost before I have the procedure and they can “run” it through the insurance. It all depends on how carefully the coders identify something at the facility before sending the claim to the insurance company. The mandate is MEDICALLY NECESSARY. Insurance will not pay for anything just because you believe you need it; for example a benign skin growth on your face: since the doctor knows it is not cancerous, and it is ONLY vanity to not want a growth on your face, you get to pay $300-$500 out of pocket and then odds are it will come back again!

Don’t get me started on the justification of that much money for a 5 minute doctor visit and action, even with sterile equipment and such.

The kicker is, with our system, it is the INSURANCE COMPANIES that get to decide what is MEDICALLY NECESSARY, not the doctors and certainly not you the patient. So you get a doctor who has already called for 20 patients to have MRIs when you come in and think you need one to assess a potential torn ligament. Doctors are judged by insurance companies by how many tests they order. If they average more than other doctors in the same area geographically and specialty, they get docked points. So at the back of the doctor’s mind is what the penalty will be for ordering too many tests, so when you show up, they decide to wait and see if it is just a sprain and gets better on its own.

Or my personal quest is to get Medicare to cover the test for Vitamin D deficiency again. They covered it once, but then “too many people” started asking for it after much publicity about how so many people are deficient, so they decided NOT TO COVER IT. In the case of multiple sclerosis, however, it IS CLINICALLY significant and does make a difference in the disease progression. But it doesn’t matter if the doctor and your disease does require testing Vitamin D levels because the insurer decided too many “frivolous” people were asking for it. This means it costs over $200 out of pocket for a before test and another for the after test to make sure the levels are where they should be for people with MS.

It is not just the complexity of the human body, but the uniqueness of each body that takes it so difficult to predict health care outcomes. Put simply, health care is not a COMMODITY. While two consumers many derive pretty much the same value from the same mid priced refrigerator, a particular course of treatment can have a drastically different effect on two different bodies. This makes it difficult for health care “shoppers” to rely on their friends’ experiences the way they might when choosing say, a computer or a car.

Nor can the consumer rely on his own past experience. Three out of four health care dollars are spend on products and services that the patient has rarely, if ever, purchased before — and probably hopes never to purchase again. To make the consumer’s dilemma even more wickedly difficult, when purchasing health care, he knows that there are NO WARRANTS and no GUARANTEES. The patient cannot return an unsuccessful operation. And if he winds up unhappy with the outcome, he may find himself stuck with something far worse than a bad haircut. (p. 3)

Of course, you sign away all your rights by giving them permission to do their “practicing” of medicine, and it takes money and a lot of effort to try to sue a doctor, who are, after all, only human.

The continual stupidity about “socialized medicine” drives me nuts. Risk pool, people. You get covered too. You could even get dental! Those pesky $3,000 to $4,000 hearing aids might end up on the durable medical goods list as well they should. So it was kind of a surprise but not a surprise to learn that the AMA (American Medical Association) was the force behind stopping “government intrusion” on medical care, i.e. universal healthcare, single payer, price regulation, whatever the profit seeking rascals who pushed out the centuries of midwives to medicalize birthing and implement “heroic” medicine that vaulted them into the top earning profession in the country. She states, “the AMA’s fierce insistence on autonomy effectively quashed any talk of a national health care system.”

Oh the pain of it, considering how many people have died due to lack of national health care, and still will continue to die, ever more with malicious little pricks like Speaker Paul Ryan wanting to kill medicare. The great god of profit and the belief in his own superiority as the hero of an Ayn Rand story, motivates him beyond reason and fools keep voting against their own interests and keep him in Congress where he can do maximum damage to us all.Pretty sure I read that the AMA is now gung ho on the prospect (gone gone gone with the Republican takeover of government) of single payer.

On page 1o, the discussion about Medicare and Medicaid mentions that it was President John F. Kenndy (in 1962) who set out to see to it that the poor and the elderly, and the people with pre-existing conditions had health insurance. The damned AMA “howled” in protest against this “slippery slope to socialized medicine.”

Damned if they didn’t win the first vote too. It was defeated, 52-48. Unfreaking believable. Following President Kennedy’s assassination, President Johnson, with “the largest plurality in US history” resurrected Medicare.

But Johnson also recognized that opposition would be fierce. IN an effort to bring both doctors and hospitals on board, administration officials followed the precedent set by the Rules. THEY CAVED.

Like Blue Cross, the government agreed to pay hospitals NOT WHAT A SERVICE MIGHT BE WORTH, but whatever it cost them to provide the service — which meant that the least efficient hospitals would be paid the most. Any hospital that managed to cut the cost of providing a service would trim its own income as well; those that reported the highest costs would receive the highest reimbursements.

As for doctors, they would be paid fee-for-service, just as they were by most private-sector insurers. Those fees would be based on what they had charged in the past. The only ceiling: what was usual and customary” in their community. “This left doctors free to create the baseline for higher fees. And they did this by hiking their fees,” [of course they did]. (p. 12)

Thankfully, the Republicans’ favorite weapon of choice against the “undeserving” — means testing to make sure only abysmally poor people got a break. There were numerous amendments tweaking it, but it ultimately passed by comfortable and resounding majorities in 1965. I was shocked, actually, about how recent it was created and marvel that the Republicans would even consider it given the last few decades of their concerted effort to make slaves of us all.

The AMA crowd was furious. They threatened to boycott. Then then decided to go along and in 1966 they discovered “the average physician’s earnings rose 11%.”

The Rise of the Specialist
At about the same time, medical school enrollment doubled, thanks to a GENEROUSLY FUNDED FEDERAL program. The Johnson administration hoped that as the supply of physicians rose, more would be forced to practice in underserved inner cities and rural areas — and that as SUPPLY met DEMAND, doctors’ fees would fall. Of course, this would never happen. As usual, health care ignored the laws of supply and demand. (p. 14)

Duh. I question the validity of the “law” of supply and demand entirely.  Nurses are in high demand but that doesn’t make hospital willing to pay them more (because they are women).

What the new crop of doctors were in it for was simply the money. No altruism there in particular by the majority of new doctors. Money was to be made by specializing and that was what they pursued. Money was a motivator after Medicare because “there was more money in the system.” Maybe that is why there are many doctors now willing to support single payer!?

“Adam Smith might have predicted that a newcomer to a community would set lower fees in order to attract patients,” Lundberg [an academic physician] continues, “but medicine was beyond supply and demand market rules. When new surgeons set higher fees, they not only got away with it, but also drove up the prevailing fees for all surgeons.”

Before long, the economic advantages of the new government programs became clear even to those health care providers who had been most horrified by the idea of government involvement. Billions of tax dollars now poured into the system. At the same time, federal subsidies of hospitals and medical research fueled an explosion, both in the growth of medical technology and in the use of hospital services.”

By the late 1960s, the funds available for health care in America seemed limitless. The financial arrangements among insurers, employers, the government, and the taxpayers created the illusion that no one was paying for the cost of medical care. Insurers handed rising costs off to employers in the form of higher premiums. Employers DEDUCTED those costs from their taxes, thus passing a good chunk of the cost on to the GOVERNMENT [TAXPAYERS]. (The more the employer spent on medical benefits the bigger the TAX BREAK.) Government, in turn, would hand the cost on to the TAXPAYER, who remained largely unaware that he was now SUBSIDIZING not only Medicare and Medicaid but EMPLOYER-BASED HEALTH CARE — whether or not he received benefits at his own job.

With both government and private insurers greasing the wheels of commerce, medicine was quickly turning into a high-growth business. That meant there was money to be made, and inevitably, in the 1960s the FOR-PROFIT hospital was born. (p. 15)

Once again, unlike most industries, health care prices did not fall with the added competition that people going for profit  engendered.


Employers and employees would share premium costs and employers would be obligated to provide health insurance. “A separate government system would provide exactly the same benefits for the rest of the population.” (p. 20) Nixon’s plan even allowed for treatment of alcoholism and drug abuse! Wickedly ironic considering he started the fake war on drugs.

Senior Edward Kennedy had pushed for reform and his plan was close enough to Nixon’s for compromise. So why then do we not have national health care today?

This time it wasn’t the doctors throwing a hissy fit, it was, sad to say, the labor unions. Great, the one time they manage to use their power effectively, they shoot themselves in the face and kill it for the rest of us. I’m not saying they were wrong for what they held out for, but in hindsight, if this major initiative had passed, their demands could have been met more easily later.

The labor unions wanted FREE healthcare, no cost sharing of premiums. They also did not want private insurance companies to “have any role in the new national health insurance program.” They rejected any compromise and demanded Kennedy’s single payer bill.

I find this to be difficult to understand. First, because Congress generally hasn’t given a damn about what unions wanted, so why did they listen to them now? Considering all the bad laws Congress has imposed on us all against our will, was there actually some secret conspiracy by private insurers to kill this bill? I believe there is more to this story than the author has delved into. Another aspect was the AMA’s effort to retain “fee-for-service” which — surprise surprise — sounds a like like Obamacare:

At the other extreme, the AMA struggled to preserve fee-for-service payment, pushing for “Medicredit” — a plan that would have the federal government provide tax incentives to help individuals BUY PRIVATE indemnity insurance. Under this scheme, there would be no cost controls whatsoever. . . .

Behind the scenes, Congress and the White House were making headway. In the spring of 1974, Nixon’s plan won a show of hands at a Ways and Means Committee meeting. In June, Kennedy announced, “A new spirit of compromise is in the air.”

It was not to be. For June of 1974 was, of course, the beginning of Watergate summer, a time when Congress was boil over Nixon’s impeachment. “If the name on the administration’s plan had not been Nixon and if the time had not been the year of Watergate, the United States might have had national health insurance in 1974,” [Ken] Starr observed. “This was the last moment in the 1970s when any such program had a serious chance of adoption.” (p. 21)

Well, that is part of the mystery solved. Congress may have ignored the unions refusal to compromise, but I guess just changing the name from Nixon’s Health Plan to National Health Plan took too much effort. Worse, the Democrats fumbled the ball once again, “. . . some liberal Democrats argued that if they [unions] just waited another year, they would have a chance at passing a plan that the unions could accept. They were wrong.”

OMG, just like the Monica Lewinsky scandal has been said to have sunk Bill Clinton’s chance to sell out the people’s Social Security to a privatization plan with Newt Gingrich,  apparently national health care suffered from a similar man can’t keep it in his pants problem. Though Gerald Ford, taking over from disgraced Nixon, asked for passage of the national health plan,  the fate was sealed by the antics of the very powerful supporter, Chairman of the House Ways and Means Committee, Wilbur Mills. Police discovered him “with a red-haired stipper named Fanne Foxe, who proceeded to leap from his car and throw herself into the Tidal Basin on the National Mall. When Mills resigned as chairman of the Ways and Means Committee, national wealth insurance lost its strongest champion in the House. The really sad part is that I remember this incident but had no clue of how significant this would be and the subsequent hell of medical care for millions and millions of Americans.

Ronald Regan was elected president in 1980. I am speechless as to what I can even start to say how much of a disaster then and now this man was to all that I hold dear and believe in; even my father confessed that the biggest mistake of his life was voting for Ronald Reagan. I am proud to say that I never have and never will vote for a party that thrives on hatred of women and so much more.

Others would argue that rather than ducking its duty [by denying federal responsibility], Washington had made a bold decision to place its faith in FREE MARKET COMPETITION. [vomiting now] With Reaganomics came a fervent belief in market forces as the solution to many , if not all, economic problems. Deregulation was the order of the day. The belief that the private sector does best without ANY GOVERNMENT INTERVENTION [historically demonstrably false] was entrenched and would carry through to the end of the century [and into the next]. (p. 23)

It was fascinating to learn that all hospitals used to be non-profit, and that the HMOs Congress passed in 1973 were also expected to be nonprofit. But then, of course, with Reagan in place, Washington “cut off the stream of federal financing. Searching for an alternative source of capital, many nonprofit HMOs turned to the markets and converted themselves into profit-making enterprises.”

The act that really burns my ass is the Bayh-Dole Act, one of the “reforms” Congress enacted beginning in the 1980s. The Bayh-Dole Act is critically important to everyone because it is the act that gave exclusive patent rights to drug companies. Theoretically, it was “designed to speed the translation of research into marketable [profitable] products.”

Under the new law, universities and small businesses doing research SPONSORED [PAID FOR] by the National Institutes of Health could patent their discoveries and then grant licenses to large drug companies ever to piggy back on their findings.

Previously, research sponsored by taxpayer dollars had REMAINED IN THE PUBLIC DOMAIN, available to any company that wanted to use it. Now the pharmaceutical giants could claim exclusive rights to the fruit of PUBLICLY FUNDED research. New legislation also let the NIH enter into deals with drug companies that would DIRECTLY TRANSFER NIH discoveries to industry. (p. 23)

Top it off with W’s no negotiation of drug prices by the government, and the “skin in the game” logic of Republicans that mandates we all must pay copays and deductibles PLUS the infamous and ridiculous “donut hole” of $2,500 where no drugs are covered at all and the system went to an amazing length to let the invisible hand of the market squash the living shit out of sick people and provide windfall profits and legal profiteering for drug companies.

Bayh-Dole was not Washington’s only gift to the pharmaceutical industry: in 1984 Congress passed the Hatch-Wasman Act, extending MONOPOLY RIGHTS FOR BRAND-NAE DRUGS. [free market my ass] “The law was meant mainly to stimulate the floundering generic industry by short-circuiting some of the FDA requirements for bringing generic drugs to market. But Hatch-Waxman also lengthened the patent life for brand-name drugs,” Angell explains. “Since then, industry lawyers have manipulated some of its provisions to extend patents far longer than the lawmakers intended.” (p. 24)

Ya think?

With Washington’s wind at its back, Big Pharma cruised. Over the course of the eighties, drugs stocks soured, along with profit margins. By the end of the decade, the top 10 drug companies boasted profits equal to nearly 25 percent of sales.

I have to look up the GDP and how it is calculated again, probably out of date formula (like the work of mothers and homemakers not being included). Health care spending has increased as a percentage of GDP since corporate health care developed since about 1982.

Some 10 years earlier, Fortune had set the tone when it declared that “the management of medical care was too important to be left to the doctors.” Now it seemed certain medicine must be subjected to the discipline of the marketplace. (p. 24)

Ha ha ha ha! The “discipline” of the marketplace. WTF is that supposed to mean? There is no discipline in the “free” market; there is only corruption, collusion, and price fixing. Plus it doesn’t take a rocket scientist to know that supply and demand does not apply: you break a leg, you go to the nearest hospital and accept whatever they charge because you have no bargaining power whatsoever. Most towns do not have more than  one hospital, and as we all know too well, various corporate factions are buying them all up.

Nineteen eighty-two also turned out to be the year that Paul Starr published his watershed study, The Social Transformation of American Medicine. Starr ended his book with a warning: “Those who talked about ‘health care planning’ in the 1970s now talk about ‘health care marketing.’ . . . The ‘health center’ of one era is the ‘profit center’ of the next . . .”

To Starr, “the coming of the corporation” seemed all but inevitable: “The failure to rationalize medical services under public control meant that, sooner or later they would be rationalized by private control. Instead of public regulation, there would be private regulation, and instead of public planning, there will be corporate planning.” The goal driving that planning, Starr suggested, would no longer be BETTER HEALTH, but rather “the RATE OF RETUN ON INVESTMENTS.” (p. 25)

Unfortunately, he was right and corporations became the rulers of us all.

There, corporate executives would become both the wealthiest and the most powerful actors on the new cultural stage. In health care, as in other industries, CEOs NOT PHYSICIANS, would make the decisions — except in those somewhat confusing cases where the physician was also a CEO, watching over his patients’ interests while simultaneously keeping an eye on the store. (p. 25)

One excellent line a bit further on (p. 28) was particularly amusing in a sad way, talking about the bull market everyone thought would go on forever in the 90s: “. . . unlimited growth was a part of the myth of the nineties — part of the DELUSION that allowed us to believe that corporate profits could rise, year after year, by 15 or 20 percent, that the U.S. trade deficit could grow to the heavens without HARMING anyone [not that they cared], and that the stock market could FOREVER POSTPONE its rendezvous with FAIR VALUE.

Chapter 2 The Cost of Competition: An Overview
. . . But economics is as much as a belief system as it is a science [NOT!!!!!], and economists’ THEORIES do not always pan out in the REAL WORLD.In practice, the scramble for health care dollars has proved extraordinarily expensive — both in terms of the quality of care and in terms of its cost.

The result is a Hobbesian marketplace where a war of “all against all” pits the health care industry’s players against one another: hospital vs. hospital, doctor vs. hospital, hospital vs. insurer, insurer vs. hospital, insurer vs. insurer, insurer vs. drugmaker, drugmaker vs. drugmaker. In this adversarial environment, “competitors do not create value, they divide it. And sometimes, they destroy it,” says Michael Porter, a Harvard Business School professor well-known for his writings on market competition. “Health care plans, hospital, doctors and payers . . . all are trying to assemble bargaining power so that they can strike a better deal for themselves while shifting cost.” But passing costs like a hot potato, from one player to another, creates NO NET VALUE. Instead, gains for one participant come at the EXPENSE OF OTHERS’ — frequently with added administrative costs. (pp. 30-32)

It is difficult for me to understand why anyone ever believed that unlimited and unrestricted profit for essential services like health care was a good thing, capitalism be damned. If they truly wanted to assure quality care, single payer is the way to go: you go to any doctor and they all get the same reimbursement. Bad doctors will lose patients and thus not get as much reimbursement. Good doctors (like those that return your phone call) will be rewarded by continuation of patient relationships. Doctors are not and should not be in the position of being CEOs that can establish a salary 100 times or more than other professions. I think if we had single payer, then maybe the doctors could be paid more per patient they carry, and not just on number of visits or number of tests ordered. I have to look for more theories of compensation on this point.

I also believe it is MORALLY and ECONOMICALLY insane to require doctors to go into $100,000 in debt to get their degrees and then HAVE TO WORK FOR FREE during their residencies. Just like in my Master’s program (library and information science), a requirement had been that we do an UNPAID internship in a workplace at 40 hours a week for a quarter as I recall. We protested, many of us had jobs already in addition to graduate school work. I personally had 5 part-time jobs at one point We were a majority of older students who had returned for our graduate degrees and as such had jobs, families, bills, and the usual stuff to pay. It was not only immoral to require us to work for free, it was worse because we were expected to pay tuition and work for free. Doctors face the same ridiculous requirements. ALL WORK SHOULD BE PAID WORK. I can’t even begin to imagine what the OVERCHARGED interest rate on student loans (more profits to the middle banksters) for $100,000 ends up costing doctors. They wouldn’t have to charge so much to make a living if they were not in a lifetime of debt peonage.

Faced with premiums that approach the mortgage payment on a small house, more and more households are likely to fall back on “pared down” plans that leave them seriously underinsured. In 2003, Texas, for example, became one of eight states that allow insurers to offer no-frills plans that exclude certain benefits. Among the “frills” eliminated: complications during pregnancy; treatment for HIV and AIDS; CONTRACEPTIVES; treatment for serious mental illness, diabetes, speech and hearing impairment; and home health care. (p. 35)

This is basically approaching the concept of no coverage for pre-existing conditions. By allowing the insurers to offer an a la carte menu of insurance coverage and change the price of the insurance accordingly, sick people pay more while having less money, and the whole concept of a pool of common resources is completely thwarted. Sick people get sicker and cost more than health maintenance.

The drug companies use of direct to consumer advertising is another cost of competition.

By 2005 the industry’s budget for direct-to-consumer ads had ballooned to $4.1 BILLION — up from $2.5 BILLION in 2001. . . .

So in 2003 market giant Pfizer poured $2.84 BILLION into promoting its products, making the pharmaceutical giant the FOURTH largest advertiser in the United States. . . .

This is not to say that drugmakers gave up on doctors. In 2001 the industry acknowledged that it spent $5.5 BILLION to send some 88,000 sales representatives to doctors’ offices, bearing trinkets, food, and “educational” materials detailing the advantages of their companies’ drugs.  (p. 50)

If you were wondering why there isn’t a longer history of drug company advertising it is because it was not allowed until FDA “gave their blessing” in 1997. ONLY THE UNITED STATES  and NEW ZEALAND allows direct-to-consumer drug advertising.

The numbers are truly staggering and this chapter has details about how much the drug companies spend on marketing versus research and marketing wins by double or more. Profit also is nearly double in some cases compared to research budgets.

Furthermore, sometimes when doctors figure out that two drugs in combination work best, but they need to establish it in clinical trials, if the drugs are patented by two different pharmaceutical companies, they can refuse to cooperate with each to “protect” their “industrial secrets.”

Another book I read on Big Pharma described how many of the big companies aren’t doing new research, especially for “orphan diseases” that are likely to be “profitable” by their definition. They simply tweak an existing about-to-expire patent to run through FDA and get a new patent for the “new” drug, that may just be changed by the filler or some other non-medical element.

More damage was wrought by the HMOs that were not such a good idea after all but they are still trying to persuade people that they are. Also under W other federal funds were directed to private insurance companies for no damn good reason.

Former NEJM editor, Dr. Marcia Angela describes what happens to the health care dollar as it wends it was through the insurance industry: “Private insurers regularly skim off the top 10 percent to 25 percent of premiums for administrative costs, marketing and profits. The remainder is passed along a gauntlet of satellite businesses — insurance brokers, disease-management and utilization-review companies lawyers, consultants, billing agencies, information management firms and so on. Their function is often to LIMIT SERVICE in one way or another. They, too, take a cut including enough for their own administrative costs, marketing and profits.” In the end, Angell reports, “as much as half of the health-care dollar NEVER REACHES DOCTORS or HOSPITALS. (p. 56)

What I don’t understand is why is this news to anyone? OF COURSE money is wasted in a profiteering system where everyone takes a cut of the money. I wonder what percentage of the 50 cents goes to CEO salaries alone!!!

REMINDER this book is copyrighted 2006 so does not cover any impact of the Affordable Care Act with limitations like 80 percent of the premium dollars must go directly for actual health care. 

There are other costs that I hadn’t thought of that are discussed, like the cost of consolidation, aka monopoly. The Catholic Church has been buying up hospitals like crazy AND demanding that they receive the Church’s unreasonable exclusion from paying taxes, including property taxes that pay to maintain the roads to the hospital and the infrastructure for utilities and other factors that cannot justifiably be excluded on separation of church and state grounds. You want you toilets to flush, by God, you pay for the sewers.

Some of the situations described in the chapter on for-profit hospitals will make you weep. One corporation, Tenet, figured out how to game the system to screw with Medicare’s formula for reimbursement. Essentially, they raised the “retail” (uninsured) rate “1,092 percent over what it cost the hospital to provide services.” (p. 100) This is another method by which the poor are screwed. No one with insurance EVER PAYS a retail rate, there are all kinds of group discounts. This scheme doubled their profit, and anyone poor caught with the full retail bill price got to declare bankruptcy. The Tenet’s CEO in 2000 , David Dennis, formerly an investment banking “sidekick” set “ever higher performance targets for hospital executives. Managers who succeeded could expect a hefty bonus: in 2001 the average chief executive of a Tenet hospital doubled his $200,000 salary.”

“We make cash flow an important part of our incentive compensation system,” said Dennis –apparently unaware that this was precisely how NME had motivated its executives to ‘put heads on the beds.’ At Tenet, just as at NME, an executives’ bonuses was directly linked to his hospital’s financial performance. Neither quality of care nor patient satisfaction figured into the calculation. (p. 101)

This attitude likely contributes to the severe understaffing of nurses in hospitals, and other deficiencies, with a cut costs at any cost including patients quelling screaming pain, lying on the floor of the waiting room because NO GURNEYS were available (true story – it happened to me).

The unaddressed assumptions behind the fight over medial care, like so much else in America, essentially devolves to religion. Our Puritan ancestors have a lot to answer for with their vicious anti-humanity constraints and moral judgements. All religions do the same thing: assumes people are lazy, greedy, undisciplined, “inappropriately” sexual beings, in need of the hard hand of a “loving father” that is God or the men in power over others.

The elites, who never have to worry about if a medical procedure will bankrupt them or not, all (Republican or Democrat or whatever) FEAR the costs that would be incurred if the lazy masses were allowed to run amok getting ANY MEDICAL CARE they could and not just what is determined by a third party such as an insurance company what is “medically necessary” (plastic surgery to remove a disfiguring facial mole = not medically necessary).

This is why, I believe, they are obsessed with the control of insurance companies to supervise the people who would otherwise just go to the doctor as a social event rather than having a “serious” medical problem. Note that even the concept of the degree of medical necessity contains a judgement, but who gets to decide how “seriously” sick you are? Certainly not YOU, the patient, the one to know absolutely that things are not well in your body.

This is why they cannot imagine medical care without DEDUCTIBLES and COPAYS. This way having MONEY RATIONS HEALTH CARE and it is just tough if you are too poor to pay that $2,500 hospital bill deductible. You get to die or go bankrupt depending on luck. There is absolutely no justifiable reason for either deductibles and copays other than to discourage poor people from going to the doctors, which results in them getting sicker and sicker, and requiring more expensive and emergency care, not to mention a sucky quality of life, and possibly an impoverished one since maybe they do not receive sick days or lose their jobs because of absenteeism due to illness.

In a nutshell, the story illustrates what insurance companies fear most: “moral hazard” (a term originally coined by the fire insurance industry to describe the risk of losing money due to the POOR MORAL CHARACTER of the insured — i.e., the danger that he might turn out to be an arsonist), now refers to the risk that when insured patients are spending SOMEONE ELSE’S MONEY, they will cheerfully sign up for $1,000 worth of services — even though, if they were reaching into their own pockets, they might assess those same services as worth only $500, and reduce their use accordingly. (Whether using the health insurance that YOU HAVE PAID FOR really ranks as a “moral failing” will be discussed later. (p. 169)

This whole concept that medical “consumers” can CHOOSE to shop around for the best priced MRI or prescription is irrational. People seeking medical care are not in a position to either set pricing or the relative value. For example, I once I asked an MRI technician why MRIs were still so costly. After all, they’ve been around for decades, surely the overhead was paid off by now? I was startled to learn that the magnets that make them work have to be replaced every few years, 5 maybe? The price of the magnets was roughly $25,000 or $50,000 I don’t recall exactly. But a lot of money! Even so, if they receive $1,000 (usually more) for an MRI and they do 10 a day (for easy math) then the $50,000 is covered in 5 days of use. Everything thereafter is pure profit so to speak (yeah I know, costs to run and labor and so on, but I think it is still an accurate point).

At the same time I had to question whether the price of the magnets at so much money could truly be justified? Again, the tech has been around, there are MRI machines all over the place, and the overhead for producing them should have been paid down by now. So why, like computers, hasn’t the prices of the magnets or the machines come down? Is there a monopoly? Is there a revised patent that allows proprietary profits to be made again? Is there collusion and price fixing? You betcha. I just don’t know how to prove it. If our government regulatory agencies weren’t subverted by corporate interests, there would be a whole lot of investigation into price fixing across the board (Think about gas stations, how is it they ALL END UP WITH THE SAME PER GALLON PRICE without coordination of some kind?). Furniture is commonly known to have a 500% markup. IS THIS REASONABLE? No, of course not. Does anyone give a shit enough to do something, no, that is the “free market” where prices can be established with no restraints whatsoever on the irrational and provably false belief that the “invisible hand of the market” implying consumers, would not buy something overpriced. The fact is, that given the massive consolidation of retail outlets and again, corruption and collusion and price-fixing, consumers have no way to know that the refrigerator they need to buy cost $20 in China (exaggerating, probably $100) and transportation gets to add on $500, the store profit and overhead $500 and you the consumer can CHOOSE to go to Home Depot and pay $1,200 (marketing costs too) or Lowes where they each have the same damn brands with ‘SUGGESTED MANUFACTURER RETAIL PRICING’ just to keep profits for millionaire “investors” who do no work to earn their income, merely take advantage of accumulated excess wealth that 90% of us will never have. Also, in effect, overpricing serves the consumers screwed, so they have to live in debt peonage, work at non-living wages, and not agitate for anything “fair” in pricing or pay lest they have their refrigerator, car, home taken away from them.

Unlike refrigerators, medical care does not provide a pretense of a “competitive market” because most “consumers” aka patients are lucky to have ONE HOSPITAL to “choose” from and these have become chain stores as well. For example, the Catholic Church has been making massive purchases of hospitals (which they seek to have be tax-free under their blanket privilege to not have to pay for streets, or infrastructure, or taxes while denying necessary medical care to people based on their religious beliefs). This makes hospitals just another chain store.

Sick people are not a “market” to be exploited for profit. That is immoral. Not the people making use of medical care for which they either pay insurance premiums for, or in an ideal world, TAX DOLLARS FOR THE COMMON GOOD.

The attitude, “no abortions with my tax money” and “your mortgage is not my problem” and “you shouldn’t have had so many kids if you couldn’t afford them” are just a few of the many claims Republicans and conservatives make to ignore the fact that CAPITALISM is an exploitative economic system that cheats people of living wages and charges outrageous price-gouging rates for EVERYTHING, especially essentials, like life-saving medication.

In fact, there are no personalized earmarked taxpayer dollars that anyone has ever been able to pick and choose how the money is spent. Theoretically, that is why we have government, to decide the best use for limited resources to do the most good, again theoretically, for people, by which I mean actual living breathing human beings. The same people that don’t want “their” money going for abortion have no problem with gun manufacturers providing killing machines or the military industrial complex dropping bombs and ruining any possible life in entire cities just because they are in another country. Similarly, rather than reach out a hand to help someone up the ladder that they themselves benefitted from (such as Speaker Ryan going to college because of Social Security money) would rather stomp on the hand of any woman or person of color who seeks the same opportunity.

This constant presence of moral judgement and the myth of “moral hazard” is why people who have been fed propaganda by the conservatives, republicans (aka old white men) and even the formerly Christian Xtian’s with their evangelical impulses while simultaneously condemning all who do not agree to their dogma as undeserving of basic bodily autonomy or free thinking. There are so many examples of Republican politicians saying really dumb and mean things it is hard to keep them all straight. The “don’t feed stray animals or they’ll become dependent” from a North Carolina politician was pretty appalling. Pretty sure he would not vote for tax dollars to pay for hot school lunches for children.

Ha ha ha! I called it right when I attributed the whole American obsession with morality to the Puritans.

Former Medicare administrator Bruce Vladeck rejects what he sees as a worn formulation. Vladeck attributes our tendency to “blame the consumer” first to “our Puritan ethos,” which “rebels at the thought of all hose overinsured consumers frivolously using up all of that valuable health care — and if the consumers are using health care because they’re sick, then that’s probably their own fault too.”

But that is only one reason why economists finger the consumer, says Vladeck. The other, he suggests, is political: “If we focus on [how much care consumers use] we don’t talk about prices — or incomes — and thus don’t directly threaten the existing structures of power and prestige within the health care system or the political system.” In other words, we don’t ruffle the feathers of those on the receiving end of a $2 TRILLION INDUSTRY — the drugmakers, device makers, hospital CEOs, and entrepreneurial health care providers who see themselves as businessmen first and professionals second.

By blaming the consumer, we also avoid flustering the many politicians who receive handsome contributions from a grateful health care lobby. As Vladek puts it, “focusing on utilization permits both health care providers and prayers to change the subject away from the more embarrassing discussion of who’s getting paid, by whom, and how much. (pp. 168-169)

Like everything else in the U.S.A., everything is all the fault of the individual, never a systemic failure of government or the morals of politicians and certainly not the corporate “people” who are the true culprits and beneficiaries of the capitalist economy apply to everything but especially, egregiously, to medical care.

There is a very damning commentary by Dr. Donal Berwick, cofounder of the Institute for Healthcare Improvement (pp. 180-186) about his own experience AS A DOCTOR trying to help his wife with a rare and difficult severely disabling disease requiring multiple hospitalizations, bad medication errors ON A DAILY BASIS, and doctors who failed to read anyone else’s notes but treated his wife as if there was no documentation at all.

EVERY FUCKING TIME I go see any doctor, the nurse or assistant or whoever asks me to tell them what is wrong. They make notes. then the doctor comes in and I HAVE TO TELL THEM EVERYTHING ALL OVER AGAIN. And they frequently do not make notes but presumably that is why I have to tell the nurse stuff. It is even worse for a hospitalization. What a NIGHTMARE or two or three I have had in the last 5 years that landed me in the hospital. In one case, I could not tell the nurses from the doctors from whoever else was responsible for doing things for me like getting a blanket while I was shivering. I was in extreme pain, which turned out to be from arthritis pinching nerves in my back. It was hard to see or recognize which people came in that I had seen before, or who had asked me stuff before, and how many people in various roles came in to discuss and exam me. AND EVERY TIME someone new came in they each asked me TO REPEAT EVERYTHING to them again. Very few took notes at that time. I wanted to get my phone out and record it and them, and I really wish I had. I later got the hospital records because they were telling me things I knew to be false, and all kinds of other issues, and I wanted to correct the record. Turns out THEY HAVE TO AGREE TO CHANGE THE RECORDS to correct them which means that they can gaslight you to deny your lived experience. One point that had specific repercussions for me (despite sounding trivial to you and probably to them) was the fact that despite my repeated telling all the care givers that I had been ARRANGING FLOWERS prior to my back going out, the notes said I had been GARDENING. There is a big difference in the physical demands of gardening and flower arranging. This was just one of many issues I had that led me ultimately to check myself out of the hospital in disgust the next afternoon. BTW, I was told that I had “ordinary backache” but several days later my specialty appointment at the spine pain center they told me I had arthritis and it was clearly visible in the MRIs so there was absolutely no reason I was told I had “ordinary backache” when in fact, I needed steroid shots in my spinal facets in order to be able to walk and not be in the worst pain in my life (and I have had a kidney stones and a BROKEN back).

I have to repeat and repeat my allergies, especially drug allergies, and yet I end up with prescriptions with a derivative that thankfully the pharmacist caught. Another experience I had was with a 10 year sinus infection because it was assumed to be cured after the “average” 10 day dose of antibiotics. The day I finally broke down and got in to see an ENT, he did a CT scan and changed his schedule to do surgery the next day.

The reason I decided I needed to see an ENT is because I read in detail with a medical dictionary by my side, a recent brain MRI (for MS) and noticed a few sentences that sounded very bad when I looked them up. Mucosal thickening was one phrase that didn’t seem too catastrophic but it was not a good thing. I was shocked that my neurologist had not mentioned that part of the report and suggest to me that I go see an ENT. But of course, like Dr. Berwick’s experiences, the condition of the sinuses had nothing to do with my multiple sclerosis so it probably never occurred to my neurologist to read much less look up what those paragraphs actually meant. The ENT later told me that the only way to know for sure if the 10 days of antibiotics has completely cured a sinus infection is a follow up CT scan, which of course, insurance will not cover because the “usual and customary” 10 days of antibiotics is deemed enough. Though since NO ONE DOES CT scans to follow up, how they can say with certainty that 10 days is FACTUALLY enough for 99% of the people, then I cannot accept that getting a CT scan to make sure you are cured is “unnecessary” as part of proper sinus infection treatment.

I am what is certainly considered to be a “difficult” patient because (a) I question authority, (b) I read a lot and know my stats and facts about Medicare that a hospital administrator didn’t even know, (c) I mostly will not be cowed by “rules” and other bullying tactics of staff that make no sense and are not justifiable. Being a difficult patient is not a good thing to be because it can adversely impact your care.

This concern is real as Dr. Berwick was well aware of because AS A DOCTOR he was absolutely a credible expert in his own right. He describes an incident where he watched an intravenous drip and knew that they had missed a dose. The nurses response was basically what women usually hear, “There there dear, don’t worry your pretty little head about it.”

Fortunately I am very stubborn and experienced and have resolved to be in charge of my medical care and do my research and the whole “Internet doctor” derision will not stop me. I have been more accurately able to diagnose myself than many of the doctors, in part I think, because of a major point this book makes: doctors do not listen to the patients, but simply order tests and procedures and discount anyone who finds something that fits their symptoms online and suggest they be tested for that — usually rare — disease, only to be proven right later on. Hopefully, before too late, like with death as the consequence of dismissing “Internet” research by a patient.

“If what happened to Ann could happen in our best institutions.” Berwick adds, “I wonder more than ever before what the average must be like.” (p. 166)

One of my long time questions was answered beginning on page 193 titled “Nor are They Paid to Listen.” Basically, doctors are not paid to spend any length of time to listen to patients because the way the system has developed, listening only pays about $35 for a half an hour, but a 10 minute endoscopy earns $900 for the procedure. The payment system was based on one ECONOMIST who determined the value of thousands of treatments in 1985. William Hsiao, a Harvard ECONOMIST (it bears repeating) and a team considered criteria such as “mental effort” and “overhead” as well as expected things like technical skill, physical effort, and surprise surprise the STRESS involved. But basically the time it takes to do something was a major factor. This was considered “rationalizing” medical care costing.

No one is cited as being a supervisor or a panel that evaluated the assumptions and decisions and weighting that the ECONOMISTS decided were relevant. It matters because MEDICARE adopted his fee schedule in 1992.

The problem with the system is that it is still so weighted toward doing procedures — and it’s so easy to make out like a bandit — that almost inevitably, we do too many procedures,” says Dr. Elliott Fisher. “I think we need to get to a reimbursement system that rewards doctors for overall health outcomes rather than paying them for piecework. Ideally, doctors would be ON SALARY, plus a bonus for better outcomes. That way,” he explains, “cardiologists would be rewarded for getting involved in efforts to persuade their patient to stop smoking”

But today counseling patients is a low-margin activity.  (p. 194)

One example that really bothers me is that doctors cannot be paid for the time it takes for them to return your phone call to discuss your situation with you. In order to be paid, you have to take time off work or whatever, make arrangements, to travel to where the doctors is and have a face to face, even so, since it is a low margin encounter and they routinely triple book to cover for cancellations and to juggle as many patients as possible for the most profit, you do not necessarily get quality fact time with the doctor who is already thinking about the 3 new patients in the waiting room.

Chapter Six perfectly sums up the state of medical care for the poor: Too Little, Too Late. Actually that could be about insured people too. Women go to the doctor more readily than men yet find their concerns too often to be symptoms that are “psychological” aka hysteria from back in the day when women’s brains and all their existence revolved around the fact that they had a uterus.

“Shunning and dunning the poor” is a subtitle and that points out one thing I had forgotten: body attachment. This is a phrase that describes, essentially, debtors prison sentences.

In 2003 The Wall Street Journal published a series of stories outlining the Dickensian tactics that some hospitals have adopted as they try to collect unpaid debts: garnishing wages, freezing the bank accounts of minimum-wage workers, and even arranging to have debtors arrested who failed to appear at a court hearing — a practice known in some parts of the country as “body attachment.” (pp. 208-209)

Congress made a law that hospital emergency rooms had to treat people regardless of their ability to pay. A humane choice, but one that hospitals consider “unfunded mandates,” that is, they make a law to force an action but provide no funds to pay for the mandated action. This is one reason why federal level politicians are so keen on BLOCK GRANTS. They provide less money than is needed to fund all the state law requirements and let everyone go after the limited funds like starving dogs for a bone. And yet, no blowback falls on the feds because the state politicians have to take the blame for the cost reductions and elimination of services.

In another case [reported by the Journal], the hospital obtained an arrest warrant for an uninsured single mother, who missed two court hearing on a $1,678 debt she incurred for a miscarriage. . . .

Why would hospitals make such aggressive efforts to collect relatively small bills from patients who quite clearly do not have the funds to pay their bills? Richard Scruggs, the lead attorney on a series of class-action suits charging not-for-profits with abusive billing practices, explains hat a number of hospital financial officers told him that they used the tactic to DISCOURAGE INDIGENT PATIENTS FROM RETURNING to their hospital. In other words, dunning becomes a form of shunning.

“Even hospitals whose [stated] mission includes treating indigent patients are reluctant to make the process TOO EASY or TOO PUBLIC for fear of becoming MAGNETS for the uninsured,” The New England Journal of Medicine observed in March of 2005. In New York City, for instance, a few hospitals post any information about charity care, discounts for indigent patient, or patient payment plans. After all, who wants to be known as the softest touch in town? (p. 209)

You can tell that the author lives in New York City and has probably never lived in flyover states because she discusses hospitals as if more than one were the normal case for everyone, but the truth is, rural areas are particularly underserved with hospital facilities, so the worry about being a “magnet” for indigent is only an issue in the bigger cities.

One of my concerns is the ethos of the development of the medical profession. Heroic medicine remains that which gains the most fame and fortune. Heart transplants, the Holy Grail cancer cure we hope to find, enabling paralyzed people to walk again, these are the glory moments for medical care. Medical care equals “cures” and fixing broken things. Medicare even requires proof of “improvement” to permit additional physical therapy, for example. For people like me, with multiple sclerosis, there won’t be improvement for the most part, but physical therapy might prevent deterioration, and that’s damned important to me. Chronic medical conditions like mine are frustrating to have and to be treated for because of so many assumptions. If I wake up with double vision (as I have done on multiple occasions) I can’t know if it means my MS is going to go bad or something else is causing a problem, like a stroke. Since I have been unable to walk, use my right arm, and numb from the waist down, requiring a five day hospital stay and extensive rehabilitation, every time I lose my balance or have some symptom of any sort, I wonder, how bad will it get?

Mostly there is little that can be done except steroid drip infusions. These are very bad for you, for example causing spinal arthritis which as noted above, is a lot worse than it sounds. So I get to choose – bone damage or 6 months or longer to wait and see how bad I get, what functionality I lose, and if any former ability returns. Rock meets hard place. So MRI of brain is ordered, but for reasons I am not clear about, they don’t always order them for the spine, but I have had the hated white spots in the spine in the past when other doctors have done MRIs of the spine. At least these days I can go in as an outpatient, get the treatment, and go back home instead of incurring a 3 to 5 day hospital stay. I shudder to think what an uninsured person with MS does. Capitalism and the market basically promotes death for the poor, that is the true nature of for-profit healthcare in hospitals, clinics, and especially pharmaceutical companies.

The description of “how the system decides whose to treat” is “the marketplace decides who receives care.” [In the U.S.] This is rationing; rationing based on ability to pay without any control or knowledge of the actual costs compared to what you are being charged. The drug company decides the market will bear $1,700 a month for a prescription, so that’s what they charge and they don’t have to justify it to anyone or even prove they are not price gouging. In the case of one med I take, the manufacturer DOESN’T EVEN KNOW WHY THE DRUG WORKS. I know that it does, and not just a placebo effect, but I wonder what else the drug is doing if they don’t know how it actually works in the body. Again, the market is not really bearing that cost in any case, because the insurance companies have to pay (apart from copay issues) so since the drug companies have a government-blessed monopoly and can charge whatever they want, isn’t that price fixing? Or do they charge different insurance companies different prices? For example, Medicare is NOT ALLOWED to negotiate prices (talk about ANTI-FREE-FUCKING MARKET). Hospitals charge poor people “full retail” but insurers get discounts on bills for their insured patients.

The author calls our system “ad hoc” rationing and it means that the insurance companies basically determine who gets what care. My neurologists has actually said to me, when concerned that I may be having an exacerbation, that we cannot do another MRI because I only had one 6 months ago and the insurance companies don’t like to do them more frequently than at least a year. So I may be VERY VERY sick, but the insurance company punishes doctors who order too many tests or too frequent of tests according to what the insurance companies have decided is “necessary” or “average” rather than WHAT YOU THE PATIENT ACTUALLY NEEDS for best medical care.

It doesn’t have to be this way. It is the obsession of Republicans to deny medical care as a basic human right, even though Constitutionally speaking they are obsessed with the “right to life” for the moment when a sperm meets an egg, but not so much if you will die due to lack of health insurance. SINGLE PAYER IS THE ONLY RATIONAL, socially just, effective and efficient way to manage health care. Other countries manage it without making the crushing foot of the market be the supreme value, compared, say, to the life of a child with leukemia.

Under Japan’s universal health system, for instance, all citizens are covered equally and can go to any physician or hospital with no difference in cost; physicians are free to prescribe as they see fit. But the government keeps a lid on total spending by setting prices for all procedures, drugs, and devices, renegotiating the payment schedule with providers, usually on a biennial basis. Sometimes these prices reflect cultural values. For example, only about one-third as any surgeries are done in Japan as in the United States — in part due to a cultural antipathy to invasive procedures, in part because the fees paid for surgery are very low.

“Relatively inexpensive services such as ordinary consultations and prescribing drugs are profitable, but expensive procedures such as surgery and other high-tech treatments are often priced below actual cost,” explains Naoki Ikegami, a professor at the Keio University School of Medicine in Tokyo Thus, the government encourages more conservative patterns. (p. 219)

I don’t agree that something should be priced UNDER COST, but we should at least have complete transparency about what the actual costs are before setting a cost plus pricing system that allows for some profit that can be used to maintain facilities, purchase new equipment, and so on.

In the U.S., under Medicare, I have to sign a form for some things that essentially means that to get the test, I have to be willing to pay it out-of-pocket. At least these days they do provide a cost estimate. Like Vitamin D testing ($200+) that is a critical factor for MSers. The form says Medicare “may not” cover it, but really, that’s just a lie. And if you don’t have the $200+ your doctor may be reluctant to give you a prescription level dose of Vitamin D (like 50,000 units) without a baseline. And of course, then after getting the mega doses, another blood test is required to assess if it is high enough or more is needed. So my choice is pay an outrageous and unverifiable amount for a test, twice, or not receive necessary treatment that could prevent further disability. What I have been trying to find out is WHO GETS TO DECIDE THIS BULLSHIT? If anyone knows, please leave a comment.

OMG, I am dumbfounded, and I wonder if this is still true: If only a state offered Medicaid to CHILDLESS ADULTS, poor single adults would be entitled to medical care. WOW. I have to look into this further. I just assumed Medicaid was for all poor people, not just for BREEDERS to use the disparaging word for people with children. Once again, as in so many things, the government supports child production in some ways, but not in so many others. Rich people get a tax deduction; poor people have too little income to benefit from a tax deduction. This is the same reason that Ivanka’s (scoff) child care proposal is useless to poor women because she bases it on the discredited notion of tax breaks to help reduce the expense, but tax breaks are only worthwhile to people rich enough to benefit from them, which is not most people. Medicaid, the author notes, is only for the “deserving poor” and “indigent men and women who do not have children — are not eligible no matter how impoverished they are.” (p. 221)

In the time period of this book, insurance costs varied based on actuarial type data, like older people get charged more, and misogyny charging women more (apart from the theoretically high cost of maternity, those of us women who do not have kids should not have to cover the costs of those that do if we are going to stick with the rugged individualist model of dog eat dog), and of course, the killer one for people like me: pre-existing conditions and the million dollar per lifetime limitation of coverage.

But hey, if the new administration has it’s way, I am going to have to die because that will be my only choice if they repeal Medicare, and gut all the social safety nets.

To conclude, this is an excellent book. Full of useful information despite being pre-Obamacare, and given the passage today by the House and the Senate of their bill to repeal Obamacare (and they used the nickname instead of the proper name, the Affordable Care Act, just another knife in the heart of the black man who dared to become president), the book might not need an update on how ACA improved things, but rather a book on the disaster and death caused by the Republicans obsession with the “undeserving poor” defined as anyone NOT RICH. Circular reasoning but they are not rational or logical, or compassionate or anything resembling public servants acting in the best interests of the citizens. Nope, dystopias are no longer appealing science fiction for me; we are going to be living in what will be worse than ever before in my lifetime and that wasn’t great and I am a white woman of reasonable privilege, despite being a worthless disabled person now that should stop being a burden to the taxpayers based on the Republican’s intent to reduce Social Security Disability by 20% back in 2015 at least.

Resist. Question authority. Never go back. Bread and roses, not half a loaf. Ideals are not for fools.


















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