Thursday, January 29, 2009

Interview with Uwe Reinhardt on Inauguration Day | Worldfocus

How the U.S. measures up to Canada's health care system Worldfocus:

"The Worldfocus signature story Canada’s hospitals cut the paperwork, emphasize care explores Canada’s health care system.

"In this extended interview, Uwe Reinhardt, a leading adviser on health care economics and professor of political economy at Princeton University, compares the Canadian and American health care systems. Reinhardt criticizes the U.S. health care culture and expresses his optimism about the Obama administration.

"As part of Worldfocus’ Health of Nations signature series, correspondent Edie Magnus conducted this half-hour interview with Uwe Reinhardt on January 20, 2008, the day of President Barack Obama’s inauguration."

Terrific interview! Highly recommended!

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Wednesday, January 28, 2009

Dodd Hears Anger, Frustration At Meeting On Health Care --

Dodd Hears Anger, Frustration At Meeting On Health Care --

"On the first day of a listening tour on health care, an issue pivotal to the new Congress and his own re-election, U.S. Sen. Christopher J. Dodd got an earful Friday.

The first comment came from a furious homeless shelter manager: He and his clients have no coverage, yet insurance giant American International Group got an $85 billion federal loan.

Over 90 minutes, the Democratic senator heard from a string of constituents, who waved their hands, hoping for a chance to describe a struggle to hang onto middle-class lives after losing jobs and affordable health care. A few were angry, others just scared.

On the way out, Dodd embraced one woman who burst into tears as she described losing health coverage for her disabled 2-year-old. Dodd held her until she stopped sobbing."
"Dodd said during his introduction that he was seeking reforms that provided universal coverage, cut costs and prevented disease. In an interview later, he made clear another condition:

"Not putting the insurance industry out of business.

" 'I hear people talking about a single-payer plan and the like," Dodd said. "That isn't going to happen. It's going to be a combination of public, private.' "

Unless, as MLK did for LBJ, we make it impossible for them NOT to do it!

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Tuesday, January 27, 2009

Panorama (BBC) Documentary on US Healthcare

The episode is entitled "What Now, Mr. President?" Sadly, there is probably nothing you didn't already know in here, but it is a good program to share with your friends who still beleive in the Best Healthcare in the World(TM) myth.

Part 1

Part 2

Part 3

Has a section on RAM Medical, which "60 Minutes" covered last year, as well as a section on wealth disparity, health care lobbying, drug pricing, and a few striking anecdotes, if you like that sort of thing. (Getting chemo in a tent, begging for Tennessee Medicaid toive a liver transplant, and thousands seeking help at RAM.)

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Friday, January 23, 2009 - Zeke Emanuel: Scrapping the Health Care System - Zeke Emanuel: Scrapping the Health Care System

"The Commonwealth Club of CaliforniaSan Francisco, CAJan 8th, 2009

"No more Band-Aids or patches, says Emanuel; it's time for a complete overhaul of health care as we know it. America spends more than $2 trillion on health care, more than any other developed nation.

"But money does not guarantee a better system. Instead, 47 million Americans go without insurance. In addition, many people suffer poor health, and often suffer financial difficulties as a result.

"Emanuel offers a bold new proposal to completely restructure our system, which he says will save money, allow for choice and give all Americans health-care coverage - The Commonwealth Club of California"

If you just want to download the MP3 audio, click here.
Dr. Emanuel's Wikipedia page is here.

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More Americans Skipping Necessary Prescriptions, Survey Finds -

More Americans Skipping Necessary Prescriptions, Survey Finds -

"One in seven Americans under age 65 went without prescribed medicines in 2007 as drug costs spiraled upward in the United States, a nonprofit research group said on Thursday."

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Thursday, January 22, 2009

Some AMA Policies Pertinent to Healthcare Reform Debate

H-165.856 Health Insurance Market Regulation
Our AMA supports the following principles for health insurance market regulation:(1) There should be greater national uniformity of market regulation across health insurance markets, regardless of type of sub-market (e.g., large group, small group, individual), geographic location, or type of health plan;(2) State variation in market regulation is permissible so long as states demonstrate that departures from national regulations would not drive up the number of uninsured, and so long as variations do not unduly hamper the development of multi-state group purchasing alliances, or create adverse selection;(3) Risk-related subsidies such as subsidies for high-risk pools, reinsurance, and risk adjustment should be financed through general tax revenues rather than through strict community rating or premium surcharges;(4) Strict community rating should be replaced with modified community rating, risk bands, or risk corridors. Although some degree of age rating is acceptable, an individual’s genetic information should not be used to determine his or her premium;(5) Insured individuals should be protected by guaranteed renewability;(6) Guaranteed renewability regulations and multi-year contracts may include provisions allowing insurers to single out individuals for rate changes or other incentives related to changes in controllable lifestyle choices;(7) Guaranteed issue regulations should be rescinded;(8) Insured individuals wishing to switch plans should be subject to a lesser degree of risk rating and pre-existing conditions limitations than individuals who are newly seeking coverage; and(9) The regulatory environment should enable rather than impede private market innovation in product development and purchasing arrangements. Specifically:(a) Legislative and regulatory barriers to the formation and operation of group purchasing alliances should, in general, be removed;(b) Benefit mandates should be minimized to allow markets to determine benefit packages and permit a wide choice of coverage options; and(c) Any legislative and regulatory barriers to the development of multi-year insurance contracts should be identified and removed.

H-165.866 All Americans Must Have Health Insurance
Our AMA strongly affirms and calls upon all of the state medical societies and all other national physician specialty organizations to strongly affirm the joint statement, "All Americans Must Have Health Insurance." (The Statement was developed in 1999 by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Emergency Physicians, the American College of Obstetricians and Gynocologists, the American College of Physicians-American Society of Internal Medicine, the American College of Surgeons, and the American Medical Association. The Statement was further endorsed by other physician specialty organizations.)

H-165.888 Evaluating Health System Reform Proposals
Our AMA will continue its efforts to ensure that health system reform proposals adhere to the following principles:(1) Physicians maintain primary ethical responsibility to advocate for their patients' interests and needs.(2) Unfair concentration of market power of payers is detrimental to patients and physicians, if patient freedom of choice or physician ability to select mode of practice is limited or denied. Single-payer systems clearly fall within such a definition and, consequently, should continue to be opposed by the AMA. Reform proposals should balance fairly the market power between payers and physicians or be opposed.(3) All health system reform proposals should include a valid estimate of implementation cost, based on all health care expenditures to be included in the reform; and supports the concept that all health system reform proposals should identify specifically what means of funding (including employer-mandated funding, general taxation, payroll or value-added taxation) will be used to pay for the reform proposal and what the impact will be.(4) All physicians participating in managed care plans and medical delivery systems must be able without threat of punitive action to comment on and present their positions on the plan's policies and procedures for medical review, quality assurance, grievance procedures, credentialing criteria, and other financial and administrative matters, including physician representation on the governing board and key committees of the plan.(5) Any national legislation for health system reform should include sufficient and continuing financial support for inner-city and rural hospitals, community health centers, clinics, special programs for special populations and other essential public health facilities that serve underserved populations that otherwise lack the financial means to pay for their health care.(6) Health system reform proposals and ultimate legislation should result in adequate resources to enable medical schools and residency programs to produce an adequate supply and appropriate generalist/specialist mix of physicians to deliver patient care in a reformed health care system.(7) All civilian federal government employees, including Congress and the Administration, should be covered by any health care delivery system passed by Congress and signed by the President.(8) True health reform is impossible without true tort reform.

H-165.904 Universal Health Coverage
Our AMA: (1) seeks to ensure that federal health system reform include payment for the urgent and emergent treatment of illnesses and injuries of indigent, non-U.S. citizens in the U.S. or its territories; (2) seeks federal legislation that would require the federal government to provide financial support to any individuals, organizations, and institutions providing legally-mandated health care services to foreign nationals and other persons not covered under health system reform; and (3) continues to assign a high priority to the problem of the medically uninsured and underinsured and continues to work toward national consensus on providing access to adequate health care coverage for all Americans

H-165.916 Government Controlled Medicine
Our AMA strongly reaffirms its unwavering opposition against the encroachment of government in the practice of medicine as well as any attempts to covertly change the American health care system to a government program with the subsequent loss of precious personal freedoms, including the right of physicians and patients to contract privately for health care without government interference.

H-165.920 Individual Health Insurance
Our AMA:(1) affirms its support for pluralism of health care delivery systems and financing mechanisms in obtaining universal coverage and access to health care services;(2) recognizes incremental levels of coverage for different groups of the uninsured, consistent with finite resources, as a necessary interim step toward universal access;(3) actively supports the principle of the individual's right to select his/her health insurance plan and actively support ways in which the concept of individually selected and individually owned health insurance can be appropriately integrated, in a complementary position, into the Association's position on achieving universal coverage and access to health care services. To do this, our AMA will:(a) Continue to support equal tax treatment for payment of health insurane coverage whether the employer provides the coverage for the employee or whether the employer provides a financial contribution to the employee to purchase individually selected and individually owned health insurance coverage, including the exemption of both employer and employee contributions toward the individually owned insurance from FICA (Social Security and Medicare) and federal and state unemployment taxes;(b) Support the concept that the tax treatment would be the same as long as the employer's contribution toward the cost of the employee's health insurance is at least equivalent to the same dollar amount that the employer would pay when purchasing the employee's insurance directly;(c) Study the viability of provisions that would allow individual employees to opt out of group plans without jeopardizing the ability of the group to continue their employer sponsored group coverage; and(d) Work toward establishment of safeguards, such as a health care voucher system, to ensure that to the extent that employer direct contributions made to the employee for the purchase of individually selected and individually owned health insurance coverage continue, such contributions are used only for that purpose when the employer direct contributions are less than the cost of the specified minimum level of coverage. Any excess of the direct contribution over the cost of such coverage could be used by the individual for other purposes;(4) will identify any further means through which universal coverage and access can be achieved;(5) supports individually selected and individually-owned health insurance as the preferred method for people to obtain health insurance coverage; and supports and advocates a system where individually-purchased and owned health insurance coverage is the preferred option, but employer-provided coverage is still available to the extent the market demands it;(6) supports the individual’s right to select his/her health insurance plan and to receive the same tax treatment for individually purchased coverage, for contributions toward employer-provided coverage, and for completely employer provided coverage;(7) supports immediate tax equity for health insurance costs of self-employed and unemployed persons;(8) supports legislation to remove paragraph (4) of Section 162(l) of the US tax code, which discriminates against the self-employed by requiring them to pay federal payroll (FICA) tax on health insurance premium expenditures;(9) supports legislation requiring a "maintenance of effort" period, such as one or two years, during which employers would be required to add to the employee’s salary the cash value of any health insurance coverage they directly provide if they discontinue that coverage or if the employee opts out of the employer-provided plan;(10) encourages through all appropriate channels the development of educational programs to assist consumers in making informed choices as to sources of individual health insurance coverage;(11) encourages employers, unions, and other employee groups to consider the merits of risk-adjusting the amount of the employer direct contributions toward individually purchased coverage. Under such an approach, useful risk adjustment measures such as age, sex, and family status would be used to provide higher-risk employees with a larger contribution and lower-risk employees with a lesser one;(12) supports a replacement of the present federal income tax exclusion from employees’ taxable income of employer-provided health insurance coverage with tax credits for individuals and families, while allowing all health insurance expenditures to be exempt from federal and state payroll taxes, including FICA (Social Security and Medicare) payroll tax, FUTA (federal unemployment tax act) payroll tax, and SUTA (state unemployment tax act) payroll tax;(13) advocates that, upon replacement, with tax credits, of the exclusion of employer-sponsored health insurance from employees’ federal income tax, any states and municipalities conforming to this federal tax change be required to use the resulting increase in state and local tax revenues to finance health insurance tax credits, vouchers or other coverage subsidies; and(14) believes that refundable, advanceable tax credits inversely related to income are preferred over public sector expansions as a means of providing coverage to the uninsured.

H-165.969 Federation and Physician Unity on Health System Reform
The AMA renews its call to the Federation, including state and specialty societies, to work together in a professional and collegial fashion to forge consensus in health system reform.

H-165.985 Opposition to Nationalized Health Care
Our AMA reaffirms the following statement of principles as a positive articulation of the Association's opposition to socialized or nationalized health care:(1) Free market competition among all modes of health care delivery and financing, with the growth of any one system determined by the number of people who prefer that mode of delivery, and not determined by preferential federal subsidy, regulations or promotion.(2) Freedom of patients to select and to change their physician or medical care plan, including those patients whose care is financed through Medicaid or other tax-supported programs, recognizing that in the choice of some plans the patient is accepting limitations in the free choice of medical services. (3) Full and clear information to consumers on the provisions and benefits offered by alternative medical care and health benefit plans, so that the choice of a source of medical care delivery is an informed one.(4) Freedom of physicians to choose whom they will serve, to establish their fees at a level which they believe fairly reflect the value of their services, to participate or not participate in a particular insurance plan or method of payment, and to accept or decline a third party allowance as payment in full for a service.(5) Inclusion in all methods of medical care payment of mechanisms to foster increased cost awareness by both providers and recipients of service, which could include patient cost sharing in an amount which does not preclude access to needed care, deferral by physicians of a specified portion of fee income, and voluntary professionally directed peer review.(6) The use of tax incentives to encourage provision of specified adequate benefits, including catastrophic expense protection, in health benefit plans.(7) The expansion of adequate health insurance coverage to the presently uninsured, through formation of insurance risk pools in each state, sliding-scale vouchers to help those with marginal incomes purchase pool coverage, development of state funds for reimbursing providers of uncompensated care, and reform of the Medicaid program to provide uniform adequate benefits to all persons with incomes below the poverty level.(8) Replacing the present Medicare program with a system developed by the AMA of pre-funded vouchers to older persons to purchase health insurance with comprehensive benefits, including catastrophic coverage.(9) Development of improved methods of financing long-term care expense through a combination of private and public resources, including encouragement of privately prefunded long-term care financing to the extent that personal income permits, assurance of access to needed services when personal resources are inadequate to finance needed care, and promotion of family caregiving.

H-165.841 Comprehensive Health System Reform
Our AMA supports the overall goal of ensuring that every American has access to affordable high quality health care coverage and will work with interested members of Congress to seek legislation consistent with AMA policy.

H-165.847 Comprehensive Health System Reform
1. Comprehensive health system reform, which achieves access to quality health care for all Americans while improving the physician practice environment, is of the highest priority for our AMA.2. Our AMA recognizes that as our health care delivery system evolves, direct and meaningful physician input is essential and must be present at every level of debate. (Res. 613, A-06; Reaffirmation I-07; Res. 107, A-08)

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Tuesday, January 20, 2009

SourceOECD: OECD Health 2007

SourceOECD: OECD Health 2007

Just a link to OECD data so I can get back to it easily...

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Thursday, January 15, 2009

Journal of Clinical Investigation -- Critical: What we can do about the health-care crisis

Journal of Clinical Investigation -- Critical: What we can do about the health-care crisis:

The section on the proposed federal HEALTH bard, from a review of the Daschle Book, by Joseph White:

"Part Four explains that the Federal Health Board would operate within a reform context similar to proposals made by major Democratic candidates in the 2008 presidential campaign. Medicaid would be expanded; private health insurance would be made more broadly available through a system of subsidies and would be marketed through an open version of the Federal Employees Health Benefits Program (FEHBP); an expanded version of Medicare would be made available to all Americans for purchase through the FEHBP; employers would be required to subsidize their employees’ coverage directly or make a contribution to the FEHBP insurance pool; and individuals would be required to purchase one of the coverage options (unless eligible for Medicaid), and their premium expenses would be subsidized by a refundable tax credit. The complexity of health policy is shown by all other decisions that would be left to the Federal Health Board. Among these would be defining the minimum benefit package (including parity for mental health care); regulating insurance marketing; standardizing medical records across all federal health care programs (including the Veterans Health Administration, Medicare, and Medicaid); and improving value in all federal programs through new quality measures, new methods of “paying for performance” (P4P), and approving or setting prices for new procedures based on cost-effectiveness research. Daschle argues that applying such reforms to the 100 million Americans (at a minimum) covered by the federal programs (including voluntary Medicare) would create “tremendous pressure on everybody else to follow suit”."

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Wednesday, January 14, 2009

What Doctors Make, and Why - New York Times

What Doctors Make, and Why - New York Times:

"In “Sending Back the Doctor’s Bill” (Week in Review, July 29), you compare the incomes of American physicians with those earned by doctors in other countries and suggest that American doctors seem overpaid. A more relevant benchmark, however, would seem to be the earnings of the American talent pool from which American doctors must be recruited.

Any college graduate bright enough to get into medical school surely would be able to get a high-paying job on Wall Street. The obverse is not necessarily true. Against that benchmark, every American doctor can be said to be sorely underpaid.

Besides, cutting doctors’ take-home pay would not really solve the American cost crisis. The total amount Americans pay their physicians collectively represents only about 20 percent of total national health spending. Of this total, close to half is absorbed by the physicians’ practice expenses, including malpractice premiums, but excluding the amortization of college and medical-school debt.

This makes the physicians’ collective take-home pay only about 10 percent of total national health spending. If we somehow managed to cut that take-home pay by, say, 20 percent, we would reduce total national health spending by only 2 percent, in return for a wholly demoralized medical profession to which we so often look to save our lives. It strikes me as a poor strategy.

Physicians are the central decision makers in health care. A superior strategy might be to pay them very well for helping us reduce unwarranted health spending elsewhere.

Uwe E. Reinhardt, Princeton, N.J., July 30, 2007"

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Tuesday, January 13, 2009

Medical Debt Is a Growing Worry, for Those With Insurance and Without -

Medical Debt Is a Growing Worry, for Those With Insurance and Without -

"'People who are underinsured end up facing almost identical problems as the uninsured,' said Karen L. Pollitz, director of the Health Policy Institute at Georgetown University. 'The difference is, they paid for the privilege.'

"Medical debt is likely to figure prominently in the looming national debate over reforming health care.

"Jim Eyler, 57, of Westminster, Md., says he needs help. The cement company manager said he spends about 33 percent of his take-home pay on unreimbursed medical bills, many connected with the advanced breast cancer his wife has been battling since 2005. 'I keep wondering, where's the money going to come from?' he asked."

More anecdotes here, of course, but the larger point is that our current cost structure is unsustainable.

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Sunday, January 11, 2009

American Health Care Since 1994: The Unacceptable Status Quo

American Health Care Since 1994: The Unacceptable Status Quo:

"Higher medical costs are also taking a toll on America's fiscal health. As the CBO has warned, 'the rate at which health care spending grows relative to the economy is the most important determinant of the country's long-term fiscal balance.' Federal health care expenditures, including Medicare and Medicaid, have risen to over $800 billion, or $2,650 per person, in 2008, from $300 billion, or $1,600 per person, in 1994 (in constant 2008 dollars). The burden on states has increased as well, to $300 billion in health care costs in 2008, from $190 billion in 1994 (including each state's share of the Medicaid program). These trends are projected to speed up, with per-person federal expenditure nearing $6,000 by 2017 and state and local expenditures projected to increase to $2,000 per-person (in 2008 dollars) over the same period.

"While some of this increase is attributable to population growth, an aging population, and changes to the policy structures of Medicare and Medicaid (including an expansion of the State Children's Health Insurance Program), much of it comes from the underlying inefficiencies and excess costs of the American health care system."

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Atlas Wanked: From Fiction to Fraud in 52 Years | Crooks and Liars

Atlas Wanked: From Fiction to Fraud in 52 Years Crooks and Liars:

"But what's especially amusing is that the economic wreckage we see before us today is in fact the handiwork of the Randian dimwits who've become endemic to conservative economics.

"Exhibit A: Longtime Fed Chairman Alan Greenspan, who was a Big Randian from back in the day.

"Of course, Greenspan now admits this approach may not have worked out so well. Especially the bit about letting the true economic geniuses/captains of industry have their unfettered way. In fact, it all turned out to be a big fat fraud, didn't it?

"Greenspan wasn't alone, of course. George W. Bush's entire approach to governance, especially in the economic sector, was fundamentally Randian: Bush never met a tax cut for the wealthy or deregulation scheme he didn't chase like a fox after a chicken. Even the Democrats who succumbed to the 'era of profound irresponsibility' did so because they were harkening to the siren song of the right-wing Randians.

"Watching Randians at work trying to convince themselves of their essential rightness in the face of the global wreckage pile of evidence to the contrary would be funny were the consequences of their historical muckup not so devastating and so far-reaching for so many of the ordinary schlubs for whom the Randians have at best a guarded contempt. It all reminds me of a bit of wisdom my granddaddy passed along to me: 'Watch out for ideologues. Ideas are more important to them than people.'"

I have this filed under "Contrarian Economics," and sadly, the Randian, absolutist free market theory backers are still manning the ramparts to maintain the mantle of respectable economic thought. So, in spite of the wreckage around us, Capitalism with a mandate for social justice is still contrarian.

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Friday, January 9, 2009

Blue Shield to restore coverage for dropped Californians - Los Angeles Times

Blue Shield to restore coverage for dropped Californians - Los Angeles Times:

"In an attempt to settle investigations prompted by articles in The Times, the insurer agrees to reissue plans to almost 700 Californians and reimburse them for expenses that would have been covered.
By Lisa Girion [January 7, 2009 ]

"Blue Shield has agreed to reissue medical coverage to nearly 700 Californians whose policies were canceled after they got sick and to make changes in the way it handles insurance bought by individuals, officials said Tuesday.

"Blue Shield of California's Life & Health Insurance Co. also agreed to reimburse consumers whose coverage was canceled for medical expenses they paid out of pocket."
"Most of the state's health insurers remain mired in litigation over the practice that has led to the cancellation of thousands of policies of sick patients, as well as financial losses for them, physicians and hospitals. In addition, Los Angeles City Atty. Rocky Delgadillo has sued Anthem Blue Cross, Blue Shield and Health Net, accusing all three of improperly dropping customers."
"When the state's charges were initially filed, Ross called them "grossly unfair." Blue Shield and other insurers have maintained that state law allows them to review a patient's old medical records after they get sick and rescind coverage if it finds something the policyholder failed to disclose on his application -- whether intentionally or by mistake.

"Consumer advocates and lawyers have accused Blue Shield and other insurers of using purposefully confusing applications designed to trick people into making mistakes that can later be used against them and of failing to properly vet the applications before issuing coverage."

God bless the American Businessman! Or woman. (Sorry, Loretta!)

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Thursday, January 8, 2009

OECD Study of Physician Income in 14 Countires

"The Remuneration of General Practitioners and Specialists in 14 OECD Countries: What are the Factors Influencing Variations across Countries?
(Published 22-Dec-2008)"

This link takes you to the full PDF file of the document. It is interesting.

For primary care, most coutries get between $106k to $121K, US is $146K. Interestingly, the dreaded NHS of the UK is the $121, and France is a low outlier at only $84K! But keep looking through the graphs, they are interesting. For example, US PCP's are payed 3.4 times the average wage of our countrymen, and this is in line with the top half dozen countries or so.

Turns out the Netherlands has physician income for specialists higher than ours, by quite a bit ($290K vs $236K). But the rest of the countries fall off fairly quickly. They do not have the large disparity of specialist vs PCP income that we do.

I don't have the data (nor the skills!) to do the analysis, but I would be very interested in how wealth accumulation differs among the countries. Considering the large expense of American colleges and Medical Schools, I would make a guess that we are so far behind the eight ball when we finish our educations and training, that we probably don't catch up with our international peers until we're in our forties or fifties, except for the highly payed specialties.

So, would it be wiser to do as other countries do and heavily subsidize our educations so there is not so much pent up delayed gratification? And would that also lead to more PCPs and less income disparity among specialties?

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Who Will Be at the Table? : CJR

Who Will Be at the Table? : CJR:

"In a presentation to Congress, acting CBO director Robert Sunshine amplified this point: “Significantly reducing the level of growth of health care spending would require substantial changes in the incentives faced by doctors and hospitals to control costs,” he said. Translation: to really reduce medical spending, doctors and hospitals might face cost controls that could lower their incomes. The American Medical Association successfully fought this possibility every time health reform rose on the national agenda, and it’s a good bet they will fight again, while angling for a prominent place at Obama’s table."

A discussion of physicians' role in the upcoming debate. Unfortunately, it seems that only the usual suspects are being considered for participation. I hope we can change this.

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