by Patrick Appel

Conor solicits advice elsewhere and links to Kevin Drum's rebuttal. A few more reader responses:

I think in general Conor is asking the right questions, and as someone who has worked off and on in the health care industry for 20+ years, I share many of your concerns.

I'll comment on a few specific areas:

"I'd bet a hefty sum that expanding coverage /and/ the role the federal government plays in health care is going to significantly increase rather than decrease costs."

Right now I'd take that bet. The existing payments and incentives system in health care is completely, utterly broken, and we need a very large shake-up to fix it.  My last job in health care was at a small compounding pharmacy that employed 3 pharmacists, 7-8 pharmacy techs, and 25-30 people in billing and finance to try and get paid for what the other 10 did.

While in general I'm extremely skeptical of the government's cost management abilities (I've also worked in Defense...), health care is one area where the government currently does a better job than the large insurance companies.

"Fear of excessive state power. It shouldn't be too difficult to imagine another Dick Cheney or Richard Nixon in the White House."

This one is a huge worry for me, and why I think it's imperative that any public option not be allowed to crowd out all competition.  There absolutely must be a huge firewall between politicians of all flavors and people making health care decisions.

"I keep seeing the argument that America is the leading health care innovator, and that if our system looks more like what Europe has, there won't be anyone left making strides in research and development."

I don't understand this concern at all.  Where is the supposed threat to America's medical R&D establishment?  It's not like insurance companies and family practice groups are funding or performing the basic research that keeps us in our current leadership position.  Medical research is dominated by government agencies, non-profit NGOs, universities, and multi-national pharmaceutical and medical equipment companies, none of which stand to suffer based on any of the proposals I've read.

"It seems like we should train people other than doctors to perform certain discrete medical tasks that don't require all those years of medical school -- a mix of pharmacists, professional bone setters, nurse practitioners and others should be able to dole out a lot of routine examinations, procedures and cures at a lower cost."

This has already largely happened, and it's a Good Thing indeed.  A huge proportion of primary care is now administered by PAs, NPs, RNs, and various non-MD technicians.

And yes, the AMA and many major med schools desperately need large enemas for how they train physicians and fight against reasonable accountability measures.  That being said, the malpractice insurance and civil tort issues are fairly confined to just a few specialties these days (OB/Gyn and plastics, for example) -- it's really a non-issue for the vast majority of MDs.

Another picks out a comment already touched upon above:

"It seems like we should train people other than doctors to perform certain discrete medical tasks that don't require all those years of medical school... [they] should be able to dole out a lot of routine examinations, procedures and cures at a lower cost."

My wife and I are expecting a baby in September, and we are choosing to birth with a midwife rather than an OB-GYN. One problem: our insurance doesn't cover midwives, so we will end up paying $2,500 out of pocket for the kind of birth we want. If we had a hospital birth with an OB-GYN, our insurance company would cover the $20,000+ bill and not bat an eye. This is not logical. This is exactly the kind of backwardness that is the backbone of our healthcare system.

One more:

We are training nurse practitioners and physicians assistants, and you may notice that they do a lot of the work at hospitals and physicians' offices. This trend will continue. Where we could do better is at reducing the cost of professional school--medical schools and law schools are cash cows for the universities that run them, and their graduates leave school hundreds of thousands of dollars in debt. (Someone who starts medical school cannot afford to leave if he or she realizes it's not the right career.) Sure, it's rare to find a poor physician, but a typical doctor will still have large student loans well into the 40s. Cut the cost of med school, and you'll be able to cut salary costs w/o hurting future physicians.

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