Web Letters: A System From Hell

Kate Michelman's letter is troubling, but even more troubling is the fact that her situation is only one of millions of nearly identical ones. Most of the other stories are happening to people who are not as articulate as Michelman and whose inherent pride forces them to face the health insurance catastrophe alone. If all these stories could be told as cogently as hers, at a Congressional hearing, we might approach the point where, to quote Bob Dylan, "Now's the time for your tears."

Our medical system has made incredible advances against disease. In parallel with it, the anarchy of our healthcare financing system is creating an unacknowledged crisis of anxiety around how to pay for those miracle cures. This mass anxiety in itself might constitute the new medical challenge of the next decade.

I am a self-employed resident of Massachusetts, and I was one of the responsible folks who bought their own health insurance before "reform" was adopted. Before reform, my health insurance cost was rising by 30 percent a year. Under reform, with the expanded risk pool, premiums are still rising, although at a slower rate. This cannot go on forever; at some point the cost of health insurance will outstrip my ability to earn enough to pay for it. Meanwhile, because my daughter is out of college, she cannot be put onto my policy, and because she is unemployed, she has to pay for her insurance out of pocket, despite having virtually no income.

The new health insurance policies developed to make healthcare "affordable" in Massachusetts generally have extremely high deductibles and copayments, which is simply a disguised way of making the expensive seem cheap. These policies are useful only to those who will never use the healthcare system. Those who do use it find out quite rapidly that primary care doctors are being ordered to cut their office visits to under ten minutes, and everything from prescription coverage to physical therapy needs to be fought for. People who are sick and injured are in no position to fight those myriad decisions.

It is true that no healthcare system, even single-payer, can succeed unless costs are controlled. As a society, we are paying a huge amount for healthcare. Those dollars are going into someone's pocket. Although every sector of the healthcare economy claims to be a victim, there has to be a sector that is being paid more than it needs to be paid. The overpayment may stem from greed, or it may simply arise from a multitude of tests, procedures and prescriptions that are unnecessary.

One silver lining in our present near-depression is that people are eventually going to realize they can make do with less. We need to be given the choice of a healthcare plan that is made truly affordable by providing no-frills care by decent, caring doctors who don't need yachts to feel important. We don't need the most expensive MRI machine, the potted palms in the waiting room or the six clerical assistants processing insurance reimbursements.

From my vantage point, the way to get there is to open up the VA system to everyone and clone its method of service delivery and cost control. We need to cover everyone, regardless of employment or anything else. We need to wind up with a system where no one going into a doctor's office needs to worry about anything except the diagnosis.

Don Solomon

Boston, MA

On healthcare I agree: we have a System From Hell. In previous letters I've read about the nightmare that is Medicaid--I don't want the same people who engineered the Medicaid system running my healthcare.

Why not adopt something like the Swiss have?

1. Require everyone to buy some sort of private health insurance, but subsidize those who can't afford it on their own. Benefits:
- Separates insurance status from employment status.
- Forces everyone to take responsibility for choosing their own benefits (although I think minimums should be established at federal level, see below).
- Allows everyone to see how much their healthcare really costs. Right now I don't think some people realize their place of employment may be doling out $12,000 a year in benefits. If everyone, not just the self-insured, realized how much healthcare really costs, I think there would be more political willpower to force cost saving measures like letting physician assistants/nurse practitioners/midwives/etc. handle more general care. (Another great cost-saving measure nixed by the Bush administration is allowing more centers of specialization, i.e., clinics that only do heart surgeries. These were found under independent review to be both safer and less expensive, but they competed too much with existing hospitals, which have more money and better lobbyists).

2. Set a federal minimum level of care (this could easily be modeled on the policies provided to government workers or union members). Allow these "minimum standard" policies to be sold everywhere. Benefits:
- Many states have very arduous coverage rules that drive up costs for everyone. For instance, here in Illinois maternity coverage covers three shots at invitro fertilization. This drives up costs for everyone who wants maternity. In vitro should be optional coverage; but any woman who needs maternity coverage should receive it at reasonable cost.
- This could allow economies of scale for insurance companies.

3. Require that premiums be based on amount of deductible and demographics--not on health status. Benefits: self-explanatory.

4. Make it illegal for insurance companies to deny coverage or make exclusions to coverage based on health status. Benefits: self-explanatory.

5. Possibly end the tax-free status of insurance. Benefits:
- Again, might give energy to cost-cutting reforms.
- Might actually wind up creating universal coverage that is revenue-neutral.
- It would be fair. Right now, wealthy individuals are getting an effective tax deduction at the federal level as high as 35 percent (even higher under Obama's tax code).

6. Possibly phase out the for-profit model of health insurance companies. Have health insurance companies beholden to shareholders and to patients, and you know who will lose out. Forcing a publicly traded company to go private is impossible, but perhaps if there were public interest in such a company, it could develop. And if it a minimum standard of care could apply to every state, this would make it much easier for such a company to gain ground.

I've read that Massachusetts is financially underwater because it implemented rules similar to the ones above; but listening to accounts of the Massachusetts plan in action, I'd say that it charges some of its residents too little. For instance, an artist profiled on NPR making $10,000 a year wound up paying only $4 for her cancer treatment. Call me heartless and cold, but a childless woman can afford to pay more than that, even when she makes only $10,000 a year. And quite frankly, I know too many artists who work part-time/full-time on top of painting/photography/writing etc. who aren't asking the rest of the world to subsidize their passion. Unless you're mentally or physically handicapped or caring for multiple dependents, you can do a payment plan.

I've written a lot about getting insured if you're unemployed or self-employed, like my husband and I, and have pre-existing conditions. It is possible now, but expensive, and at times unfair (I have laughable maternity and am currently trying to save $16,000 to have a baby). Still, it's better than nothing--at least we hope.

Finally, everyone interested in this topic should read Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer--it is simply one of the best books out there on "rationing" and real health--and it is wonderfully non-partisan.

Carolynn Gockel

Chicago, IL

If you want to understand the failure of the anti-choice movement, here’s exhibit A. Vincent Canter, apparently a reading-comprehension challenged troll, couldn’t forgo an opportunity to hijack a story of personal tragedy--and courage--to insert an incoherent anti-abortion screed. Try reading more carefully next time. Then you would see that Ms. Michelman was abandoned by her first husband, not the one she is heroically supporting in every way. But then again, when did people like you care for facts when they get in the way of your opinions? By the way, that streak of misogyny in your comments also undermines your argument, such as it is.

Marianne Harding

Washington, DC

I can completely relate to the author's story and life because it sounds so parallel to my life and experience.

My 34-year-old husband was diagnosed with a brain tumor just over four years ago. Since then he has undergone three brain operations and now has moderate-to-severe brain damage that effects him both cognitively and physically. He currently lives in a long-term care brain injury recovery facility because I can not take care of him and our now 3- and 6-year-old daughters. He is like an Alzheimer's patient.

My 3-year-old daughter has chronic kidney disease as well as congenital vision problems. She is expected to need a kidney transplant one day.

Prior to our healthcare bomb dropping, we too were contributing members of society, living the typical suburban life. My husband and I both have engineering degrees. I was a stay-at-home mom for our two girls and we did everything right. We worked hard, paid our way, had no debt, long- and short-term savings, and of course... great health insurance--the best BCBS offered!

Now, in order to pay for my husband's care, we have lost all our savings, been forced to cash out our abundant retirement accounts, sell one of our cars and our house. Now that we are destitute, my husband can receive Medicaid to pay for his rehab since BCBS (which I still pay close to $400 a month for) will not pay for his care anymore. Oh, and I lose the BCBS insurance in two months.... I'm not sure how I'll then pay the $1,000-a-month-plus in medical bills for our daughter.

The girls and I live on his Social Security and long-term disability check--which are not enough, even with the most meager budget, and I go backwards each month. I would love to return to work to use my engineering degree to take care of my family, but if I do, Medicaid will seize my paycheck to pay for my husbands $10,000-a-month care, while refusing to consider my now necessary child care costs, for daycare. So I would actually go deeper in a hole each month if I went back to work!

This wonderful system leaves me no option but to financially emancipate myself from my husband through divorce in order to be able to preserve my paycheck and provide for my girls. Nice, huh? Yes, the Republicans are so concerned with family values!

It makes me sick, and I'm convinced there is a special place in hell for politicians and insurance company executives.

Julie Demers

Albany, NY

Many writing in this forum and ranting against private insurers seem unaware of how medical insurance works. Private for-profit, non-profit or public, insurers must make or collect enough money to pay future and existing claims.

The public option simply digs deeper into taxpayers' pockets or borrows, kicking the problem down the road. Private insurers raise premiums, co-pays or deductibles. Either way, someone pays.

The real problem with the US healthcare system is that its costs are out of control and out of line with the rest of the developed world. Healthcare in those other OECD nations is also expensive, but the out-of-control costs are only half those in the United States (see the graph, Exhibit 1, on the Kaiser Family Foundation site).

It's not clear from the story whether Ms. Michelman engaged any kind of advocate to negotiate the bills, especially those of her uninsured daughter. Uninsured patients are routinely gouged by the medical industry, being charged retail prices for services that are heavily discounted to insured patients. These "retail" prices can be double or even triple. Then activists and pundits scapegoat uninsured patients for failing to pay these inflated "uncompensated" costs.

Sadly, while lack of health insurance is one piece of the problem outlined in Ms. Michelman's story (I agree with the writer who observed that if you're gonna ride horses, it is wise to carry protection), the issue is a lot bigger than the much-parroted "47 million uninsured Americans" popular definition of America's healthcare crisis.

Massachusetts "solved" its problem by using the tax system to force the uninsured to buy private insurance or giving it to poor people. Of course, if your economics are underground you can continue to "go naked." Costs continue to skyrocket in every liberal's favorite blue state, but Bay State lawmakers and their owners--hospitals, insurers, healthcare workers and drug companies--continue to taut the success of "near-universal coverage."

Rick Evans

Boston, MA

Ms Michelman's tragedy struck a chord to me, as she was always one of my personal heros. In the responses, what is missed here is that healthcare is a responsibility--not a right or a privilege or an entitlement. A personal or family health crisis is tragic and emotional. In that state, no one wants to hear responsibility, they just want relief.

But we have been "relieving" ourselves with an unhealthy diet consumed on a polluted, toxin-laced planet. If we do not, as a culture, get after the core causes of most chronic illness and bad health, and take responsibility for risky behavior (as the actuary said)... well, we will be paying all of our disposable income for healthcare taxes.

We have also been fooling ourselves that our convoluted policies on birth control and sex eduction are working. We have one of the highest teen pregnancy rates in the world--we are literaly popping out uncared-for beings into a society bursting at the seams.

But we have no meaningful cultural structures in place to promote "universal," healthy, connected, personally responsible family systems. A generation looks to goverment systems for values no government can ever provide.

And abortion... Abortion is tragic. Abortion is a conumdrum. I too, like Ms. Midelman, believe the decision should not rest with politicians but with the pregnant woman herself. But it is still killing for convenience. There is still a demand for abortion because, in so many segments of society, another being to care for signals the end of hope.

The irony is not lost on me that Ms Midelman, in 1969, had aborted a pregnancy of a being she "could not care for." And now, a generation later, she is burdened with the tragedy of living family members she cannot care for, but would certainly not consider killing.

We get easily emotional when we read stories of the the families of these chronically ill--because it is, for the caregiver, a signal of the end of hope.

Still, overtaxing all of society to pay these massive growing expenses is not the answer. It's a knee-jerk emotional response, well-meaning but wrong. We are rapidly loosing our incentive to be productive under a confiscatory tax system that is unfair, indecipherable and, as we see every day, misused and hopelessly corrupt.

Government is not the answer to all problems. I began life as prochoice not because I am proabortion but because I want government out of my business. Government is not good at business! Look what it did with the education, banking, insurance & auto businesses. Putting the US government into yet another business, the healthcare business, signals another end of hope.

My hope is that we are capable of making our own decisions, solving our own problems, cleaning up our own planet, with the ability to keep what we earn. We need to rethink the risks we take and rethink what we allow to be put into our water, our soil, our food supply and our bodies.

For that we all need to change cultural conciousness, and stop expecting the government to provide hope, or bailouts of any kind, on any level.

Jill Peters

Dallas, TX

Frankly, lady, I can't make heads or tails out of this story of yours. You say your husband "abandoned" you, yet you say he was also physically incapacitated by Parkison's at the time. I'm guessing he didn't leave you for a hot young nurse, but rather you left him because you got sick of taking care of him.

Fair enough. Life's tough, you do what you have to. But as a loving dad, I can tell you that most fathers out there take immense pride in providing for their kids. As a loving and responsible parent, I would really appreciate it if some doctor didn't kill my kid without at least asking if I'd be willing to raise it myself. I think the requirement to at least ask the real dad before they kill his kid is pretty reasonable. I realize their are rare circumstances such as rape that would make the requirement unreasonable. But I think you would also admit that those circumstances account for a small minority of abortions.

Maybe you married a bum who abandoned his kids. Or maybe you married a good man who suffered from Parkison's like thousands of other men, and he simply couldn't provide for you anymore. Sorry about your situation. But not every man is a deadbeat. Contrary to the steroetypes of single fathers and their kids out there, most of these aborted kids actually have a loving parent who'd be perfectly willing to raise them. It's just that it isn't always their mother.

What right-to-life organizations find when they actually talk to scared young mothers is that when these women get information about the family and community resources that are out there (that is, resources including the dads), many of these women actually take great pride in raising these kids successfully, in cooperation with the dads, even when they don't stay together with the dad. The reason abortion rates have declined so quickly in the last decade, even while unwed pregnancy has skyrocketed, is that women are discovering that in fact they have not been "abandoned" by a man but, rather, they have made a choice to create a child out of wedlock, just as much as the father made that choice. Once they realize that, they may understand that the kid still deserves a father and a crack at life, even after the mother has decided to end the sexual relationship with the dad.

Vincent Canter

Grass Valley, CA

I think Kate Michelman touched the one element of our current crisis that is going to force change this time, and that is that now it is affecting those that have previously been untouched. It is touching those that in the past probably fought a universal policy, thinking the care would be sub-par to what they then had.

I am probably about the same age as Kate; I too feel like I have done everything right and proper. First, I was the first member of my family to ever attain the level of college graduate. I did this in part by serving in the US Air Force for six years to obtain financial assistance. I have had great jobs, though never at the financial level I had once thought I would achieve with a degree.

During my entire adulthood I have been employed and insured. But, over the last twenty years we have watched coverage deteriorate to the point that it is almost immoral to call it "insurance," as this word insinuates some form of protection, which it no longer offers. First, optical and dental were removed as part of the packages of most companies. Then the great coverage usually fully covered by employers started to deteriorate, and company contributions either were reduced or simply couldn't pay for coverage anymore. We have been asked year after year to pay more and more for an ever-declining level of coverage. Many are given no choice to go elsewhere, as small companies would lose all coverage if employees were allowed to flee the system. So we are forced to pay more and more for what amounts to useless coverage.

For me, it has induced more than anger as I detect from Michelman, and more than hard decisions, which I too have been forced to make. I have luckily been healthy throughout this time and never really needed nor used my insurance. Part of my anger is that I have paid for my coworkers and their families for thirty years, but the only two times in my life I have needed it, I have now been let down.

My story started in 2001 when my child was diagnosed with autism. I would soon discover that in my state or Oregon, insurance coverage is denied for any autism treatments. Despite them telling me that there is no treatment and that her fate lay in an institution, I found out otherwise. So, like Kate, I drained my IRA and sold my home to pay for my child's treatments to our great success. I now have a child mainstreamed in school. While not 100 percent recovered, most laypeople would never know she had such a devastating diagnosis nor prognosis. I still pay tremendous amounts for tutoring and care to keep her progressing and at grade level, along with the social issues that are now our only real true obstacle left.

So in October of 2008, I received the devastating news that I have cancer. Six months before, my company had switched to an HSA and I was given no choice in the matter. No one told me this was George Bush's attempt to give the wealthy a tax-free cash haven and was not really a viable insurance format for everyday people. With only six months to contribute to the IRA, it was woefully inadequate, and this horrible coverage was costing me $300 out of pocket a month just to have it, while it used to be free, This was the money I could have put into the HSA but could not only afford an additional $50 a month. The deductibles were $3,000 for me and $3,000 for my child, and then a $10,000 out-of-pocket before it kicked into 100 percent. My total out-of-pocket for 2008 was nearly $20,000. And this they call insurance.

But this is not the end, of course, for me, I can now look forward to this $16,000 to $20,000 a year if I want to try to survive for my child's sake. It is simply not viable, not possible, it is a pure catastrophe. Michelman is right in that she is not alone. I was even refused treatment by the first hospital I went to because my insurance was so bad. They wanted $15,000 up front or they would not treat me. I am quite sure that I am being counted as "insured" by the new administration, possibly unaware the millions of us are not even close to being insured.

My decision is a medical "Sophie's choice." If the cancer re-occurs I have three options: (1) continue racking up tens of thousands in debt, and if I die anyway, I leave my child with nothing to contribute to her care; (2) quit my job and hope I can get on public medical assistance before we become homeless; (3) stop all tests and treatment, hope for the best and let the dominoes fall where they may, meanwhile putting every penny I make into a fund so my family can care for my child and be able to offer options for her future.

This is what our country has come to. Some still believe compromises and simply modifying the current paradigms will fix things. If my case and Michelman's show anything, it is why this is impossible. Nothing will fix this except remaking the entire medical system, turning it on its head and rebuilding it from scratch. An American system of single-payer, where no one is left out, no one has to decide to commit "suicide by cancer," no one has to come up with thousands or die, where mayonnaise jars collecting coins at rural stores is not our backup system for catastrophic medical crisis in our nation. I am tired of hearing how Canada or France or the UK is not what we think, as if we can't do it better. The system we have cannot be fixed, we need a new system and that means throwing out all of the babies and the bathwater and starting from scratch.

Kate, I will gladly join you in your new fight. Just call me. Trust me, I have nothing left to lose.

Kendra Pettengill

Roseburg, OR

This article was upsetting to read. How did the United States ever get itself in this position? Why have our citizens put up with it for so long? Why are the insurance companies allowed to get away with "legalized fraud"? It is so difficult to comprehend.

One part that really struck home for me was the fact that Mr. Michelman's long-term insurance plan only paid for a "fraction" of the cost of his long-term care. Was he warned of this when he purchased the policy? Something similar is happening to my own husband (also a former college professor). Seriously ill for three years, he is battling his "excess major medical plan" (AIG!) that promised to pay "all" out-of-pocket expenses. I can't even begin to describe what this company has put us through, but I'm seeing an insurance attorney. I hope Ms. Michelman does too.

As a fellow American, I have this to say to Ms. Michelman: I am so sorry you and your family are being treated this way after a lifetime of good citizenship and service to your country. I apologize for not doing my part to fight the inequities of our healthcare system. I promise that from now on I will do all I can to work towards the goal of universal healthcare.

This is probably unconstitutional, but I wish the federal government would nationalize all the health insurance companies and make them non-profit.

It has taken many years, but I believe our citizens are on the brink of an old-fashioned revolt! It can't come soon enough for me!

Linda Mele Johnson

Long Beach, CA

Ms. Michelman's heart-rending tale shows many of the failures of our current health care system, including the fallacy that is private insurance. If I have learned one thing in my years as an Emergency Physician it is this: if you get really sick in this country, you ultimately end up on Medicaid/Medicare. Private insurances generally have a lifetime maximum of $2 million. A patient with a serious trauma will go through this in a month, generously. Unfortunately, for the disabled it takes two years to qualify for Medicare even after getting Social Security, I don't know why. Obama, whatever his other failings on healthcare, is trying to rectify this.

However, I do have a couple of suggestions to avoid falling into the same situation. First of all, private insurance is helpful for most medical costs, and one should obviously not undertake activities such as riding horses without it. If an uninsured non-dependent family member with minimal assets--the situation I assume for Ms. Michelman's daughter--falls seriously ill, it is much more advisable for her to file for bankruptcy and get on Medicaid/Medicare than for a family member to pay exorbitant bills.

In terms of chronic disease, if a family has assets, long-term care insurance is no substitute for estate planning and consultation with a good trusts and estates attorney. A sad state of affairs.

The irony, of course, is that had Ms. Michelman's family had no assets and no insurance, Medicaid would have stepped right in and paid for all this care pronto, often even if the patient was undocumented.

Private insurance is a scam... pure profit for the insurers. Once anyone gets ill, seriously ill, the government ends up being the insurer of last resort. I see it every day and any hospital social worker will tell you the same.

Our medical system is not without its pluses and mercies. In Canada, a non-resident cannot necessarily go to the ER without paying; here anyone can and does receive treatment. My guess is that Ms. Michelman's daughter received a much higher level of trauma care than would be available in any other country; trauma is a high-resource field not generally deemed cost-effective in most other countries. The American health care consumer would not find rules limiting mammograms to those 50 and older, excluding those over 65 from dialysis, limiting high-cost cancer drugs or excluding those under 25 from cervical cancer screening acceptable, as is common throughout other healthcare systems.

Unfortunately, the financing and provision of that care worsens by the day, and the system is untenable, unfair and cruel. We need something better, if still imperfect. Until then, hide your assets and talk to a lawyer.

Jenifer Lingeman

Salt Lake City, UT

Requiring citizens to spend good money to purchase questionable insurance to participate in a failed healthcare system is harsh and counterproductive.

Kate Michilman is not alone saying: "If there is an upside to the country's healthcare crisis, it is that the problem is hurtling toward a point at which it absolutely cannot be ignored without immediate and disastrous consequences. If there is an upside for me, it is this: returning to those difficult days of poverty and fear in 1969 also means returning to a place where anger inspires activism...."

The Wyden-Bennett Healthy Americans Act is a bad plan being crafted to appease entrenched insurance interests at the expense of citizens who would be forced to purchase insurance and to pay higher costs for care.

In the Wall Street Journal (April 10), Gerald F. Seib presents "A Health-Care Plan That Could Bridge the Divide."

Obstacles abound, of course. Here's a big one: Many Democrats would want to include a so-called "public option" -- that is, a health-insurance plan provided by the government itself -- alongside private insurance plans. Mr. Bennett and other conservatives are dead-set against that, arguing that the government's ability to impose cost controls doubtless would make its plan the cheapest one, sucking consumers away from private insurers and opening the way to universal government health care.

This concern for big contributor's profits over our citizens and our nations fair treatment and well being has reached a volatile point.

Everyone needs health care regardless of their circumstances.

A low cost federally operated VA style National Health Care option needs to be made available that anyone could choose to use.

People happy with their existing systems do not need to change, they can continue paying for and keeping the private system that they like.

For perhaps as many as 100 million people no practical system for health care exists, nor is a usable one being proposed.

Current health plan reform proposals will only add to the bloat that has destroyed the practicability of our current health care system.

Businesses would also benefit if they were allowed to choose between staying with their private system and switching to a new national health care system that would not force them to be involved in any way for the health services their employees receive.

A National Health Care system is needed that will care for everyone who chooses to use it, made available for free, no restrictions, no more insurance needed period.

This can only be accomplished if costs of delivery are lowered.

The Veterans Administration model could deliver healthcare to users, at a fraction of the cost per patient, of existing systems.

The service could be funded by a national sales tax. That way everybody pays for service.

Our financial disaster has demonstrated that expenses recur day after day, for everyone.

People like Kate and her family provide an example that screams that everything we are doing is inadequate, even when like Kate, you think you have a good plan and good insurance coverage.

Expenses continue for the unemployed, or for those who have lost their money through their own misfortunes.

Missteps or frauds caused by financial institutions that citizens trusted to protect their, savings, investments, and retirement accounts have also made it impossible for many people to pay for needed health care.

People among us who are just plain down on their luck or those incapable of caring for themselves also need health care and any proposed solution requiring payment from them is totally unrealistic.

Even people with good incomes are not immune from the pressures of meeting voracious continuing expenses.

It is in everyone's best interests to have a healthy population that enjoys the most comfortable, productive, and happy life possible.

A large population of infectious unhealthy citizens interacting within society is a health threat to all citizens.

Health care is too important to remain in the hands of those protecting special interests profits.

The Veteran’s Administration model, has been providing care for qualified Veterans for years, totally free, including all prescribed treatments and medications, with total transferability between regions, and it has no restrictions for any preconditions.

The VA's proven system could relieve patients of the unsolvable problems that block many from receiving care caused by preconditions, or their inability to afford the financial outlays required.

A VA style system, controlling the problems with access, cost, quality, and malpractice is THE solution for America’s healthcare problems.

The system could be jump started by using bailout money to purchase existing private systems choosing to sell to the National Healthcare System.

Building and staffing this system will provide immediate and perpetual economic stimulus's by employing millions of health care workers.

If funding is raised through a national sales tax on non essential purchases, rather than insurance premiums and co pays, demanded from patients, a giant immediate and perpetual stimulus will be provided to everyone choosing to use National Healthcare.

This would transform family money from budget busting medical funding burdens, into family discretionary income.

“What most Americans fail to realize is that recessions are much easier to weather when citizens are provided guaranteed and affordable health care. Now is the time to push for a single payer system.” Commented marc from Maryland in the NYTimes April 7, 2009 .

National Health System users will never have to pay another insurance premium, medical service co pay fee, or prescription cost.

No more medical bankruptcies, no more uninsured people denied care, no more forced dilemmas between going without food or other necessities in order to pay for needed medications or care.

This is a real stimulus for getting people back into the stores and car dealer ships and improving everyone's health and outlook.

Happy days will be here again.

The Best Care Anywhere

Ten years ago, veterans hospitals were dangerous, dirty, and scandal-ridden. Today, they're producing the highest quality care in the country. Their turnaround points the way toward solving America’s health-care crisis. By Phillip Longman

By 1998, Kizer's shake-up of the VHA's operating system was already earning him management guru status in an era in which management gurus were practically demigods. His story appeared that year in a book titled Straight from the CEO: The World's Top Business Leaders Reveal Ideas That Every Manager Can Use published by Price Waterhouse and Simon & Schuster. Yet the most dramatic transformation of the VHA didn't just involve such trendy, 1990s ideas as downsizing and reengineering.

It also involved an obsession with systematically improving quality and safety that to this day is still largely lacking throughout the rest of the private health-care system.

http://www.washingtonmonthly.com/features/2005/0501.longman.html

Bill Watson

Menlo Park, CA

Kate, you have written brilliantly and passionately about a topic which affects us all, whether we have yet realized it or not. Brava! As a registered nurse for thirty-two years, and as a woman I have seen the "system" from all sides, my heart goes out to you and your family, and I sincerely hope that someone will pay you large amounts of money so you may use your very articulate voice and sharp wits to help fix our broken system.

Laura Allender

St. Louis, MO

Kate Michelman's plight is so familiar to me, in several ways. Bad luck for her and her family, you say? Her family should have foreseen this possibility and adequately insured themselves? I defy any human to devise an insurance scheme that will cover every possible combination of health situation that can come up for a family.

There are always cracks to fall through. I should know--I was a spousal caregiver for my first wife for twenty-nine of our thirty-one years of marriage, which ended in her death. We lived in Canada, the home of the single-payer health system so touted by many Americans. Well, we still had to have insurance for drugs and treatments not covered by Canada's universal healthcare system. One year our out-of-pocket expenses reached $17,000, and over those twenty-nine years I, as the single-income source in our family, must have paid out-of-pocket at least $150,000 for healthcare. In Canada!

The moral of my tale is that yes, the US desperately needs some kind of blended system, or even single-payer--but don't expect it to cover everything. On the other hand, as a "refugee" from Canada living in the US, I see a system so chaotic that the people it "serves" and their family caregivers end up getting sick from the frustration, aggravation and worry of dealing with it. As President of the Well Spouse Association, I and our 3,000 sustaining and associate members can attest to that.

In the US, individual wealth creates health inequalities. In Canada, waiting lists create inequalities--unless you have enough money to go south and buy your own treatment!

Richard Anderson
Well Spouse Association

Alexandria, VA

I have read both Kate Michelman's story of family tragedy, and a number of the letters sent in response. The writers of those letters question why tools such as health insurance, LTC insurance, and disability insurance, or even Medicaid, was not available.

I write from first hand experiences similar to Mrs. Michelman's. It is a story, and a system, I know all too well. My family experienced a similar series of illnesses and tragedies--my mother sufffered from multiple sclerosis for thirty years, until her death a few years ago. My sister has suffered with MS for three decades as well. My brother suffered a traumatic brain injury in a motorcycle accident and has permanent brain damage. My father had Parkinson's, and declined over a period of about four years.

And all of this was happening at once. My sister's spouse and my brother's spouse "quit" and let the family of origin deal with it.

It was overwhelming, for about six years. That's how long it took to sort out living arrangements for everyone, get them onto Medicaid and try to get everyone the care they needed. The out-of-pocket costs were approximately $250,000 for all four of them, paid for out of assets of all four and other family members.

And that was with good health insurance, medical retirement, Social Security Disability, and every other source of income we could come up with. (There was no insurance settlement/lawsuit in the case of my brother's accident, as he was racing and took on those risks himself, just like the young woman riding horses.)

We are a middle-class family. It is a miracle that we got everyone through it with good care in the end. And here's what we learned:

a) Health insurance helps a great deal, but out-of-pocket costs could still be as much as the $8,000 experienced by the family in the story. But that is only the beginning.

b) the real costs are in assisted living, as the Michelmans found out. Medicaid does not normally cover assisted living. Nor does insurance, though long-term insurance can help contribute to the costs. Most long-term insurance policies that I had examined would not have covered many of the costs of my stay-at-home care or assisted-living care--would have helped, but not have solved the problem for as many years and with the requirement of 24/7 care. My mother could not feed herself, could not change her clothes or dress herself. She was a complete quardraplegic for about ten years, and before that required a great deal of care, which my father provided before he declined. He retired early to take care of her, which decreased their retirement income and savings.

c) Nursing homes are not an option if a person is still healthy enough and independent enough--the grey area between nursing homes and assisted living is precisely the problem for long-term care. Medicaid beds exist in nursing homes, but not in assisted-living care (although many nursing homes continue to cut back on the number of Medicaid beds because they are costly to the institutions struggling to meet their budgets).

d) $8,000-$9,000 a month is a bit high for 24/7 care, but not out of the question either. For brain injury, the private-pay institutions are $10,000 a month. When I quit my last job to spend full time looking for a place for my brother to live, I was told by my boss to take a few weeks' family leave and go find a living situation, just as one of the board members of the company had for a relative. The board member is a muti-millionaire. We are not, I explained. His family can pay $10,000 a month for many years. We cannot, and there are no affordable alternatives for a 30-something-year-old man with brain injury.

e) Most nursing homes won't take a patient under the age of 55.

It is living, for years, with disability, that is so costly. The article explains the $8,000 out-of-pocket costs but never talks about the real long-terms costs of care over years. I imagine that the writer was just too overwhelmed to think about it, as we were at times.

With the help of excellent lawyers, we were able to set up special-needs trusts with what little assets were left, allowing a little bit of money to pay for extras like cable TV and a telephone for the family members once they were on Medicaid and had a nursing home room. It took six years, tons of lost income, many hours by family members providing care directly, a few guardian angels and much luck to get there. And I feel for Kate Michelman, because I know exactly what she is going to. There is no answer.

Assisted living must be covered over the long-term somehow, through Medicaid, more affordable insurance with better coverages, or something. Long-term care insurance should be offered and perhaps even paid for in part by corporations--because chances are very good that without it, the employer is going to lose employes to caring for their aging parents, or an injured sibling or child. It is unavoidable.

The alternative for these patients is death, homelessness or ... well, those are the alternatives.

Something has to give. Medical care now can prolong the life of an MS patient or a Parkinson's Patient or a brain-damaged person--but with all the advances in medicine, there has been no corresponding advancement in sufficient means to pay for those patients when they are kept in our lives for decades longer than they ever would have fifty years ago.

Barbara Buchanan

Vienna, VA

Kate Michelman's "A System From Hell" should be required reading for all legislators in the United States. Here is reality in a nutshell: the reality of health insurance is it's a game of Russian roulette. Even doing all the right things, many people face the risk of financial devastation simply because the system in the USA is broke.

For all the cries of "socialism" and the turgid braying of Republicans, the truth is that only publicly funded, single-payer healthcare works to avoid the sort of unfair hardship Michelman and her family now face.

I have lectured on public healthcare to audiences large and small, and I can say with absolute certainty that the only people who benefit from the current American model of health insurance are the insurance companies themselves.

Kate Michelman says in her piece she wants to fight for healthcare. I applaud her sentiment and encourage The Nation's readers to rally in support.

Believe me, it is more imperative than ever that healthcare be accessible to all and not become a mine field of avoidable financial casualties!

Lynnette Dubois
Artemis Services

Toronto, Ontario, Canada

Mr. Zimmerman, the actuary (and self-described troll), provides a fantasy-filled letter about Ms Michelman's joining the healthcare fight. Especially noteworthy is the closing paragraph that manages to compare the notion of universal health insurance to Marxism, when even conservatives like Hayek can be found suggesting that the state should help organize a universal system of social insurance (go run to your copy of The Road To Serfdom, all you conservatives out there, and check page 125).

Furthermore, a little Google search will verify that when it comes to for-profit health insurance in the United States, Mr. Zimmerman's notion of being charged $10,000 overhead for every $200,000 paid out in benefits (5 percent) is a fantasy on par with the Tooth Fairy and the Easter Bunny. Careful studies put the overhead of our for-profit health insurance north of 25 percent (this study by Public Citizen, for example, found 31 percent).

To rephrase that in terms that are almost comprehensible, when we speak of for-profit health insurance in the United States, we're not talking about a little bit of overhead to "file financial reports with the state insurance department" and keep "electronic records, etc." We're talking about the biggest privately created bureaucracy in the world--rivaling the Pentagon! We're talking about the waste of hundreds of billions of dollars every single year, even more money than has been blown on bailing out AIG (so far).

Speaking of bailing out AIG, where are the howls of protests from conservatives when executives from AIG and Citibank arrive hat in hand? So "to each according to his needs" has never, ever, worked? Funny how the "old-fashioned" "responsible" talk disappears when billionaires start having big needs.

All the for-profit health insurance industry is good for, if you don't own stock, is vacuuming up our money and causing the sick to suffer needless heartache, bankruptcy and premature death. Call me old-fashioned, but I think the true definition of "irresponsible" is standing idly by while human beings needlessly suffer.

Myles Sussman

San Francisco, CA

The most comprehensive analysis of the American health system has been given by Michael Moore in his documentary Sicko. Every American citizen should see this documentary with a open mind. Even more instructive are the interviews in the DVD's special features section; watch them and think about them.

After all, it is about a more humane society.

Fortunately, President Obama seems to have a clear view about what is wrong, but the road to efficient and affordable health insurance will be long. One of the main issues will be to recognize the difference between acute ilness and chronic disease; nobody can cope with the financial consequences of chronic disease in the long run, which makes it a responsibility for the government to provide care for the chronically ill out of taxpayers money. It leaves only acute and curable disease to play with for the shareholders' controlled healthcare industry.

Victor Wiedijk

Willemstad Curacao, Netherlands Antilles

Ms. Michelman's article is yet another example of how screwed up this country is. Then I read some of the letters in response. One in particular was ao cold and so indifferent to the human condition that I found myself thinking this person has a problem. He does not offer any good ideas, just mean-spirited conservative rhetoric that does nothing except reinforce a bankrupt ideology. This kind of mentality is self-serving at best and is the reason why we will most likely never solve this issue.

Are we as a collective entity of consumers purchasing health insurance with the idea that it is supposed to defer the cost enough that we don't end up on the street in a cardboard box? If we are putting millions of dollars into these companies, what is the point of it if we can't use it when we need it most? Take Ms. Michelman's husband, who is retired and spent his entire working life paying into this system and yet it still failed him and his family.

Our system is broken, period. We don't have a healthcare system, if you get right down to it--we have a market.

Opponents are quick to use Canada as a model of why universal system does not work. Well, there is a reason that these people use Canada as a bad example, they have the worse system of the countries that have universal healthcare. If you look at the Netherlands, Switzerland, Germany and France, you can find healthcare systems that work well. The Netherlands and Switzerland are particularly good to look to; they have a system that could be used as a model for us, as it is a combination of government and private insurance companies.

jeff freedner

Voston, MA

The first three letter-writers show why we may not survive as a society. Gut reaction: Too bad we didn't let a lot of insurance firms like AIG go under.

(The actuary's shows how having a material interest in insurance can determine your world view.)

William G. Bagnuolo

Social Circle, GA

My heart goes out to you, Ms. Michelman. You have had to endure far more tragedy than most Americans do in their lifetime. I would be terribly jaded and probably despondent, rather than determined, if these things had happened to me.

However, as a medical student who has seen the academic/public healthcare system in action, it is not a system that should be used to replace private insurance on a massive scale. It really would be akin to abolishing all private schools and enrolling everyone in public schools because many children get bad educations outside of private education. It simply wouldn't work.

While you think the government has all the money in the world necessary to compensate you and those like you for extended costs/co-pays, it really does not. This does cause rationing, which leads to the lack of purchasing of needed, expensive equipment, such as MRIs, which are lifesaving.

As someone pointed out, you had $8,000 in bills for a months-long hospital stay, but this probably was a fraction of the cost of labor, test, equipment, food, etc. that happened in all that time.

I wish we had a limited system that could pay for extended care. Perhaps the government could have a fund that guaranteed medical treatment for people with catastrophic or perpetual medical conditions.

The only way to truly reduce costs is preventive medicine, which requires steps that we may not be willing to take. One major one that could reduce costs by 30 percent or more in the long run would be to ban cigarette smoking. Although most argue that banning a substance increases its use, this wouldn't be true for tobacco, which is only semi-intoxicating. It also requires extreme, chronic use to cause pathology. Banning it would prevent the latter from happening.

Another way to do it is tort reform. Many doctors in certain fields (such as neurology, which you are certainly familiar with) have huge malpractice premiums because they treat incurable conditions. People love to sue over incurable conditions, because they are attempting to seek justice for metaphysically unjust outcomes. Higher premiums means high doctor overhead just for practicing, which leads to high labor costs. We are all paying indirectly for people to sue their brains out. It has to stop.

I would love for the government to pay for health care for all if it had the money. But it doesn't, it can't, and it never will. That's the way it is. Abolishing private healthcare, I'm sorry to say, will just extend the horror stories from a subset of the population to the entire population.

Jeffrey Planchard

New Orleans, LA

There are multiple tragedies that have taken place, but most are not the "fault" of the healthcare system. The daughter was uninsured by choice, one can assume. This is an error many young people make.

It appears that the family exhausted funds on the daughter (understandably). However, was there an opportunity for the daughter to access state funds such as Medicaid? This was not related.

The husband is another of the tragedies. But what health insurance options were available to the family? Could they have gotten a policy with lower deductibles and co-pays? Could they have obtained long-term care earlier in their lives? I am not trying to be cruel, but could better financial decisions along the way have avoided some, if not all, of this financial issue for the family?

What has happened is awful and real. However, if the government pays for all of this, from where will the money come to do so?

It is quite easy to talk of universal healthcare in the abstract, but costly to implement it. It will ultimately require rationing. Is the US ready for that? Canada has it, and not because of the current government. My wife lived there for thirty-five years and can relate horror stories under both the liberals and conservatives. How about this: her father waits in the emergency room for forty-eight hours to get into the ICU! No transfer to another hospital offered.

Rationing is a way of life. In the early '90s Toronto had four MRI machines for 4 million people. Philadelphia, a similar-sized city, had over fifty. Philly may have too many, but Toronto certainly has to few. Why?

Universal coverage may be the answer--but not run by the government, please.

Gerry Good

Long Beach, CA

Life isn't fair. I feel sorry for Ms. Michelman's family members for the unfortunate events that have afflicted them. And it is unfair that Ms. Michelman has had to devote more of her life caring for her family than many others have had to do.

People who have spent time on the message boards here know me as Darin_the_Troll. Many of you know that I am an actuary. Actuaries do many things: the most common is to quantify the financial consequences of risk.

Here's a riddle: What do hundreds of millions of people buy with the hope they never use it? The answer is, insurance. Actuaries determine the price of insurance. In order to do this, we need to understand what insurance is. Too many people believe insurance is what gives you money when bad things happen to you. That's not insurance, that's Santa Claus.

Insurance is the pooling of similar risks. If there is a 1-in-1,000 chance that your house will burn down, I need to charge 1,000 people (with $200,000 homes) $210 dollars each. So that I will have $10,000 for expenses (I need to file financial reports with the state insurance department, keep electronic records, etc.) and $200,000 to replace the home of the unlucky one. It is not rational to expect me to simply replace every home that burns down. I can only replace the homes of the people that participate in the pooling by paying the premium.

It is hard to imagine a figure more tragic than Ms. Michelman's daughter. A young woman who was just beginning her life, was paralyzed in an accident. But I have to ask, why didn't she have health insurance? Why didn't she have disability income insurance? Surely it wasn't that she couldn't afford it. If she could afford to pursue her dreams of working with horses, surely she could afford to insure against the risk of sickness or accident. She was aware of the risks involved with working and playing with 1,500-pound animals, but she chose to accept those risks and self-insure. Call me old-fashioned, but I believe that is irresponsible. Now, I'm not blaming the victim. I didn't say she deserved to be injured. But I do believe it is irresponsible to accept risks when you know others will have to pay the costs of your risks.

I do not believe that the purpose of government is to subsidize you (at taxpayer expense) so that you can pursue your dreams. I do not believe the purpose of government is to eliminate the consequences of irresponsible decisions. (Again, it is not irresponsible to take risks; it is irresponsible to take risks when you know others will have to pay for the consequences of your choices.)

As to her husband, if the LTC policy doesn't pay for his care, he should have purchased a bigger policy. LTC is one of the best values in insurance. Twenty years ago they were terribly under-priced, and insurance companies have lost billions of dollars because they were under-priced. As to his health policy, $8,000 sounds like a lot, but he spent four months in the hospital. His total bill was probably $200,000 dollars and his share not even 5 percent of the total cost.

To each according to his needs, from each according to his ability--that economic principle has never worked in the history of the world, and it never will, because people are motivated by self-interest. If you find your abilities far outpacing your needs, your abilities will suddenly disappear. If we are to leave anything to the next generation, we must, on average, produce more than we consume. If we engage in private insurance, we will all, on average, produce more than we consume, but the unlucky will consume more than they produce because they will be subsidized by people who pay insurance premiums and never collect.

Basing your healthcare on need alone will certainly ensure that people produce less.

Darin Zimmerman

Charlotte, NC

I read with interest the story of the problems of extremely costly health problems. What was missing was an acknowledgement of personal responsibility.

To go without health insurance is not responsible. I am self-employed, so I must deal with the problem/costs 100 percent. But if one is willing to assume high deductibles, insurance is relatively reasonable. But you are protected from the ravishing impact of a catastrophic event. A single young person can get excellent insurance for less than $100 per month, less than most people spend at Starbucks. Yes, you will pay the first $3,000 of expenses annually, but you will have excellent coverage for a terrible fall, Parkisons, cancer etc. And this is from your first-tier insurers, Blue Cross, United etc.

I pay slightly over $400 per month for care for my wife and myself, both close to retirement age, with the option to pick my own doctors, hospitals, with a several-million-dollar max limit. Yes, I have to pay most of the day-to-day costs, and that means it is in my interest to eat healthy, exercise, keep my weight down and give up technical rock climbing, another risky hobby I have enjoyed. But I am covered if I am run over by a bus, or develop one of those catastropic diseases.

Smoking, drinking, excessive weight, participation in high-risk activities demand that we take responsibility for this behavior. Many exteme health problems are beyond anyone's control, but fortunately the insurance companies can take this risk and at reasonable costs, if we act prudently in advance.

Dennis Storhaug

Littleton, CO

Ms. Michelman's letter about the destitution visited upon her family when she tried to get healthcare is one of millions of such stories. Yet nowhere did she mention the obvious solution: single-payer health care a k a Medicare For All. Please visit my organization's website and view the sincere plea to the president by Mike Farrell, then take action to make healthcare a right, not a commodity. As Mike says: Everybody In, Nobody Out.

Clark Newhall
HealthJustice

Salt Lake City, UT

A moving account of personal and family tragedy. Most of us could find ourselves in similar straits with a run of bad luck. Life is unfair. Personally fairly conservative, I have nevertheless come around to the view that universal coverage, i.e., some variation of Medicare for everybody, is warranted, both on grounds of equity and because of the deleterious effects our present jerrybuilt system has on the over-all economy. But the basic dilemma is intractable. The ever spiraling costs of Medicare alone threaten to bankrupt the country down the line if they are not somehow contained.

Should the Michelmans' personal misfortunes be largely addressed financially by the overall society? Perhaps. But multiply their sad situation, with all its variations, by the thousands or millions. There is no conceivable system, including those in Europe, that can give everybody everything the double-edged sword of modern medicine can provide, particularly at the end of life. The laws of economics cannot be repealed by a compassionate view of social justice. In short, some form of rationing, whether by private economics or governmental determination, is simply unavoidable. The choices are agonizing, but the best we can hope for is some mitigation of the vicissitudes of life and death, and any wider initiative will be hugely expensive. To pretend otherwise is a well-meaning but delusional evasion of the harsh facts.

Andy Anderson

Bronxville, NY

Ms. Michelman, I read your article with extreme interest because I personally have seen too many stories like yours. I noticed that you had no specific complaints about the medical care except the cost! If you really do have one last crusade left in you, then help bring medical costs down! I and other physicians know how to do this, but our hands are tied. The solution is to end liability lawsuits in healthcare. Prices will plummet overnight. And I warn you, it might not be a popular stand, but nothing else will work.

Lawrence Bailey, MD

Georgetown, KY

My heart goes out to Ms. Michelman and her family for the pain and indignity she has been forced to endure through no fault of her own. It is bad enough to have serious illness beset a family, but to then be stripped of any financial support to get care is unconscionable. Unfortunately, her sad story goes on all over our wealthy country, which cannot bring itself to create a just healthcare system for its citizens.

As a US citizen living in Canada as a permanent resident, I qualify for care under our Universal Health Care system. Yes, we have shortcomings, mostly due to lack of sufficient financial investment in our system by the Conservative leadership now in place. However, no one is exempt from care, even when there are waiting times for specialists, tests to be done, etc. Persons with serious illnesses are given priority care as well as emergency cases, and many of us are pushing for better coverage all around.

No one need go bankrupt in order to have healthcare nor lose their health coverage should they lose their job. This is true of most industrialized countries that deliver good care at a fraction of the cost of the United States.

I have supported the fight for a similar system in the United States for a long while, even before our current economic meltdown. Remember, such a possibility has been on the back burner since Harry Truman's presidency.

I am disappointed that President Obama is supporting a hybrid plan, involving the private sector as well as government involvement, since this will not address the serious problems we face. Since the majority of US citizens, a majority of the members of the American Medical Association and many other concerned organizations support a Universal Health Care Plan, the president is not responding to the will of the people on this issue.

Congressman Conyers has a Universal Health Plan bill before Congress with increasing support for its passage, and we can only hope that it will be passed eventually. Certainly, the desperate need for decent healthcare coverage should take priority over the vast amounts of money going to support our senseless military involvements.

Pearl Volkov

Burlington, Ontario, Canada