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Dr. Feld, thanks for adding your insightful notes on this healthcare conundrum and offering some common sense solutions for repairing it. I really appreciate your analyses and recommendations. I’m now curious to read Gingrich’s book, Real Change, and understand his model of a buyer-seller system; in particular, how he envisions getting enough people to buy into it -- especially those who don’t have the means to do so. And there are many. Which is one part of this gnarly problem: the economics of health care. The other part is more problematic and personal: the care of our health. The process of convincing people that they must take better physical care of themselves to the best of their abilities -- practicing everyday positive habits of body and mind -- strikes me as the most complex challenge of all. It requires a life-changing attitude with action; meaning, we must personally change the way we take care of our body and wellbeing, while encouraging others to do the same but in their own way. In fact, we make it easy to fail this personal, “primary healthcare” system, which includes prevention.

To that point: I was disappointed to hear the newly appointed head of the Medicare and Medicaid programs, Dr. Don Berwick, comment that “one over-demanded service is prevention: annual physicals, screening tests, and other measures that supposedly help catch diseases early.” How can we encourage people to be personally responsible for maintaining their health on the one hand, only to discourage or penalize them from taking preventative actions on the other hand? That doesn’t make sense. Also, why would Dr. Berwick advocate “placing a commitment to excellence—standardization to the best-known method—above clinician autonomy as a rule for care.” Presumably, your primary physician, whose advice you trust and follow, shares this same commitment and applies this standardized methods to maintaining your health.

Question: How will the healthcare system you’re advocating (which I believe is better in many ways) help those individuals who’ve taken exceptional care of themselves through exercise, wellness practices and prevention—people who’ve accepted all the responsibilities of managing their health—but don’t have the financial means of covering special, urgently needed services? How will the Gingrichcare system help these individuals deal with those unexpected health catastrophes (aneurysms, strokes and heart attacks that occur out-of-nowhere, rare cancers, neurological disorders, and so forth), which neither these patients nor their families can pay for?

It’s tough to clear one’s mind and mute those signs heralding "The Republican Health Care Plan: Die Quickly," which Rep. Alan Grayson (D-Fla.) pointed to in his House floor speech. Surely, there’s some grave truth to that.

As you know, the process of educating and incentivizing people “to be informed buyers of medical services” is propelled by one of our most fundamental human rights: freedom of choice. Sadly, many people shirk the responsibilities that accompany this freedom, either because they dread the hassle-n-headache of thinking critically for themselves in choosing a healthcare plan that may serve them best (but isn’t on the main menu). Or they simply don’t want to take the time to wade through the swamp of confusing literature in seeking a service that’s “worth the price.” Or they don’t have the money to pay for the most basic health insurance. So they’re willing to sack this freedom, leaving the care and maintenance of their lives in the anonymous hands of the medical and healthcare insurance experts. This amounts to that buyer-seller-receiver bureaucratic model you’ve probed here, which puts the government in the driver’s seat of one’s life rather than the back seat (or, as the Libertarian’s would prefer, in the trunk!)

As the Republicans see the situation: Obamacare is driving us all in one bus with an “oversize load” on a one-way highway that has no exits to alternative routes. From their perspective, our nation is being steered toward a single party payer system.

As the Democrats see it: There’s more than one bus. And these buses are traveling along different routes. From their perspective, Gingrichcare will likely pass “The Phantom Tollbooth” on a narrow road that leads to “an unfinished bridge-to-nowhere.” Why do they see it this way, and believe what they see? They’re in a helicopter following these buses from above!

All attempts at light humor aside: I’m not sanguine about the future of a healthcare system that’s designed to work-for-all and that provides universal coverage in a fiscally sound way. I’m skeptical not because I believe it’s impossible to realize these ideals, but because the act of keeping this system healthy and fit requires a majority of Americans to be ‘the keeper of their health and the manager of their disease.’ You’d think that most people would resonate with that proposition, rather than fight it or do the “unthinkable”: mindlessly entrust that some kind, benevolent third party payment system will always care for them like children in need. Clearly, there are millions of citizens who don’t understand what’s at stake for them or their families, and couldn’t be bothered to learn as long as their lives aren’t inconvenienced by some personal health crisis. Of course, nothing seems to instantly engage people to learn-for-their-lives than some startling crisis. Suddenly, we’re no longer indifferent about taking responsibility for our own health and wellness. In such times of crisis, we’re inclined not to leave all important health-related decisions up to the experts who supposedly “know what’s best for us” when, in many instances, they don’t.

The upshot is that neither Obamacare nor Gingrichcare will succeed, if people don’t want to learn to take care of themselves, and don’t want to make that lifelong commitment to do so. And for all the reasons you’ve earmarked here, among them: “The receivers (patients) have little concern of cost [for healthcare services]. They have first dollar coverage. They have no incentive to save money. They have been conditioned to believe the medical care is an entitled service. Patients want more service with more convenience. They have no accountability for their habits. They have no incentive to lose weight or exercise consistently. Obesity leads to chronic disease and its complications. Patients have no incentive to care for their chronic disease.”

All this needs to change. The faster, the better. But the mechanisms for changing things needs to change, too -- along with the incentives and rewards for changing, together with the penalties for not.

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