The Swiss Example

So can any wealthy, modern country get health care right without resorting to socialism? Yes. You never hear it touted by the media but Switzerland uses market forces, not government rules and red tape, to create a private, affordable, high-quality health-care system for its 7.5 million citizens. And it spends 40 percent less per capita than we do.

Sen. Tom Coburn, an Oklahoma Republican, a fervent fiscal watchdog and a practicing physician, knows all about the Swiss system. Much of his proposed health-care reform bill — the Universal Health Care and Access Act — is modeled on it. Coburn’s plan, a major overhaul that can be found at coburn.senate.gov, is complicated, controversial and in no danger of becoming law anytime soon, if ever. The bill’s key elements include achieving universal health-care access by using tax credits to pay for individual or family insurance, phasing out reliance on employer-based insurance, allowing people to choose their own doctors and health insurance and stressing preventive care. On Wednesday, Sen. Coburn explained why he likes the Swiss system, which operates sort of like our car insurance: You must buy health insurance but you can choose among many plans from many private companies. Since every Swiss is covered, Coburn said, there is no cost-shifting — i.e., no hidden subsidizing of those who don’t have insurance at all or don’t have enough. Cost-shifting costs Americans about $250 billion a year, Coburn said. Ending it would save a family of four about $4,000 a year. Another virtue of the Swiss way, Coburn said, is that it has fostered a range of innovative insurance products. For example, there are five-year policies that reward customers with lower and lower rates if they do the preventive things the company asks. A third virtue, he said, is a national high-risk pool that all insurance companies contribute to that essentially protects companies from suffering heavy losses in a given year.
Switzerland is tiny and doesn’t have our social problems. But Coburn says its consumer-driven approach — which is transparent to consumers in price and quality — would work here. Coburn knows markets aren’t perfect. But he knows why the Swiss system works so well: ‘It forces people to shop, it forces people to make decisions….The point is, markets work — if, in fact, we’ll trust them.’

Consumer Driven Healthcare

I just finished reading what is probably the best book I have ever read on this subject.  The book is “Who Killed Health Care?” by Regina Herzlinger.  In the book, Ms. Herzlinger lays out a plan to provide for health care for everyone while at the same time, REDUCING government involvement in the system.  She calls her plan “Consumer Driven Health Care”.  It basically creates a system whereby the individual consumer drives the market.  Not a good idea, you say?  In most other areas of business, this is how things already work.  She presents this argument against a government run, single payer system in which the government would say what medical treatment you could and couldn’t have.  What if the government was equally involved in the auto industry?  We would all be driving the exact same car because the government would mandate how the car was built, what color it was, what features it had, what options it had, etc.  We would also all pay the same price because the government would mandate that as well.  What do we actually have in the auto industry?  We have manufacturers who make cars with the features we want, competitive on price, etc.  Competition has brought us more choice than ever before and more affordability than ever before.  Why can the same not work in health care?  Well, it will require significant restructuring of the industry.  I will leave it to the book, for now, to make the case for those changes.  I will attempt in future posts to explain it the best I can, but can not do justice to what it took an entire book to lay out.

Illegal immigrants and healthcare

I do not believe that illegal immigrants should have the same access to healthcare as US citizens.  For further reading, check out this article.

http://www.jewishworldreview.com/michelle/malkin022103.asp

I agree that US citizens, or immigrants here legally, should receive preferred treatment on transplant lists.  As stated in this article, this family paid a smuggler $5000 to get here for treatment. There does exist a route whereby they could have received treatment and been here legally.  It is called a medical need visa, and they are granted quite regularly.  There is very little ‘red-tape’ involved, the biggest obstacle being to have a physician here who agrees to take them on as a patient.  This probably would have been even cheaper than the $5000 they paid the smuggler.  Further, should you not have to be a legal citizen to file a malpractice lawsuit?  You are here illegally, yet you are perfectly free to to walk into court and sue someone?  This makes no sense whatsoever to me.  And in case you are wondering, yes they did sue.  Did they win?  We will never know as the University settled the case out of court, with a confidentially clause.  Neither the University or the family can tell the public what the settlement involved.  I am sure it was in the millions, however.  I am also sure that any hospital bills involved disappeared.  I do not think this operation should ever have happened.  Do I think hospitals should be required to establish legal status before treatment?  No, this would be inhumane, but I do believe that any type of treatment that involves enough time to investigate this should be investigated.  Also, this girl somehow was covered by Medicaid.  How did this happen?  I agree that Medicaid, and other types of government assistance should be restricted to those here legally.  Am curious how others feel.

the 3% myth

While it may be true that Medicare’s administrative costs may be only 3%, I am not sure I believe it.  My guess would be it is more a matter of playing tricks with the accounting.  Also, does this number factor in Medicaid as well? Does this factor in the fact that it is the states’ responsibility to administer Medicare/Medicaid or is this only the feds portion of the administrative costs?I work in healthcare as an RN in a pediatric ICU, so I do have working knowledge of the current system.   Currently, the Medicare/Medicaid system is the absolute worst to deal with when it comes to insurance coverage.  They have set reimbursement rates for alot of procedures in a hospital that are below what it actually costs the hospital to provide them.  Every time these tests are performed for a Medicare/Medicaid patient, the hospital loses money.  And there is no recourse to negotiate more fair rates.  There are hospitals closing everyday because of this very reason.  How would UHC rectify this issue?  If the answer is to make all medical providers government employees, I would have serious reservations about staying in this field.  Combined with reimbursement rates, getting ‘approval’ from the government programs makes Barnum and Bailey look like a serious opera.  I will not go into further detail here unless asked to, then I’d be happy to lay it out.  I have seen many patients permanently harmed and even die while awaiting Medicaid approval for a procedure.

Bottom line is this for me; while I fully agree that the current system is broken, mostly through the fault of insurance companies, and needs to be fixed, I am 100% convinced that single-payor, government run healthcare would be a mistake of monumentally historic proportions.  It does not work anywhere else it is in place (if you want examples, I will provide them) and will not work here.

Name one federal government program truly outperforming the private sector?!?  And I just might be convinced to rethink my position.

Marty G., RN

HR 676 and it’s problems

This is my critique of the current HR 676-Conyers/Kucinich bill in the House creating UHC.

SEC. 101. ELIGIBILITY AND REGISTRATION.

(a) In General- All individuals residing in the United States (including any territory of the United States) are covered under the USNHI Program entitling them to a universal, best quality standard of care. Each such individual shall receive a card with a unique number in the mail. An individual’s social security number shall not be used for purposes of registration under this section.

I would like to see this changed to say: …All individuals LEGALLY residing in…

SEC. 102. BENEFITS AND PORTABILITY.

(a) In General- The health insurance benefits under this Act cover all medically necessary services, including at least the following:

(4) Emergency care.

(c) No Cost-Sharing- No deductibles, copayments, coinsurance, or other
cost-sharing shall be imposed with respect to covered benefits.

I would like to see a provision added that would provide for a substantial penalty, copay, fine (call it what you will), for visiting an emergency room in a non-emergency situation.

SEC. 103. QUALIFICATION OF PARTICIPATING PROVIDERS.

(a) Requirement To Be Public or Non-Profit-

(1) IN GENERAL- No institution may be a participating provider unless it is a public or not-for-profit institution.

Why? What is the fear from any clinic/hospital being a for profit?

SEC. 201. BUDGETING PROCESS.

(a) Establishment of Operating Budget and Capital Expenditures Budget-

(1) IN GENERAL- To carry out this Act there are established on an annual basis consistent with this title–

(C) reimbursement levels for providers consistent with subtitle B

No different than the current system of government price controls.

SEC. 201. BUDGETING PROCESS.

(c) Capital Expenditures Budget- The capital expenditures budget shall be used for funds needed for–

(1) the construction or renovation of health facilities; and

(2) for major equipment purchases.

Who would be eligible for these funds? Would it only be government owned facilities or would any facility be able to get money for these purposes? Who would decide who needed improvements and who didn’t? Lot’s of room for pork-barrel spending here.

SEC. 202. PAYMENT OF PROVIDERS AND HEALTH CARE CLINICIANS.

(a) Establishing Global Budgets; Monthly Lump Sum-

(2) ESTABLISHMENT OF GLOBAL BUDGETS- The global budget of a provider shall be set through negotiations between providers and regional
directors, but are subject to the approval of the Director. The budget
shall be negotiated annually, based on past expenditures, projected
changes in levels of services, wages and input, costs, and proposed new
and innovative programs.

“Global budget of providers set through negotiations”? Does this mean the government is now going to mandate the operating budgets of private businesses? How much closer to socialism, no communism, can you get?

SEC. 202. PAYMENT OF PROVIDERS AND HEALTH CARE CLINICIANS.

(b) Three Payment Options for Physicians and Certain Other Health Professionals-

(1) IN GENERAL- The Program shall pay physicians, dentists, doctors of osteopathy, psychologists, chiropractors, doctors of optometry, nurse practitioners, nurse midwives, physicians’ assistants, and other advanced practice clinicians as licensed and regulated by the States by the following payment methods:

(A) Fee for service payment under paragraph (2).

This seems to say that only individual providers, not hospitals or clinics, are eligible for the “fee for payment” option. Why can organizations such as hospitals and clinics not be paid on a fee for service basis?

SEC. 202. PAYMENT OF PROVIDERS AND HEALTH CARE CLINICIANS.

(b) Three Payment Options for Physicians and Certain Other Health Professionals-

(2) FEE FOR SERVICE-

(A) IN GENERAL- The Program shall negotiate a simplified fee schedule that is fair with representatives of physicians and other clinicians, after close consultation with the National Board of Universal Quality and Access and regional and State directors. Initially, the current prevailing fees or reimbursement would be the basis for the fee negotiation for all professional services covered under this Act.

(B) CONSIDERATIONS- In establishing such schedule, the Director shall take into consideration regional differences in reimbursement, but strive for a uniform national standard.

How is this any different at all from the current Medicare/Medicaid system? You still have the government dictating to providers how much they will be paid for each of their services. How does this in anyway prevent the current situation from happening wherein the provider receives payment for services that is below what it costs to provide the service? You say I cannot compare the newly proposed system to the current Medicare/Medicaid system, yet this part of the bill tells me that comparing the two systems is comparing apples to apples, period.

SEC. 202. PAYMENT OF PROVIDERS AND HEALTH CARE CLINICIANS.

(b) Three Payment Options for Physicians and Certain Other Health Professionals-

(3) SALARIES WITHIN INSTITUTIONS RECEIVING GLOBAL BUDGETS-

(A) IN GENERAL- In the case of an institution, such as a hospital, health center, group practice, community and migrant health center, or a home care agency that elects to be paid a monthly global budget for the delivery of health care as well as for education and prevention programs, physicians employed by such institutions shall be reimbursed through a salary included as part of such a budget.

Explain to me how this does not say that I, as an RN and employee of a hospital, will have my salary mandated by the government through the budget control process pointed out above? I, as a professional, do not want any government controls placed on what I am allowed to make. How is this better for me than where I am now, where I negotiate a salary for myself? Not all nurses do this, of course. I am able to because I travel as a nurse. I work for a company that finds nursing openings in areas of the country where I want to go and in the type of units I work in. A salary is then negotiated between the hospital, my employer and myself. There is a contract involved spelling out all the details. Will this new system put this entire industry out of business? Why should I not have the FREEDOM to decide how I wish to make my career and how much I can make?

SEC. 205. PAYMENT FOR PRESCRIPTION MEDICATIONS, MEDICAL SUPPLIES, AND MEDICALLY NECESSARY ASSISTIVE EQUIPMENT.

(a) Negotiated Prices- The prices to be paid each year under this Act for covered pharmaceuticals, medical supplies, and medically necessary assistive equipment shall be negotiated annually by the Program.

(b) Prescription Drug Formulary-

(1) IN GENERAL- The Program shall establish a prescription drug formulary system, which shall encourage best-practices in prescribing and discourage the use of ineffective, dangerous, or excessively costly medications when better alternatives are available.

(2) PROMOTION OF USE OF GENERICS- The formulary shall promote the use of generic medications but allow the use of brand-name and off-formulary medications when indicated for a specific patient or condition.

Explain to me how this is any different than the current system that both the government programs and private insurance companies use now? Read my forum topic entitled “Universal Healthcare Won’t Work” for my discussion of my personal experiences with this very point. Also, who is to make the decision as to what is medically necessary? Will it be as it is now with non-medical business people making that call for every claim? How does this make any sense? On this point, the bill is way too generalized and open to interpretation.

SEC. 211. OVERVIEW: FUNDING THE USNHI PROGRAM.

(c) Funding-

(1) IN GENERAL- There are appropriated to the USNHI Trust Fund amounts sufficient to carry out this Act from the following sources:

(B) Increasing personal income taxes on the top 5 percent income earners.

(C) Instituting a modest and progressive excise tax on payroll and self-employment income.

Why only the top 5%? Why not simplify the tax code as has been discussed with a flat tax and appropriating a portion of this? Also, I have concerns in subparagraph C of the use of the word progressive. When it comes to money and accounting, progressive means gradually increasing. To what point? Until the budget can be met?

SEC. 211. OVERVIEW: FUNDING THE USNHI PROGRAM.

(c) Funding-

(3) ADDITIONAL ANNUAL APPROPRIATIONS TO USNHI PROGRAM- Additional sums are authorized to be appropriated annually as needed to maintain maximum quality, efficiency, and access under the Program.

Where shall these additional funds be appropriated from? More additional taxes? I thought one of the lynch pins of the argument for single-payer, universal healthcare was that it could be done by spending even less than what we do now? Comparisons are always made to countries who have UHC and how they spend less than we do? So why the need throughout this entire section about the need for additional revenue to pay for the program?

SEC. 303. REGIONAL AND STATE ADMINISTRATION; EMPLOYMENT OF DISPLACED CLERICAL WORKERS.

(c) Regional Office Duties-

(1) IN GENERAL- Regional offices of the Program shall be responsible for–

(A) coordinating funding to health care providers and physicians; and

(B) coordinating billing and reimbursements with physicians and health care providers through a State-based reimbursement system.
Again, how is this any different from the current system wherein states are required to administer the federal program? Talk to any state legislator about how big a bite is taken out of the state’s budget to administer federally mandated federal programs. Shouldn’t a new, comprehensive reform to the healthcare system relieve the states of at least some of the fed’s unfunded mandates?

SEC. 303. REGIONAL AND STATE ADMINISTRATION; EMPLOYMENT OF DISPLACED CLERICAL WORKERS.

(d) State Director’s Duties- Each State Director shall be responsible for the following duties:

(2) Health planning, including oversight of the placement of new hospitals, clinics, and other health care delivery facilities.

(3) Health planning, including oversight of the purchase and placement of new health equipment to ensure timely access to care and to avoid duplication.

Why should the government (any government state, federal or local) be in control of how a hospital may wish to expand their offerings? How is the government in any better position to decide whether or not an area can support a hospital expansion? Would a hospital expand their facility if their market could not support it? Are the people running hospitals that bad when it comes to running a business? Where is your precious freedom of choice if the government is going to ration the availability of services?

SEC. 303. REGIONAL AND STATE ADMINISTRATION; EMPLOYMENT OF DISPLACED CLERICAL WORKERS.

(e) First Priority in Retraining and Job Placement; 2 Years of
Unemployment Benefits- The Program shall provide that clerical,
administrative, and billing personnel in insurance companies, doctors
offices, hospitals, nursing facilities, and other facilities whose jobs
are eliminated due to reduced administration–

(1) should have first priority in retraining and job placement in the new system; and

(2) shall be eligible to receive 2 years of unemployment benefits.

I see no provision for how exactly this will be funded. Will these people then be bumping the people who are already enrolled in these programs or who become eligible in the future? If not, then there must be a new funding source for this section. Has there been any investigation done to determine what just this will cost?

SEC. 305. NATIONAL BOARD OF UNIVERSAL QUALITY AND ACCESS.

(a) Establishment-

(1) IN GENERAL- There is established a National Board of Universal Quality and Access (in this section referred to as the Board’) consisting of 15 members appointed by the President, by and with the advice and consent of the Senate.

(2) QUALIFICATIONS- The appointed members of the Board shall include at least one of each of the following:

(A) Health care professionals.

I would like to see some kind of provision here that this will include those people ‘on the front lines’, not just management. Were you aware that the organization of nurses in supervisory positions (AONE, American Organization for Nurse Executives) is a subsidiary of the American Hospital Association? Therefore, the people involved in nursing leadership may not actually represent the needs of the majority of working nurses. This must be addressed.

Bottom line is this, yes I have read the bill, but I cannot support it in it’s current form. To gain my support, and others in my position, these weaknesses I have pointed out must be addressed. Secondly, without reform to Malpractice Litigation Reform as a part of this type of system, I will NEVER be able to support it. I am for COMPREHENSIVE reform of the healthcare industry, NOT band-aids and quick fixes. I see a start in the right direction here, but much more needs to be done. However, you and I both know that as an individual working class American, my voice will NEVER BE HEARD, no matter who the candidate or office-holder is. We can discuss and debate and iron out the kinks here all day, but what we discuss here will not be taken into consideration. I would welcome the opportunity to sit down and discuss these points with someone who can actually do anything about it, but alas, that will never happen. This when I currently live INSIDE the DC beltway, albeit in Virginia. I am sincerely hoping I am wrong on this point and we really are being listened to. I think any politician who could admit to not knowing everything and be open to discussing things with ‘commoners’ would be a REAL breath of fresh air.

My final point is this. I do think that nurses salaries need to be brought more in line with the job we do, however with the government (AKA Congress) setting salaries, this will never happen. How many doctors and laywers are in congress vs. nurses? You do the math.

I sincerely hope that I am coming across as discussing these points with respectful disagreement. If I come across any other way, please know this hope is my intent. I mean do disrespect or disregard for anyone else’s opinion and I sincerely hope others can view my opinion likewise.

Marty G., RN

Universal Healthcare Won’t Work

I am an RN who works in a Pediatric ICU, so I see first hand the internal workings of our healthcare system. I work as what is known as a traveling nurse. I work in a location for 13 weeks and then move on to a new location, so I also have experience in more than one area of the country as well as different types of hospitals. I have worked at Duke University and also at the county hospital in Phoenix, AZ. Currently, I work at a hospital just outside Washington, DC. Throughout all these experiences, I have gained pretty strong opinions about what is wrong with the system and what it will take to fix it.

First, what I believe to be wrong with the system. In a nutshell: insurance companies, including government programs. Actually, the medicare/medicaid system is probably the biggest offender here. Every hospital I’ve ever worked at has had to have a number of people on staff whose full-time job it was to “deal with” insurance issues. I am not referring to the accounting and billing people, these are clinical people (nurses, social workers, etc), who spend their entire day talking to insurance companies about why a patient is still in the hospital, why they’re still in ICU, etc. We have insurance adjusters picking apart the patients medical condition and attempting to micro-manage their medical care. On a daily basis, the nurses and physicians involved in the patients care are asked to explain and justify why we’re doing what we’re doing. I understand the need for accountability, however, when physicians are spending a couple of hours everyday justifying their actions to an insurance adjuster, how are they compensated for this time? Further, how can a nurse provide appropriate care when they know that every action is going to be torn apart for billing purposes? People often wonder why a visit to the doctor costs hundreds of dollars yet they only see the doctor for 5-10 minutes. Because that 5-10 minute visit results in 1-2 hours of additional work for the doctor, the nurses and the office staff. Some of this time is due to legal paperwork having to do with licensing requirements in the sense of “we may need to defend a complaint over this visit to keep my license”. Even greater is making sure paperwork is in order enough to withstand being torn apart by an attorney in a malpractice suit, justified or not. I have experienced this same problem in my own family. When I made the decision to step down from a staff position as a nurse and begin to travel, it resulted in a change in employer, hence a change in insurance. My 3 year old son is on a couple of different medications for severe allergies. We were unable to keep him on his established medicines because the insurance would not pay for one until another, cheaper, alternative had been tried. Of course, we had already done this previously, but this documentation wasn’t good enough. He had to spend 3 months in agony ‘trying’ this other medication because the insurance would not pay for the one that we had already established worked for him. In speaking with the insurance company myself, I asked the adjuster I was speaking to (who had the power to approve the correct medication) what type of college degree she held. I was shocked to learn that she had no degree at all. I have since asked this question anytime I have had to deal with an insurance company professionally and found that commonly, the people at insurance companies deciding whether to approve or deny coverage either have no degree at all or have a degree in business or accounting. In my opinion, these people are making medical decisions with no medical training whatsoever. My question regarding insurance companies is this: Why should someone with no medical training or background at all decide what medical care someone should receive? We have people with no more than a high school education second guessing medical specialists in their care of their patients. Does this make any sense at all? I have witnessed this and can tell many more stories in great detail if you would be interested in listening.

I work in an ICU where split-second life or death decisions are made. i.e. the patient is dying and we must save them…do something in the next 15 seconds or they are dead. If you have ever watched an episode of ER when they are scrambling to save someone and doing many things very quickly, remember that all those actions must be documented to defend against an insurance company’s examination days later, calmly sitting at a desk somewhere with all the time in the world to sit and think. Worse yet, to defend against a lawsuit up to 10 years later being microscopically examined by attorneys with all the time in the world. I am sure you have seen episodes of different attorney shows where the attorneys are dissecting a physician’s action on the witness stand. Keep in mind the statute of limitations for malpractice suits is 10 years, longer if the patient is a child. They have until they turn 28 to file a suit. We as healthcare professionals always must keep in mind as we do our “charting” that we must write enough information so we can confidently defend our actions 10 or 20 years and hundreds to thousands of patients later. I make a point of remembering my patient’s names while I am caring for them, but I am just not good enough to remember them all by name forever. Even a few months later, I am sorry to say I remember them better by their medical course than by name. Therefore, in addition to changes in how insurance operates, the court system as relates to malpractice must be changed. You do realize that malpractice insurance costs more for physicians than a lot of people make in a year? For physicians that I work with, their malpractice insurance costs up to $100,000/year. This money must come out of their billing rates. Hence another reason why your 5-10 minute visit costs hundreds of dollars. People tend to think of doctors as rich. Nothing could be further from the truth. Yes, they make a good living, but they literally make life and death decisions on a daily basis. Remember, I work in a Pediatric ICU, so if your child were critically ill or injured, how much is it worth to you for the doctors and nurses who save your child’s life? Thinking about it from that perspective, how much should they make? And keep in mind, the doctors to make quite a bit more than us nurses. Add to this equation that most of the doctor’s decisions are made based upon information they receive from the nurses and we get into a whole other argument regarding nursing salaries.

I could ramble on more and more about the problems, but it does not fix anything. Solutions are needed and I have a few thoughts in that area as well. You may think I would be in favor of nationalized healthcare. Actually, I think nationalized healthcare would be even worse than what we already have. As I stated earlier, the government programs are the worst offenders when it comes to what I call insurance meddling in medical care. They say no the most often and have no avenue to make a more detailed argument to attempt to prove the necessity of a needed treatment. Talk to anyone, especially someone in the medical field, who has emigrated from Canada and they will tell you how poor the healthcare is in Canada. Sure, everyone is covered and all healthcare is essentially free, but what level of healthcare do they have. I have worked with many nurses from Canada who have stated without reservation that the medical care provided in Canada is vastly inferior to that of the care here. The principle of free enterprise and competition improving the quality of a product applies in healthcare as much as it does anywhere else.

I sincerely feel and believe with all my being that the insurance industry as it exists is the very foundation of the problems in the healthcare system. How to fix that? Somehow create a system whereby decisions on coverage are made based on sound medical grounds, not financial considerations. Perhaps a law requiring physicians in the appropriate specialty making decisions regarding coverage and authorizations without regard to costs. Insurance companies always complain about the high cost of healthcare, yet they are the primary reason for it. Perhaps a standard form whereby the physician can state “this is the patients condition, this is what we need to do”, and then get a yes or no without multiple requests for more information. This would result in the physician performing much more efficiently, thus enabling the billing rate to be more reasonable. There are other ways to address this as well.

In combination with this must be some kind of reform of the malpractice laws. There are much too many frivolous lawsuits being filed and making it all the way to trial. There has to be a way to hold attorneys accountable for clogging the system with cases that should not even see the light of day. I have encountered respected attorneys who have medical personnel on their staff who research cases for merit before deciding to even take a case. The burden in medical malpractice is “acceptable medical practice”. This perhaps needs a more specific definition. Also, not to put a value on a life, but is “uncle john”, who dies at 85 due to complications after surgery really worth $100 million? This seems outrageous to me. The constitution states “a jury of peers” in criminal cases. Should a doctor or nurse in a malpractice case not be afforded the same protection? Perhaps a jury composed of doctors or nurses who actually have the training and experience to judge the actions taken in the case?

I do not claim to have all the answers to this problem, but I do feel I am extremely qualified to pinpoint the causes of the problem. I would be happy to answer any questions and/or discuss further with anyone who is interested in discussing this issue with an open mind. Bottom line is this: show me a government run program in ANY AREA that works, and I may rethink my position somewhat.

Marty G., RN