Sunday, September 25, 2016

The Successful Patient: Being Mortal

My father
Years ago, when my father was diagnosed with prostate cancer, we had no idea what was about to happen. He already had severe heart disease and carried nitroglycerin pills all the time (and used them). Because of his heart disease, surgery to treat the cancer wasn't an option. He had chemo which was actually taking estrogen. He didn't like that. He thought it would make him a woman with breasts. I never found out if anyone explained to him that it was more complicated than that. He knew the cancer was serious and got his affairs in order. We knew that he wanted to die at home. That was really all we knew for a while.

Being a successful patient means educating yourself about your body, about the health issues you have. It's also about knowing yourself, what kind of life you want, and how to live when you're dying. Well, technically, we are dying from the moment we are born. But after about age 50, mortality starts to become much more of a subject for thought and for planning. We live in a society that focuses on youth and good health. As a result, we don't know how to talk about dying or how to live in the face of our mortality, i.e. the last months of living in old age or when terminally ill.

Since my lung illness last year, I've been thinking more about mortality. But like anyone, I really didn't want to think seriously about it. I still don't. I'd heard about a surgeon who writes interesting books about his work and was curious to read his books. His name is Atul Gawande and he's a general surgeon in Boston. The first book of his that I found was Being Mortal: Medicine and What Matters in the End. I borrowed it from the library. Reading the front inside cover copy, I wasn't sure I'd picked the right book. But then I decided to read it anyway.

I'm glad I did. Dr. Gawande writes about what medicine does right and what it does wrong when doctors treat elderly people or those who are terminally ill. He writes about how he was trained to heal, to cure, to treat, and to be informative so that patients could choose treatments. He wasn't trained to help the elderly and terminally ill to make choices of how to live in their final months. Describing cases from his own medical practice, he writes honestly about his own feelings of inadequacy, frustration, and confusion about what was expected of him and what he should do. His tone is real, human, warm and personal, and I found it hard to put this book down, even when a story brought tears to my eyes.

Dr. Gawande searched for answers for other doctors and for us. I'm grateful that he wrote this book and shared his hard-won wisdom. It has helped me to think about my own mortality and my own wishes. Dr. Gawande learned that it was necessary to ask patients questions about what they wanted in their lives, no matter how sick they were. It wasn't about medical treatment, but about living well when sick, failing in health, and dying.  He sums it all up:
"We've been wrong about what our job is in medicine. We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being. And well-being is about the reasons one wishes to be alive. Those reasons matter not just at the end of life, or when debility comes, but all along the way. Whenever serious sickness or injury strikes and your body or mind breaks down, the vital questions are the same: What is your understanding of the situation and its potential outcomes? What are your fears and what are your hopes? What are the trade-offs you are willing to make and not willing to make? And what is the course of action that best serves this understanding?"

There is one thing any adult can do as a first step in this process: do an Advanced Directive (find an example here). This is a legal document that spells out your wishes on paper so that if you are ever incapacitated and cannot speak for yourself, it provides medical professionals, family and friends with a legal record of your wishes. It also provides the names of at least 2 people whom you'd trust speaking for you. I've done one. It takes some time, but it's worth the effort. I spoke with my Primary Doctor about the technical medical details. I asked two people I know will honor my wishes to be my medical proxies, and gave them copies of my Advanced Directive.

Doing the Advanced Directive forced me to think about my beliefs about living, dying, and medical care. It is a tool for starting conversations among family members about end-of-life decisions. It is a huge step toward answering the questions Dr. Gawande wrote in his book. As a successful patient, I've found that being prepared gives me the power and the control that I need when dealing with doctors, nurses, and other medical professionals.

My father didn't have an Advanced Directive. At that time, in the mid-1980's, there really wasn't a document like that that an individual could fill out, sign and notarize. My father told us what he wanted. Even then, it wasn't enough because he could not have anticipated everything that was going to occur. Fortunately, Hospice provided my mother with much needed relief by sending a volunteer to stay with my father, take him on drives, and help out. My mother hired a part-time nurse also during the final months. What would have been especially helpful? To know exactly what happens to the body in the final weeks and days before death. I think this would have helped us immensely. But it's hard to ask that kind of question, and we really didn't know whom to ask.

Thanks to Dr. Gawande and his book, I now have a much better idea of what to expect and how I want to live out my last days. I highly recommend it for everyone.

Tuesday, August 30, 2016

Let's Talk About "Consent"

Photo: Pioneer Press: Scott Takushi
Last evening, I heard on the local news that the freshman class at the University of Minnesota-Twin Cities was moving into dorm rooms this week. In the next 10 days, each and every one of the freshman class must complete satisfactorily an online class from the University about sexual violence, consent, and drinking. While I was heartened to hear that freshmen needed to complete this online class, I wondered why the other classes weren't require to repeat it each year also.

This morning came the news that Brock Turner, the Stanford University student convicted of felony rape this past March will be released from jail this week after only 3 months of a measly 6-month sentence. He could have received a sentence of 14 years in prison. The judge in this case, Aaron Persky, revealed his sympathy for Turner which really horrified me. Where was his impartiality? What about the young woman Turner raped? She must live with that violation and trauma for the rest of her life. It will color her sexuality and her sexual life for the rest of her life. Didn't Judge Persky care about that? Also, does Stanford University have an online class about sexual violence, consent, and drinking that its students must complete at the beginning of each year?

Brock Turner (Photo: Santa Clara County Sheriff via AP)

Yesterday, I also happened to read a blog post by Doug Muder at The Weekly Sift this past June 13. The post is a round-up of news from the previous week, and Muder addresses the Brock Turner case, "and that rape case," about two-thirds of the way through the post. I really liked Muder's thinking, and he states much more clearly than anyone else I've heard or read what consent is in any situation.  He begins:

"At the trial, Turner claimed the woman consented, which seems hard to square with her being unconscious."
Then Muder writes that when we talk about sex, consent becomes tricky. However, I was taught, as are most women I'd guess, that if we say "No" or if we say "stop" at any time during a romantic or sexual encounter, the guy should stop. If he doesn't stop, then it's rape. In the last few years, we've seen more and more cases of young men, often in college, who use alcohol or Rohypnol, the tranquilizer also called "Roofie" or the date rape drug, to incapacitate young women so they cannot say no or stop. In other words, these young men have learned that in order to be able to have sex with a young woman, the young woman needs to be pliable and under their control. If she's passed out, asleep, or unconscious, so much the better. The whole notion of "consent" doesn't seem to enter into the equation for these young men only to have power over the young women so they can have sex. In other words, they don't seem to know, comprehend or understand that in order to have sex with another human being, the other human being must, must, give consent to it. No exceptions.

Where did these young men learn this? Where did they get the sense of entitlement that they could do as they wished with the body of another human being without the other person's consent? And that it was OK to incapacitate a young woman in order to have sex without her consent?

I love what Muder writes next in his post, because he talks about consent in terms of a financial transaction:

"For example, imagine I ask you for money and you say no. If I then take your wallet, I’m a thief. It doesn’t matter at all whether you’ve given me money in the past, or if you’ve been giving money to lots of other guys. Maybe your jeans are so tight that the wallet in your pocket is totally obvious, leaving nothing to my imagination. Maybe hundred dollar bills are hanging out of your blouse pocket. Maybe we’re both drunk and you pass out before you get done turning me down. None of that matters. If you never said “Here, take my money” I’m a thief."
Do you suppose that young men today would understand consent better if put in those terms?  In other words, it's not consent if the other person is unconscious and cannot say no or stop.  The transaction for sex needs to occur with both parties able to understand what they are doing, and what the consequences are, and able to actually say "yes" or "no." Both sides.

I wonder if Judge Persky understands that himself? I certainly do not understand how he could be so much more sympathetic for Brock Turner over the young woman he raped. I wonder if Judge Persky understands that this could quite possibly be the reason that reasonable people have been outraged by the sentence he handed Turner. Persky in effect told Turner what he did was no big deal, that there are no major consequences to his actions, in spite of the law.

Personally, I'd like to see an online class about what sexual violence is, consent, and drinking for seniors in high school. And I'd like to see parents teaching their kids to respect each other from an early age, no matter gender or sexual orientation. When kids are brought up to feel entitled, which seems to be the case for males still in American society, when they are in fact not entitled, that sets those kids up for something terrible when they enter the world as young adults. 

Parents are the primary teachers of morality and behavior, right? Schools and churches and society reinforce what parents teach. According to a letter Turner's father wrote to the court in defense of his son, he wrote, "His life will never be the one that he dreamed about and worked so hard to achieve.... That is a steep price to pay for 20 minutes of action out of his 20 plus years of life.” Wow. Why wasn't Mr. Turner talking about his son's terrible judgment, his terrible choice, and how they were going to affect another human being for the rest of her life? That his 20-minute action has serious consequences? That he's not terribly happy with that 20-minute action?  Mr. Turner demonstrated in his letter where his son's poor judgment and choice came from. But that shouldn't excuse Brock Turner from the consequences of being convicted of felony rape and sentenced to 14 years in prison like anyone else convicted of the same charge.

I would like all parents and teens to read the victim's statement that she read in court to her assailant, Brock Turner. It should be part of any class about sexual assault, consent, and drinking. This is what happens to a victim of sexual assault. The assault is not only physical, but also psychological, emotional, and spiritual. 

Rape has been, and continues to be, a huge social issue in our society despite some progress in establishing women's rights as human beings. Clearly more needs to be done. Will the online class at the University of Minnesota-Twin Cities be enough?

Friday, August 26, 2016

"The Doctor Blake Mysteries"

My Aussie friends in Melbourne and Adelaide would probably chortle at my recent obsession with the TV mystery series The Doctor Blake Mysteries, set in Ballarat, Victoria, and produced there. The Public Broadcasting System has made a smart move by importing this series (and another, Miss Fisher's Murder Mysteries) from Australia. They definitely spice up the programming schedule of my local PBS TV station.

It doesn't bother me that none of the actors are familiar names or faces. Or that the series is set in the late 1950's. I love that it's a "period" piece, set in a time long before personal computers, cell phones, and blockbuster anything. These mysteries pit a doctor, a "police surgeon," against the murderer and his or her methods, flaws, mistakes, and pain. The police help or hinder depending on who's in charge -- there's been one Chief Superintendent whose handsomeness hid a black heart -- and always provide the authority Dr. Lucien Blake requires to catch the villain. These mysteries proceed quietly, slowly, penetrating the social strata of Ballarat and the surrounding area with some of the most haunting music you will hear on television.

Dr. Blake, the son of a beloved doctor in Ballarat, returns after years spent abroad. His background story seeps through each mystery episode, revealing his flaws and his pain, as well as his character as a person. He takes up residence in his father's house and office, and asks his father's housekeeper, Mrs. Jean Beazley, to stay and work for him. He takes in a district nurse as well as a young police constable or two as boarders. His medical practice would be that of a general practitioner at the time, supplemented by his work with the police. The nature of the show, of course, means that it actually seems like his police work is his major practice.

Craig MacLachlan, as Blake, brings a real presence to the role, a thoughtfulness as well as a kind of reckless drive to solve each mystery. I love that the medical forensics are so early in their development and use -- no DNA profiling here. We learn that a suspect can have the same blood type as that found on a murder weapon or at the murder scene. Poison seems to be a preferred method of murder in Australia, however, in stark contrast to what would be preferred in America, i.e. shooting with guns. Psychology is also in use by the police and Blake, although they don't ascribe to its use. They depend on their knowledge of and experience with human behavior. And so far, the writing has been original and imaginative, giving the actors opportunities to develop their characters as well as making interesting, sometimes twisty, stories.

Two subplots have been threading their way through all the stories, at least so far. One is the politics of the police in Victoria, and how Blake's work with Ballarat's police has shone too bright a spotlight from Melbourne on them. At times, it looks as if Blake will lose his job. At other times, it looks like he could end up in prison. How this subplot plays out is just as suspenseful as each of the mysteries, as complicated, and as full of nastiness as you can imagine. It makes office politics look tame.

The second subplot involves Blake and his housekeeper, Jean Beazley. Over time, the two actors do a masterful job of showing the gradual romantic attraction growing between these two characters. It has been fascinating to watch their reservation, their restraint, the way the social norms of the time govern their behavior, and so on. They are both middle-aged with grown children, and this is especially refreshing to see. They have problems, pain in their pasts, and have each lost a spouse in war. Will they get together?

Jean and Lucien (Not what it looks like)

What's been especially fascinating to me has been seeing Australian culture and a moment in Australian history after World War Two. They were an ally of the Americans in the Pacific Theater and have their own war stories to tell. I grew up hearing mostly about the European Theater of that war despite my father's service in New Guinea which he rarely talked about and then not in detail. Australia had its own struggle with Communism and prejudices, corruption and vice. I feel like with each episode I'm experiencing this time in Australia through these characters and their stories.

I'm almost finished with the fourth season and have been excited to learn that there will be a fifth. If you're looking for something different and you love mysteries, request (demand) your local PBS station to air it (if they aren't already)!

Wednesday, August 17, 2016

Who Founded ISIS?

If there's one thing that will disgust me, it's when a "politician" spouts off about something he or she knows absolutely nothing about and is too arrogant to admit he or she knows absolutely nothing about it. Such politicians can be quite dangerous, and actually toxic to government and the general public. But how can we possibly know when a "politician" is spouting off and exposing his or her ignorance?

We rely on our Freedom of Press and the media protected by it to help us out. We need journalists to take the time to research and write/talk about what the truth is about a subject. We need journalists to persevere in pulling out of arrogant "politicians" just how much they know about a subject to reveal their ignorance. I'm not seeing that happen enough right now during the American campaign for president.

Let's take a recent example. Donald J. Trump claimed over and over and over that Barack Obama and Hillary Clinton co-founded ISIS. And not only in one day's news cycle, but over 7-10 days he repeated this claim, embellishing it at times with derogatory adjectives for Obama and Clinton. Trump insisted over and over that what he said was true. Obama and Clinton had co-founded ISIS. (He's since "clarified" his statements by saying their policies made ISIS strong.)

What is the history of ISIS?

Who really founded ISIS? Let's take a look at its history. If you'd like to read more lengthy articles about this group, try The Atlantic's "What ISIS Really Wants" or the Wikipedia entry for ISIS.

To summarize, this group was founded in 1999 under the name Jamāʻat al-Tawḥīd wa-al-Jihād by Abu Musab al-Zarqawi, who eventually led al-Qaeda in Iraq. It wasn't known as the Islamic State of Iraq (ISI) until after Zarqawi was killed in 2006. So, long before Obama became President, in fact, when first Bill Clinton, then George W. Bush were President, this group came into being. In response to Bush's invasion of Iraq in 2003, Zarqawi aligned the group with al-Qaeda and joined the insurgency.

In 2010, after the leaders of ISI were killed by US and Iraqi forces, the current leader, Abu Bakr al-Baghdadi, took over. The Syrian Civil War, begun in 2011, has served to grow this group into what it is today, i.e. the Islamic State of Iraq and the Levant (ISIL). The Syrian government's response to the Arab Spring uprisings opened the door for ISIL to capture territory. Al-Qaeda cut all ties with ISIL in 2014. ISIL operates on its own, and al-Baghdadi has developed it into an extremist Islamic war machine bent on creating a world-wide Caliphate and destroying every other religion and the people who follow them or go down in a blaze of glory.

As far as U.S. policy toward ISIL, it has had to respect the sovereignty of Iraq in developing operations against the group. As for Syria, I suspect that much more is going on behind the scenes than is available for the general public to know. Trump's ideas about nuking ISIL mean that he'd be nuking the countries of Iraq and Syria in the process. I doubt any Middle Eastern country would stand for that much less Iraq and Syria. Not to mention their allies -- Russia is one of Syria's staunchest allies.

And really, all Trump has to do is a little reading to educate himself on the history of ISIS (ISIL). The fact that he doesn't and that he fails to demonstrate that he has tried to educate himself only affirms his ignorance of how to deal with an enemy of the country.

Trump's ignorance of the Constitution

The U.S. Constitution is the foundation and organizing document of the American government. With the Bill of Rights and subsequent Amendments, it is the law of the land. When Trump states that Obama, our current President, and former Secretary of State Clinton co-founded ISIS which is an enemy of the United States, he betrays his ignorance not only of recent international history, but also ignorance of the U.S. Constitution. And this guy wants to hold the highest elected office in the country and swear to uphold a document that he clearly knows nothing about?

"So what?" you might ask. Well, if Trump is going to lead our country and head our government, he needs to know, at the very minimum, the Declaration of Independence, the Constitution, and the Bill of Rights as well as the subsequent Amendments. Trump has demonstrated only ignorance. Why?

In Article III, Section 3 of the U.S. Constitution:

Treason against the United States, shall consist only in levy-
ing War against them, or in adhering to their Enemies, giv-
ing them Aid and Comfort. No Person shall be convicted
of Treason unless on the Testimony of two Witnesses to the
same overt Act, or on Confession in open Court. 
The Congress shall have Power to declare the Punishment
of Treason, but no Attainder of Treason shall work Corrup-
tion of Blood, or Forfeiture except during the Life of the Person attainted.
Since ISIS is an enemy of the U.S. and is at war against us, saying that Obama and Clinton co-founded it is the same as accusing them of treason against the U.S. by "levying War against them (the U.S.), or in adhering to their Enemies, giving them Aid and Comfort." That is a serious charge. Trump needs to have one or more other witnesses for this co-founding and substantial evidence to prove the claim. By making this claim, Trump demonstrates just how ignorant he is of ISIS, of the U.S. Constitution, and of his own ignorance which is probably the most dangerous thing about his loose lips.

So in addition to not being familiar with the law of the land, of the documents that organize our democratic government, Trump has demonstrated an ignorance of the meaning of his own words in the context of the U.S. Constitution.

I fervently wish the Media would point these things out to Trump, call him out, make him uncomfortable, show him that he needs to do the work and not just stand at a lectern and spout lies and ignorance. I just have not seen it, and you know what? I doubt I will. Why?

First of all, educated people and people who seek out the truth (not mutually exclusive groups, by the way) already know about Trump's ignorance. Second, Trump's followers probably really don't care. They care only that Trump has the moxie and the influence to say in public what so many think. They believe he's right because Trump says he's right. They are not the kind of skeptical minds that think critically about what politicians say. And Trump believes he's the best person for the job. Sad but true.

Trump will continue to spout his ignorance, even though he's begun to try to sound statesmanlike. He will continue to alienate women, minorities, people of all religions with his ideas and policies for "making America great again." His followers will agree with him. I can only hope that come November, Clinton routs him in the election. And then perhaps our public education system can be improved to teach kids how to be skeptical, to research and educate themselves, and to think critically.

Monday, August 15, 2016

If I Were in Charge.....

What is the big deal about single payer medical insurance that makes so many people angry and upset?  Actually, I think it's the insurance industry that promotes activity against single payer medical insurance even though they have already made inroads into Medicare by offering supplemental medical insurance as well as Medicare-approved plans.  Maybe it's time to take a hard look at what Americans need vs. what they currently receive in terms of medical insurance, i.e. if I were in charge....

We need medical insurance that doesn't make us sick or make it necessary to hire someone to deal with it for us (Patient Advocates).

Here's an example of this: last spring I received a letter from a company I'd never heard of telling me that they'd assessed my medical need for a medication I was taking, and they'd approved coverage for that medication by my insurance through October. My first reaction was "Oh, no! Who are these people? Why are they assessing my medical need for a medication? They know absolutely nothing about me!" I was in a panic that my insurance would eventually decide not to cover this medication that I need, I'd have to go off it because I couldn't afford to pay for it (unless the drug company would be able to help me), I'd become quite ill again, end up in surgery and cost the insurance company tens of thousands of dollars more than if they'd covered the medication. Not to mention the stress and the devastation of illness.

I sent my doctor's office a note asking if the prior authorization had been revoked. I thought that we'd gotten a prior authorization for a year from my insurance company. So why did I get this letter from a company I'd never heard of? They assured me that they'd gotten the prior authorization, and sometimes medical insurance companies run medical necessity assessments on a quarterly basis, especially for expensive drugs. What?  They think my necessity will change every three months? Wrong.

Of course, this incident upset me and angered my medical team. It created work for me that took me away from my livelihood. Does my medical insurance care? No. I spend so much time on issues like this with my insurance, I sometimes think it could be a full time job. I'm in relative good health right now (thanks to that medication) but I don't know how someone who's very ill can cope with this work. I have learned that there are people you can hire to do it for you if you don't have a family member adept at maneuvering through the insurance mazes. My insurance company even hires an outside company to do their medical necessity assessments.

Doctors decide medical necessity, i.e. the patient's doctors not doctors who have never even met or seen the patient that work for a company that works for the patient's medical insurance. Wouldn't life be a lot simpler if that were truly the case? It used to be the case years ago.

We need medical insurance that's easy to understand.

When I began dealing with medical insurance after my chronic illness diagnosis 15 years ago, I struggled to read through my policy. I still need help with understanding how the medical insurance industry works. Does anyone else get the feeling that they make their policies and procedures difficult to fathom in order to catch patients or to protect themselves from paying out too much on claims? Policies and procedures need to be written in plain English that anyone can understand, and need to be simple to do, fast, and supported by the company.

For example, I have a prescription for injectable B12 that I must do every 3 weeks. In my insurance policy, it says that coverage is for a one month supply of a medication. OK. Sometimes, because of the every-3-week schedule, I need to inject the B12 twice in one month. I thought that getting 2 vials per month rather than 1 would solve the problem. So, I talked with my doctor. She called the pharmacy with her approval, but would not write a new prescription because my dosage was once every 3 weeks. But the pharmacy couldn't do the 2 vials per month because of the terms of my insurance. I finally asked the pharmacist how I was supposed to follow my doctor's dosage instructions. She told me that I could get my prescription refilled every 3 weeks and my insurance would cover it because of the doctor's prescription.  Who knew that the one month supply restriction stated so clearly in my policy would not apply to my B12 prescription?

Supporting bureaucratic language and procedures wastes time and money for everyone. Patients don't have the time or resources to be constantly checking on the rules medical insurance companies do not publish in their policies.

We need medical insurance that isn't more expensive than the medical expenses that we have.

If the insurance coverage pool consisted of every American, i.e. approximately 400 million people, that would be the biggest risk pool any insurance company could ever wish for. That in and of itself could bring down costs for both insurers and the insured. I don't buy that insurance companies are non-profits, that they use their surplus each year to cover shortfalls.  There was a gigantic insurance company in the last year who tried to claim a loss in my state when they had a surplus pool many times the amount of their alleged loss, and they were supposed to use that surplus to cover that loss.  The reason they were trying to claim a loss was to charge people more for their premiums and coverage.

Insurance companies are in the business of making money, pure and simple. In that respect, they are for-profit entities. We need to take out the whole notion of making money from medical insurance.

We need medical insurance that applies to everyone, without any kind of discrimination, no matter what age or health status.

We now have the situation in the U.S. that several big medical insurance companies have pulled out of participating in the ACA (because they are allegedly losing money), and therefore, their policies are no longer eligible for the tax credit subsidy offered under the ACA for people who have problems affording sky high premiums. This move by these companies has shrunken the number of policies available to patients and the amount of coverage.

I think that it should not be a choice for insurance companies, but a requirement on the state and federal level that they participate in the ACA. When they don't participate, that means that they can return to their practices that led to the ACA years ago, like discriminating against people with chronic illnesses, for example, and older adults.  And charging so much in premiums and out-of-pocket expenses that people cannot afford to buy coverage. We are already seeing this happening.

We need medical insurance that will cover everyone equally, that is reasonably priced, that has streamlined procedures for administration. Some have suggested Medicare for all as a solution, but Medicare needs cleaning up itself.  However, Medicare is single-payer medical insurance -- yes, the U.S. already has single-payer medical insurance for everyone 65+ years old. Why not channel all the energy being spent on insurance companies and the ACA into cleaning up Medicare, making it more efficient and less prone to fraud, and phasing it in over the next 10 years as a single-payer medical insurance for every person no matter what age he or she is in the U.S.?

And we need to make the insurance industry want single payer medical insurance.  

Guess who screams the loudest against a single-payer medical insurance system available to all? Of course. The medical insurance companies. They haven't the imagination to figure out that they could still play a role, and therefore not lose their business, in a single-payer system. But no one who has supported a change to single-payer insurance has ever explained how it would be in the best interests of the insurance industry to make that change.

First, most medical insurance companies already offer Medicare-approved plans for seniors. Second, those plans can be the foundation for phasing in Medicare for all, and the insurance companies can contract (as they already do) with Medicare to be regional centers for processing Medicare claims. What then happens is that as Medicare phases in for all ages, the insurance companies become independent contractors working for Medicare, i.e. the government. They can be a part of streamlining Medicare's business processes so that everyone saves money and time. And Medicare will then have the clout to negotiate with drug companies and pharmacies for lower drug prices for patients, and will be able to continue to establish pricing for hospitals, clinics and private practice physicians.

And so.....
I often tell people that medical insurance companies are not our friends. They really don't care if we live or die. All they care about is whether or not they must pay out on claims. They don't want to pay out. Instead, they want to accumulate as much money as possible, ostensibly to pay out on claims, but I wonder just how much of that money goes to executive pay, perks, and non-business expenses. The insurance industry, like the pharmaceutical industry, could benefit in the long term from financial transparency and being more responsive to the market. And from transforming into a single-payer system under Medicare.