Marks Daily Apple
Serving up health and fitness insights (daily, of course) with a side of irreverence.
1 Aug

Deconstructing Healthcare in America – a Modest Proposal

I’ve been giving a great deal of thought to our system of healthcare lately. Frankly, I am disgusted not only by the perverse waste of money (we will spend 2 trillion dollars – that’s 17% of our GDP – next year on health related expenses), but also by the obscene lack of success our current system has in helping people achieve, maintain or regain good health. We are getting sicker and sicker as we continue to spend more on healthcare.

cash

While we rank number 1 worldwide in health-related spending, we rank 37th in overall health performance. Sure, Americans live longer now on average than we did 20 or 30 years ago. But the truth is we are only surviving longer, because we are most certainly not thriving longer. Drug companies are keeping us alive just so they can pump more meds down our throats while they pump up their own bottom line. And we are now told that the generation in grade school today may be the first – in centuries – not to outlive their parents. Something drastic has to be done soon. This current system is beyond repair. But if you are one of the 45 million uninsured Americans, for whom the thought of getting sick is, well, sickening, you already know that.

As I’ve been reading all the pre-election political proposals to fix our current “healthcare” system, I am struck by the fact that they are trying to fix something so badly broken that it simply can’t be repaired. Even Michael Moore’s new film “Sicko” doesn’t get to the heart of the problem. The assumptions upon which the current system are built are outdated, obsolete, and illogical. The system requires a wholesale reevaluation and rebuilding from the bottom up, including our rights, our responsibilities – and our reasonable expectations. If virtually every other developed nation (and several underdeveloped) can take care of their sick, we certainly ought to be given the chance.

With that in mind, I would like to offer a “modest proposal” to overhaul the U.S. healthcare system into one that, in my opinion, would do a much better job of caring for its sick and making sure the rest of us stay healthy. I realize that what I’ll be suggesting is a radical change and one that may irritate more than a few professionals who currently operate within our existing healthcare system. Nevertheless, this discussion is vital and I can no longer sit back and watch the system and its patients self-destruct. We gotta talk.

While the problems with today’s healthcare system are many, I have chosen a few to illustrate why we need a massive intervention:

1) Let’s start with the patients. Americans have lost all sense of personal responsibility. We want to blame anyone or anything but ourselves for our illness or condition. Furthermore, we have ceded all control of our health to the people in the white coats. We tend do whatever they say because we hold them in such high esteem. But doctors (like lawyers and accountants) do not have answers. All they really can offer are opinions and advice – only slightly more educated than our own and often biased by Big Pharma, medical supply companies or the fear of being sued. As a result, we way spend too much money on unnecessary visits, drugs, tests and procedures.

2) There aren’t enough doctors in the U.S. One report suggests that as baby boomers start needing even more care, there will be a shortage of close to 200,000 doctors as early as 2010. One of the reasons for this shortage is simply because it takes far too long (usually 7-10 year) and costs far too much to train doctors. Furthermore, most doctors have to pay for this training themselves, often incurring huge student loan debt. It’s not unusual for kids these days to incur six figures in debt simply to get through a regular four-year degree – you can see the problem for the youngsters who desire to go on to medical school. As a result, and to compensate for all this, doctors have to charge too much money for too little service, and then hope that some day they will be reimbursed by the for-profit insurance companies. This doctor shortage is also why when you really need to see one today, the earliest available appointment isn’t until two weeks from Thursday. It would be funny if it weren’t so tragic.

3) The current system depends on private insurance companies to reimburse all costs. This profit-driven insurance-based medical reimbursement system is fatally flawed on several levels – and always has been. The basic business model of any insurance company is to do everything possible to collect premiums and then do everything possible to deny coverage. Therefore, people who need medical attention are frequently denied expensive (but often the most effective) treatment or, alternatively, people with pre-existing conditions can’t get insurance coverage in the first place – when they are the ones who need it most. As a result, insurance companies often dictate the most critical medical decisions more than the physicians. It’s just so wrong.

rats

4) The majority of conditions for which people seek treatment can be better treated (and in most cases cured) with lifestyle intervention and education, yet our system of medicine would rather treat symptoms with drugs and/or surgery. Obesity, diabetes, heart disease, osteoporosis, arthritis, digestive problems, asthma and a wide range of other conditions often respond far better to diet and exercise or environmental changes than to even the best “state-of-the-art” pharmaceutical interventions. But doctors are under the gun to meet payroll, pay the rent and pay off the student loan, so they limit office visits to eight minutes and move on to the next patient. Under these circumstances they are far more inclined to prescribe meds than they are to spend 45 minutes or an hour to fully “describe” a lifestyle change that could cure the condition. Of course, they are even less inclined to follow up on any educational visit. What’s the incentive?

5) Pharmaceutical companies, medical equipment providers, hospitals and even a few doctors have a vested interest in keeping their patients ill. You’d think that a successfully “cured” patient should represent a major victory in strict medical accounting terms, yet a cured patient generates no income and no profit. Type 2 diabetics are a good example. Drug companies view a diabetic as the perfect patient – a 20, 30 or 40 year income stream generating $500 to $1,000 a month. The longer they live with the disease, the more additional drugs they’ll need and the more profit the company will make. In fact, the drug company has zero interest in the patient altering his or her lifestyle (and as I have said here often, type 2 diabetes is an entirely preventable and curable condition). They just need to keep them alive.

pills

Moreover, when the market on one disease is tapped out, our friends in pharmacology manufacture new ones: “restless leg syndrome”, “social shyness”, “erectile dysfunction” and “PMDD” are not diseases, but they represent huge profit centers for doctors and pharmaceutical companies who see a lifetime stream of income from patients taking their prescription meds month after month, year after year.

6) The fear of lawsuits causes many physicians to assume a “cover your ass” approach to avoid any potential implication of liability, however remote. Medical malpractice has become a huge industry as personal injury lawyers seek outrageous settlements for even minor mistakes or misdiagnoses. Many physicians leave the business because they can’t afford the malpractice premiums, and they fear the one multi-million dollar mistake that could ruin them. As a result, doctors resort to generalized “standard of care” methods even when those standards have been proven ineffective. For example, there is no good evidence that statin drugs lower the risk of death from cardiac events when cholesterol is between 200 and 250, while there is compelling evidence that diet and exercise interventions dramatically reduce deaths in that same group.

Nevertheless, most physicians prescribe statins and spend minimal time aggressively outlining lifestyle changes because statins are the “standard of care” for high cholesterol cases and because there’s safety in knowing that’s what most other physicians are doing. A physician who does not prescribe statins might be subject to a lawsuit if his patient died of heart problems because, shunning statins, he had tried but failed to get the patient to follow his diet and exercise advice. Fear of lawsuits is also why your doctor will sometimes run hundreds or thousands of dollars worth of diagnostic tests “just to be on the safe side.” You might think your insurance company pays for it all. But those costs are passed on directly to you and everyone else via annual insurance premium increases. God forbid the insurance companies should have an unprofitable year.

These are just a few of the problems with the current system. There are many more. These problems will not go away with the kinds of compromise proposals offered by politicians today. Forcing business to cover the costs of employee healthcare is ludicrous. Other than worker’s comp coverage, by what logic is it the obligation of business to pay for the bad luck, unfortunate genetics or unhealthy lifestyle choices of its workers? The single-payer system that has been often proposed has many merits, but is continuously shut down by Congress. Government guaranteeing the profits of private insurance companies using taxpayer funds is viewed as a misuse of taxpayer money. Yet there is a strong argument that perhaps the time has come for government to step in and do something drastic to fix this mess.

When it comes to business and economic models, I’m one of the biggest Freidman free-market proponents you will ever meet, but sometimes the basic needs of the people require that the government get involved. You could even argue that in the 21st century, given the health tools science has provided us, access to quality healthcare has become a constitutional right (provided you are willing to take personal responsibility for it). It has become my opinion that access to basic healthcare for all, like defense, fire departments and interstate highways, should be viewed as a public good, not as for-profit business with corporations’ profits favored over the health of our poorest citizens.

Yes, I’m advocating a federally funded and federally driven program that would allow anyone of any means access to basic healthcare at little or no cost. Now before you get all Republican on me, let me explain that I am also in favor of keeping parts of the current system for people who prefer and can afford a private medical system. After all, cosmetic surgery, Botox, stomach stapling and Viagra still need to be made available to those willing to spring for it.

It’s not often you’ll hear me suggest that government could do a better job than for-profit industry, but there are so many players in the current healthcare system that require a profit at the expense of the sick – and who have so shamelessly lobbied Congress to allow them to continue this charade – that the concept of “free-market forces” left the building with Elvis decades ago. For example, according to a 2003 study we spent almost $300 billion on “administrative costs” associated with medical experiences in one recent calendar year. From the patient point-of-view, that’s $300 billion of your hard-earned dollars completely wasted.

My proposal is a two-tiered healthcare system which offers government-sponsored healthcare to everyone (we’ll call it “public healthcare”), yet still allows for private medical practice as we know it today to be available to those who prefer and can afford it (“private healthcare”). Anyone of any means could access the public healthcare system with minimal co-payments (which could be reimbursed via tax credits for low-income patients). There would be no private insurance involved in the public system at all because taxes would cover almost all expenses, but the private system would still largely depend on private insurance reimbursements. For those who wonder how or why a two-tiered system could work in this country, look no further than the US system of retirement planning which offers social security to everyone (and mandates taxes to insure it), yet allows those who prefer and who have the means to set up additional private retirement accounts (IRAs, 401ks, defined benefit plans, etc) with tax benefits and almost unlimited upside.

The public system would work much the same way that the armed forces work today. In fact, it could be its own branch of service. Prospective medical students who elected to go through the public system would enlist and would be trained within that system. Their entire training, as well as room and board would be free (paid for with tax dollars), and in exchange for the training, they would guarantee to provide at least eight years of service within the public health sector compensated at a reasonable rate of pay (let’s say $80,000 a year, comparable to a public defender). After eight years of service, they could elect to remain in the system (with an increase in pay) or they could go into the private healthcare system and hang out a shingle (remember how most commercial airline pilots came out of the military?). Nurses, physicians’ assistants, exercise and diet coaches, even administrators could all be trained within this same system. All this could even take place within today’s current armed forces structure with added pay incentives for actual combat-readiness training, but might be more effective as a stand-alone service branch.

With regards to the growing shortage of trained doctors, my system would fix that in relatively short order. This does require a major re-evaluation of what it takes to be a doctor. Bottom line: it shouldn’t take eight years to train a competent specialist like it has up until now. Aside from general practitioners and Emergency Room docs, almost all medicine is specialized today (just tell an orthopedist you have a GI problem and see how fast she runs the other way). I would argue that you can train a smart pre-med college grad 90% of a chosen medical specialty in under two years and have him or her be perfectly competent to begin supervised practice on real patients. After all, most diagnoses theses days are done by computer modeling anyway – not by the actual physician. I don’t wanna say a monkey could do it, but let’s get real.

monkey

If a condition is not immediately obvious to attending physician today blood, urine, stool and saliva samples are sent to labs and returned with nice distribution curves and all the relevant data with which to make a cogent diagnosis. CAT scans, X-rays, MRIs and other imaging techniques allow almost anyone to spot a problem and begin treatment.

Even surgical techniques no longer require years of practice with a supervisor looking over your shoulder. Surgeons today can be quickly trained using computer simulators. Ironically, most new surgeries these days are taught to older surgeons by 30-year old medical sales reps (who most definitely are NOT doctors) shilling the latest stents, shunts, implants and titanium joints. The idea is to train more doctors quicker and pay them less. Pure and simple. Those doctors who wish to charge more for special services could either train and operate within the current system or enter that system after their years of public service. But as we have seen in the private system, most of our healthcare money goes to greedy middlemen (insurance companies, pharmaceutical companies, bureaucracy-laden hospitals, student loan collectors) or to wickedly non-productive overhead (office rent, administrative staff, malpractice insurance). As a result not much of our health dollar flows through to provide patient services. That would change radically under my system.

The public system would rely on generic drugs wherever possible and would negotiate very favorable pricing on brand-name meds when those are absolutely necessary. Drugs would only be prescribed when truly medically necessary (sorry, no Viagra or recreational Oxycontin) and elective surgeries would usually be discouraged. Experimental drugs would be allowed if they were the only recourse in critical cases, but only with patient permission and waiver, adequate supervision, and oversight from a restructured FDA. The more expensive drugs would be used on a “pay-for-performance” basis, where the drug company would supply them, but would only be paid if they worked within acceptable parameters.

Education would be a major focus of the public health system. The current for-profit system is based on maximizing treatment as opposed to maximizing prevention. Under the system as it is, we will never make progress preventing or curing the lifestyle diseases that threaten us the most: diabetes, obesity, heart disease, stroke, arthritis, even some cancers. In most cases these respond very favorably to lifestyle interventions, but no one is willing to spend the time or energy to educate. Under my proposal, doctors would be paid for their treatments, but would also incentivized for successfully weaning their patients off meds and for having their patients achieve medical milestone numbers such as losing a certain percentage of weight or bringing fasting blood glucose to under 100 for two successive visits.

These goals can only be achieved when the patient is educated, understands the mechanisms and then takes responsibility for her health. Under my proposal, specialized health educators (maybe those who didn’t fully qualify for the medical training, but who exhibited the interest and the intellect) could be trained within the system and then deployed to schools or assigned to work with physician groups to do hands-on small-group diet, exercise and stress-management coaching. The success private clients currently enjoy working with personal trainers could then be made available to those who currently have no hope of ever gaining access to the true secrets of health and wellness.

Within the public system malpractice and medical “mistakes” would not be subject to the same litigation system we see in private medicine today. Instead, a 3-person panel of experts would hear cases and, upon finding gross or willful negligence, could choose to award reasonable costs according to a set schedule. This would ensure that any patient harmed by the system would be looked after, but would not be awarded lottery-like sums from aggressive tort-lawyers impressing overly sympathetic juries.

In the best of all possible worlds access to a public health system would bring the realization that there are no more excuses. We must each take responsibility for our health and realize that if we don’t make the lifestyle changes necessary to heal, we give up our right to complain or blame “the system” for leaving us behind or for not taking care of us. As we’ve seen with the current system, there’s only so much modern medicine can do at any price.

There, I’ve said it. Give it some thought and let me know what you think. In my opinion, without serious dialogue and outrageous ideas like this, our health will continue to deteriorate until we are a bankrupt, obese, diabetic, arthritic and Alzheimer’s-ridden nation with no good prospects for the future – and no good memories of the past.

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Imagine you’re George Clooney. Take a moment to admire your grooming and wit. Okay, now imagine someone walks up to you and asks, “What’s your name?” You say, “I’m George Clooney.” Or maybe you say, “I’m the Clooninator!” You don’t say “I’m George of George Clooney Sells Movies Blog” and you certainly don’t say, “I’m Clooney Weight Loss Plan”. So while spam is technically meat, it ain’t anywhere near Primal. Please nickname yourself something your friends would call you.

  1. Your health proposal is definitely well thought out and comprehensives, and I agree with the spirit and the ideals behind it, but – and you knew there was a but coming – with our current political system there is no way this could work. Enter the special interest, the PAC’s, the lawyers, the pork spending politicians, and the social minded who would say you are an elitist because you propose 2 systems one for the “rich” and one for the “poor” – even though that is not what you said. If, you could cut through all that quagmire and get them all to agree to implement your ideas, there is still another problem. Name one major federal government agency that is well run, not fraught with overspending and does not waste taxpayers money – personally I can’t think of one, but I have been wrong before. We can’t even fix something as basic as Social Security.

    I know it is easy to poke holes in ideals, I applaud the effort and I wish your ideas would work, because the health care system is going to implode. But if we first fixed the root problem of government accountability, then your solutions would work. Because yes I believe “access to quality healthcare has become a constitutional right”.

    Brian wrote on August 1st, 2007
  2. Nothing modest about this. Needs to be forwarded to all Presidential Candidates and President Bush.

    I am contemplating a full response.

    Oxybeles wrote on August 1st, 2007
  3. Thanks, Brian. That’s partly why I titled it “A Modest Proposal.” I agree that the likelihood of this ever happening is slim to none, but I wanted to fantasize and use an outrageous outline to underscore failings of the current system. I think the biggest glitch is the “government accountability” gap. That’s what’s missing in all our most heavily-funded programs. Second biggest is probably the lack of personal responsiblity that continues to permeate our society.

    Mark wrote on August 1st, 2007
  4. And how about some sort of reduction in the co-pay for those who maintain a healthy weight/BMI. It’d be hard to prove whether or not you exercise (my neighbor is very thin but she doesn’t exercise beyond chasing after her kids, much like me) but it’d be great if you could also “reward” good exercise and eating habits. That way those with the problems like smoking related illnesses and weight related illnesses would pay more of the burden for treatments of those diseases.

    I’m with Brian too, on the government not having a stellar record with running anything (I’m a military wife so I get to deal with that directly). But it is nice to dream of a government that isn’t driven by money. A goverment by the people, for the peoplr, oh wait! I think someone had that idea once. Too bar we’ve gone so far from that! Politicians shouldn’t be able to make extra money because of their jobs. I think public defender pay and no kick backs is a good idea!

    Nancy S wrote on August 1st, 2007
  5. Nancy, I love that idea! Your car insurance give a discount if you’re female, student, no cell phone, safe driver, etc. Why not do the same and reward those who are fit and lean? I agree it would be hard to prove, but certainly a gym membership or a few grocery receipts proving smart food choices could be ways to offer proof.

    I’m pretty sure the founding fathers would faint if they saw our system today. They wouldn’t even recognize it. Ben was against commerce, Madison surely would have been against lobbies and special interests, and Jefferson warned against a two party system. But what did they know?

    Sara wrote on August 1st, 2007
  6. Nancy, I like your idea of the discount, but we can’t be using BMI… if they did I’d be scr — uhmm — “out of luck”. My BMI is 30.5 — AHH! I’m obese, but wait my last hydrostatic test said I was at 14% body fat???

    I only gripe because my life insurance was using BMI and I had to get a physical and a visit from their nurse before they would give me a better “Healthy” rate…

    Brian wrote on August 1st, 2007
  7. The New Zealand health system is largely based around the proposal that you have outlined. It is far from perfect but anyone who needs healthcare is entitled and receives it. I don’t know of hand the per capita spend but I understand it is about one third of the US spend. All prescription drugs are purchased by a government agency at negotiated prices from drug companies who submit tenders. We have an Accident Compensation Corporation that workers and employers subscribe to. This pays the cost of treating accident victims and provides lump sum compensation for various injuries. It is based on a “no fault, no blame” principal and there is no litigation possible for accident compensation. This is a fair system that cuts out expensive unnecessary litigation. It isn’t perfect but I think is better than the US system

    John wrote on August 1st, 2007
  8. There’s also a shortage of Registered Nurses. Many work overtime and swing shifts and some even on call, esp. if a nurse works in surgery.

    Donna wrote on August 1st, 2007
  9. I belong to that large group of people w/o health insurance. I am not working right now and my husband was layed off a couple years ago. We had private insurance for awhile which is outrageous $$. Later I was denied any insurance….they looked into my history and found out I had thyroid surgery. They called me on the phone and rudely told me I was unhealthy. Sorry, no brownie points for living a healthy lifestyle. I like your proposal, Mark. I have found that I get better care when the doctor knows up front I am paying cash. Sometimes, you don’t have to wait for weeks for an appt. if they know the patient is paying cash. You usually get a pretty good discount as well. I have a friend who is a doctor. He said, between the insurance co., drug co., and hospital regulators, he can’t practice medicine. The insurance co. truely tell the doctors what to do, even if it’s against his best judgement. Everyone should have medical care. That would be great for broken bones, stitches, etc. but I am afraid I’d still be paying out of pocket for quality health care. I just spent 2 hours talking to a doctor(MD.) in his office. The meeting was between him and I only. How refreshing.

    Crystal wrote on August 1st, 2007
  10. Brian, don’t know much about BMI, just knew it was some sort of “standard” being used. I don’t even know what mine is. But I’m fine with using a different measure. I think so much of what people think of as “healthy” has to change.

    Nancy S wrote on August 1st, 2007
  11. I don’t agree with much of your positions, so that as background, but particularly #2 and #6 are not consistent. We need more doctors, so we institute a system paying doctors almost no money (compared to their equally educated peers) and imposing an onerous 8 year servitude to the government?

    RM wrote on August 1st, 2007
  12. That’s a heck of an article. While some I agree with, and some I don’t…I respect that you wrote it all out, and gave so much thought to it. What we do know is it’s time to fix the problem…..and we need to start looking at preventative health instead of waiting until people are broken.

    Deb wrote on August 1st, 2007
  13. After much thought and consideration, I offer my $.02 worth:

    1. While one can argue that the US Constitution guarantees certain inalienable rights, i.e., Life, Liberty and the Pursuit of Happiness; it does not specify the quality of the life. Hence, free medical coverage appears to be a stretch.

    2. To establish a Government bureaucracy for medical care both administratively for coverage, let alone as a quasi-employer of thousands of medical professionals would be costly and inefficient. While a military is needed, one successful example is the US Post Office. It has only taken over 200 years to get it close to right and I am not sure if I want to hear about some irate physician “Going Doctor.”

    3. The establishment of a two-tier medical system for the Have’s and Have-not’s could violate the Equal Protection Provision of the 14th Amendment.

    4. Clearly, prevention is the paramount issue, but Government attempts to regulate morality and habits have not been an overriding success. As recently as 19 July indicated that anti smoking ads directed toward Middle School Children had the opposite effect. http://www.ajc.com/metro/content/news/stories/2007/07/19/smoking_0720.html

    Unfortunately, bigger government is not the solution. If the system is to be replaced, the replacement must come from the private sector. The internet provides a communications cornucopia of educational possibilities. New technologies, such as podcasting, also provide an avenue of enjanced communication.

    As always, education at an early is age is best from the parents. Hence, the young can be educated. Draconian measures by some employers are being adopted charging additional premiums for Health Insurance to those that are over-weight or smokers. Is the stick approach the solution?

    I would favor Medical vouchers with a tax credit for lower income, uninsured citizens, not illegal aliens, as well as Tax Breaks for the Medical Insurance companies that enroll these participants. Furthermore, a feedback form, included with the 1040 would rate the Health Insurance Companies and HMOs and the rating would contribute to the percentage of the tax break.

    Keeping it surreal!

    Oxybeles wrote on August 2nd, 2007
  14. Not sure that emulating the two tier retirement savings program we have is all that good of an idea. Let’s see, we have the private tier, 401ks, and everyone seems happy with that. Then the public tier, social security, which creates unending complaint and is likely to send this country into bankruptcy since it was designed for a faster growing, quicker to die population.

    Also, you cannot say the free market system has been tried and failed. There is nothing free market about the current system. There are so many government regulations that barriers to entry to all parts of the industry (becoming a doctor, designing new medicines, starting a new insurance company, etc.) that it is nowhere close to a free market. We do know one thing…. Medicare and other medical entitlements create all the wrong incentives, and always cost magnitudes more than they were initially estimated to cost.

    So please, feel free to argue against a pure free market system, but since none exist, it’s hard to say how it would work out. We do know that socialized medicine has a lot of issues. I sure as heck don’t want to live in a Scandinavian country where they have socialized medicine and ridiculous tax rates and one-time fees that get paid over and over again.

    Ben wrote on August 2nd, 2007
  15. Oh yeah, and don’t forget that every single other country in the world gets a HUGE discount on medical care because pharmas in the United States spend billions creating the drugs that the rest of the world then uses without having to worry about development costs. And a new drug, partially due to the influence of existing government regulation, costs billions and billions of dollars to design and walk through the over-onerous and mis-aimed FDA testing.

    Ben wrote on August 2nd, 2007
  16. Ben et al., all good points. I think the one that resonates most with me is “barriers to entry.” If we had an FDA that worked properly and we could train docs quicker (much quicker and for much less money), a free market system would drive prices down. It would be interesting to observe. But at some point, we will always have a large number of people who can’t afford medical care at any price and the question will be “who pays for them?”. I am no fan of a welfare state – I think everyone should have to earn some sort of keep – but as I said, I now feel as if access to some form of healthcare is a right.

    Mark wrote on August 2nd, 2007
  17. On another note – the BMI thing. I am 5’10” and 165 pounds and 8% body fat. My wife thinks I should gain a few more pounds. Oddly enough, if I gained 10 pounds I would drift across the BMI line into the land of “overweight” – even if it was all muscle!!

    Mark wrote on August 2nd, 2007
  18. Your proposal reads nice on the surface but manifests many serious flaws.

    One of the largest problems is the degree to which you discount the knowledge and training of doctors and FNPs. While many functions currently performed by MDs could be broken out into other vocations, many couldn’t or shouldn’t.

    Another major problem is that the majority of the specifics of your program must be determined by committee. History has shown us that that government committees are usually tainted by private interests and crippled by cost structures. Given the huge amount of capital infrastructure associated with hospitals, there is a severe risk of turning them like public utilities or public schools.

    One beneficial element of a private hospital is that they rarely turn into slums like county hospitals. Once they start to lose money, they are sold to new owners and revamped.

    Your plan, while containing some intuitive sounding elements doesn’t demonstrate any sound evidence or research. When the Tennessee state government implemented “Hillary’s” enriched medicaid plan in the form of an enhanced Managed Care style Title XIX charter, it not only bankrupted the state, but it brought healthcare standards to unthinkable lows, and ended up causing millions lower income families, formerly ensured through their employers,to become unensured. That plan also seemed quite intuitive.

    The nature of legislative compromise and oversight will invariably corrupt any system. The only one hope for revamping the healthcare system… a federal healthcare board, completely independemt from the other branches of government with broad powers. This board should follow the model of the federal reserve board, internally nominating and approving members autonomously. It should initially be appointed by a special independent council or healthcare czar nominated by congress, and approved by a wide body of interested advocate groups (AMA, Consumer Groups, Medical University Boards, etc.)

    It should be the primary duty of this independent body to investigate problems in healthcare, and create and enforce healthcare ordinances that perform 2 functions: increasing access to healthcare and increasing quality of healthcare.

    And when the whole country screams uncle because they are resistant to change, there will be no worth blaming, and no one to impeach.

    Needs Work wrote on August 2nd, 2007
  19. It’ll be interesting to see how Massachusetts’ system goes.

    Sara wrote on August 2nd, 2007
  20. Realize that the ‘free market’ is a theoretical construct, which has never been seen in the wild.
    Health care in particular cannot ever reach even a first approximation of a free market, since the supply and demand curves are not simply determined by price.

    Free markets in their pure theoretical Platonic form produce efficiency, not equity. It’s necessary to remind the free marketeers that we live in a society, not just an economy. It may be efficient to let poor children die for want of medical care, but it’s not usually considered rational or humane.

    For experiments with free markets in healthcare, see for example Medicare Plus:
    http://www.washingtonmonthly.com/archives/individual/2007_05/011257.php
    That isn’t working out very well..

    Drugs cost a lot because drug companies like big profits. It’s certainly not R&D that causes these costs, as can be verified by inspecting the SEC filings of any pharma company. R&D spending is a small fraction of profits, and an ever smaller fraction of marketing expenses. Most new drugs come from taxpayer-funded research at universities or NIH, not drug companies. See:
    http://www.nybooks.com/articles/17244

    Every other First World country spends far less for far better health care than the US. For details, I’d recommend the series from Ezra Klein,
    http://ezraklein.typepad.com/blog/health_of_nations/index.html

    Doug wrote on August 3rd, 2007
  21. Much of what you say is worth attention — in fact lots of it is out there already. Couple of things: first, doctors don’t “charge” any more. What they get is decided by insurers and governments. There are virtually no doctors nowadays that decide what to charge, charge it, and get it. I can say my fee for, say, a colon resection is any number I want to pull out of the air. What I get is exactly what the insurer pays, no more, no less. And, in general, it’s considerably less than what’s written down somewhere as my fee.

    Another: it’s true that detail reps show doctors lots of techniques. However the reason they can pick it up from someone like that is that they are already well-grounded in skill they’ve been taught and acquired over a lot of time. It’s definitely true that robotics, computer models, etc, are eliminating much of the need for using humans to learn on. And that’s good. It’s not true, however, that those skill get learned after a couple of hours at a console. And, there’s a lot to learn. The fact is that with the limited hours of training in the last few years, many people are coming out of training programs much less experienced and skilled than in earlier times. It may be true that if you subdivide everything enough, you can train what would amount to technitians to do things. A thyroid operation. A gallbladder. But unless you want to lug all your parts to hundreds of different specialists (what happened to the cry a return to the family doc who knows you and cares for the whole package?), with each “doctor” knowing only a few things about a few things, fragmenting care and leading to even more of the communication issues we see nowadays, I think your plan sort of falls down. Who knows? My plan, seeing what’s going on in health care and the training nowadays, is to never get sick. I’ll follow your lead on that.

    Sid Schwab wrote on August 3rd, 2007
  22. My Husband Is 5’10”,So Am I, He Weighs 162 lbs. And I Don’t! He’s A 33 Waist. My Opinion-I’m always encouraging him not to gain not a pound.
    He does agree. 9 years ago i taught him to eat right, exercise, and he lost 60 pounds in one year. I told him to lose weight over a period of time, slowly, not fast.

    Donna wrote on August 3rd, 2007
  23. Mark,

    You titled your piece A Modest Proposal. Well here’s my modest proposal:

    One out of six babies is born with a birth defect. This includes everything from slight hearing loss, to severe brain damage.

    One out of 6 babies adds up to roughly 150 million people living today with genetic defects. These people are the ones most likely to tax the health care system with the largest hospital bills and they are also the most likely to produce offspring with birth defects.

    I modestly propose we recycle the 17% of babies born with genetic defects. We will perform En Utero tests during a mother’s third trimester to determine if her baby will be recycled. Then upon delivery, we will utilize the recyclable baby for one of several purposes.

    The largest portion of birth defect babies will be used for human consumption. The waistline of average John American is expanding every year due to poor dietary standards. Regimenting baby (a great source of protein, calcium, and baby fat) into the American diet will likely be the initial spark necessary to convince Americans there is a healthier way to eat. Furthermore, the source of food will have been clearly documented from conception, so there is no chance of unwanted artificial additives, or poor food quality due to unknown conditions from foreign food processing plants.

    The rest of the babies would be used for research experiments vital to improving the health and welfare of the rest of the nation. Much time and money has been lost because research is being carried out on innocent mice, which in very few ways resemble the physical human condition. Testing drugs on humans simply leads to more possibilities of finding cures.

    There are also beneficial side effects to this proposal. The recycling of birth defect babies will truncate the number of lobbyists and pharmaceutical company executives as it has been well documented that these people aren’t entirely human. Thus, lobbyists will be recycled before reaching lobbying maturity. In this same way, the baby recycling process might also rid us of a large percentage of the population who would grow up to become people who feel it necessary to ask their doctor about a drug because they saw a commercial with gorgeous people running through fields.

    In conclusion, the recycling of defect babies will increase the standard of American health, reduce the number of harmful lobbyists, and eliminate the possibility of future generations of babies born with birth defects. A modest proposal; and a very decent proposal.

    McFly wrote on August 6th, 2007
    • I think I just threw up in my mouth.

      CKB wrote on August 29th, 2009
    • I suggest that we “Swiftly” implement this proposal

      dot wrote on June 24th, 2011
  24. Your health proposal sounds like a winner, something has to be done. Americas toxic food supply is making our children obese and causing all sorts of illnesses also. 2 years ago I took charge of my own health. I took on the paleo lifestyle, started exercising and using supplements. I lost 70 lbs. and feel 20 years younger and have lots of energy. I am now off all my medications. Proloftin lowered my blood pressure. Thank you Mark for doing a public service to us all. Shirley

    Shirley wrote on August 14th, 2007
  25. I like how everyone loves the ‘government pays for everything’ health care solution. Here’s my, everyone hates idea: Everyone PAYS for the care they get! Wow, you want time with your doctor, pay for the time and I bet you’ll get it. Free market health care. No health insurance. Everything will become a lot more affordable this way.

    Dr.J wrote on September 21st, 2007
  26. I recently read a free online book that has some good ideas on this and other economic matters. The books is called “The Conservative Nanny State” at http://www.conservativenannystate.com . Despite its name, I think it would be good for any concerned citizen to read. The author is an economist who has exposed how much of the economy in America is set up to benefit the few at the expense of the many, and that Republican, pro-business policies are anything but being “free market.” Note: I’m not in any way affiliated with the web site or the writer, and it can be read online for free.

    One of the best ways to would be to lower costs by doing away with patents on drugs and medical devices. It’s extremely inexpensive to make synthetic chemicals. With the current for-profit system, a drug costing hundreds of dollars a month may have only cost a few cents per pill to actually make. The costs would probably be even lower than generic drugs today since companies manufacturing them would compete with each other over any and all drugs. There would have to be an alternative funding program obviously such as the government rewarding researchers directly who discover life-saving drugs. Maybe we need to reform medical research and “Big Pharma” along with how patients get and pay for healthcare (which is what the discussion is all too often only about).

    mark wrote on October 29th, 2007
  27. Beautifully written. I love works that are written in this way to get a point across. I was extremely drawn in and feel very informed about the topic. After reading Swift’s A Modest Proposal, I began trying to write some too. I want to start a blog and would be honored if you would read what I have and let me know what you think. http://mymodestproposal.blogspot.com

    Thanks again for the great content. I plan on joining your readers list!

    USCBlogger wrote on March 5th, 2008
  28. Now.. I’m a tad bit dissapointed you NEVER gave mention to the effect of the nursing shortage on healthcare.
    hhmmm..

    Strong One wrote on June 29th, 2008
  29. I’d like to urge caution about accepting at face value the studies that claim that the US health system ranks 37th in the world.

    There are some serious methodological problems, as discussed here:

    http://www.westandfirm.org/blog/2007/08/misleading-rankings.html

    For a more detailed discussion of problems with “universal health care” as well as some viable free market alternatives, see:

    “Moral Health Care vs. ‘Universal Health Care'”

    http://www.theobjectivestandard.com/issues/2007-winter/moral-vs-universal-health-care.asp

    Paul Hsieh, MD
    Co-founder, Freedom and Individual Rights in Medicine (FIRM)
    http://www.WeStandFIRM.org

    Paul Hsieh wrote on November 5th, 2008
  30. Good article and several good posts picking at the particulars. I have been involved in cancer research, medical education and the drug industry for the past 11 years. The following summation is based upon that knowledge and is organized based on the fields mentioned in the article.

    1-(Patient Responsibility): Yes, patients do need to do their homework and there is evidence to support this theory. In my experience Americans are the most educated/informed and vocal in the world. This trend causes practices/doctors to be well educated and order additional tests thus increasing expenditures.

    2-(Not enough Docs): True, but you can blame the AMA and Congress for not approving/funding the construction of new medical schools, fellowships, ect. Additionally, the AMA heavily influences lawmakers to keep low levels of graduates so that current HCPs can see all those pts out there.

    3-(Insurance Co and RB): True, nothing to say it is a flawed system; FYI, our government spends more of its tax revenue supporting our semi-private healthcare system then western european countries do.

    4-(Changing Habits): N/A, Americans will eat and drink as they choose, however, there should monetary personal costs associated with living a poor lifestyle, which is ofcourse outside of environmental issues.

    5-(Pharma): True, yes this is how patients are seen. The Pharma industry needs to be more tightly controlled by the FDA so that fewer Me-To drugs are developed and Americans can pay the same price for RX as the rest of the world. Currently Americans pay nearly 50% more for the same drug.

    6A-(Lawsuits): N/A, the author’s opinion I find to be wanting, however, America should adopt the malpractice related legal protocols of Britain wherein, a plaintiff has to pay all the defendants costs if the outcome is for the defendant. This would cause most ambulance-chasers to really think about which cases they will pursue.

    6B-(Federally Managed Health-System): N/A, I am a proponent of the German Healthcare system wherein it is a right that all citizens are granted healthcare, however, there are many options (in Germany there are over 500) nearly all of which are privately operated. It is true that the federal government does nearly nothing correct.

    In conclusion is healthcare insurance a Constitutional Right? Yes; Life, Liberty and the Pursuit of Happiness –> Without decent health those three mean nothing; therefore it is necessary pre-condition.

    Jon R wrote on December 3rd, 2008
  31. This is a fantasic post! I agree with about 90% of what was said. As a future doc, I am a little scared myself, but have to assume that change is coming. This, or free market, is THE way to go.

    Tara wrote on January 24th, 2009
  32. Are you suffering from benign prostate hypertrophy? Then don’t worry because Avodart has brought for you a complete solution for this. With the use of this you can heal your enlarged prostate problem.

    プロペシア wrote on May 18th, 2009
  33. You make vaild points. I even agree with many of them. I do take exception with some however.

    1)Shorter Training times for doctors. I feel you are wrong here. One of my attendings once said that he could teach a monkey to do surgery. This is true. The problem is not the mechanics but everything leading up to and after the surgery.
    Sure I could order an MRI and determine that a tendon is ruptured, but what then… Which of the numerous procedures would be most appropriate for that patient. Following the surgery an infection develops (accepted rate in orthopedic surgery is 1%). Which antibiotic should you use. Should you go back to the OR and do an incission and drainage? These are just a few of the questions that can and often do arise. Only doctors who have seen these complications in the course of a rigorous residency training program will be able to handle them properly.
    You do see providers such as Nurse Practicioners and Physician Assistants who have generally shorter courses of training who do an excellent job, most of the time. But its when the you know what hits the fan that you want a doc who has seen it all and is comfortable with his skills.
    2) You mentioned a system where people were discouraged from elective surgeries. This sounds nice on paper. “Great no more of those silly elective surgeries to gobble up our healthcare dollars”. But when it is you who has chronic and unrelenting pain from a severly arthritic ankle, or hip you may feel differently. I could easily envision a scenario where the “single payer” doesn’t outright say no but rather strings the process along so long that people live with crippling pain. I’m not even saying this is wrong per se. At the end of the day you only have so much money to go around. But I gaurantee that those who have mone will have that bad ankle or hip fixed. They may pay out of pocket, but it will still be done. In a way this almost seems worse to me. I have a friend who practices in Spain he told me that in the morning he sees his state sponsered health care patients and in the afternoon the self pay or private insurance patients. Wait to be seen in the AM 6 months, wait for the PM 6 days. Oh and if you live in England dont bother getting Renal Failure after age 60. The nationalized health insurance doesn’t pay for Kidney dialyisis for the old or infirm. (in other words you die) This might sound ok on paper, and ultimately that is what you have to do if you only have so much money, but when it is your mother, father, brother, wife you may feel differently.

    In conclusion I dont know the right answer. The path we are on isn’t great but proposed plans dont inspire much confidence in me either. HMO’s and managed care were supposed to reign in health care in the 80’s and 90’s but worked too good. Doctor’s didn’t want to participate anymore and people didn’t want to either. I fear a state sponsered system wont do any better.

    Dr. Hamilton wrote on June 5th, 2009
  34. I would end with a word of caution…

    “A government big enough to give you everything you want
    Is a government big enough to take away everything you have.”

    Gerald Ford

    Dr. Hamilton wrote on June 5th, 2009
  35. Go to Europe and try out the socialized health care there and come back and tell us about it. I’ve been and my relatives have been and we had to utilize it. Not something I would want to experience again. Health care is a right, free health care is not. People have no right to demand that professionals give them services for free. And if people want to stay out of doctor’s offices, then maybe they should take better care of themselves. And funny how those same people always manage to have money for a cell phone, television, computer, hair appointment, new car, make-up, new clothes, whatever but health care seems to be at the bottom of the need to have list. Besides tort reform is what we really need, not socialized health care. Bigger government is never the answer to any problem.

    Suzanne wrote on September 19th, 2009
  36. Being from the UK, I have always lived in a place where healthcare was “free”, in as much as you didn’t need to pay an insurer to cover you should you need treatment. As a result, it seems alien to me and others here that people would be against their government providing this facility. As a talk show host over here recently commented “Only in America can a President say he is going to make healthcare accessible to all… and then watch his popularity scores plummet”.

    Here we do sort of have a two-tiered approach. Everybody has access to the NHS(National Health Service)and, if you want to pay extra to someone like BUPA, you can opt to have private cover… the main benefits of which are that you can leapfrog waiting lists and private clinics are nicer to look at (the surgeon you see will do private and NHS work so quality of care is no different, although you will probably be treated to a one-bed room).

    Everybody who works in the UK obviously pays PAYE tax which (in addition to council tax, VAT and various stealth taxes) covers the stuff that tax generally covers (plus our politicians ridiculous expense claims). We also pay National Insurance at a fixed percentage of gross income on a monthly basis which covers the NHS.
    So, it’s not really free – I pay around £250 a month towards it currently. If it made people feel better, we could privatise the NHS and we could all pay that £115 to a non-government body… but the problem then is that people would get blase about it, stop paying and then be up a creek when they fell over or developed cancer.
    My view is that by having it as a government body which we basically pay another, separate tax on, we are protected from ourselves (the human tendency to say “it’ll never happen to me” and therefore try to save a few quid by not paying).
    People who are out of work get their NI paid by their dole money – I do however, think that the scum in this country who are long-term dole-ites (by which I mean the lazy sods who won’t work, not those who can’t due to medical/mental problems or caring responsibilities) shouldn’t have access to the “free” service for anything other than emergency treatment.
    As I said, growing up in a place where this has always been the case (under 18’s go free by the way), it seems strange to me that people do not want their governments to provide this safety net. I remember watching the movie John Q a few years back and, not knowing any health system other than ours, I could hardly believe the predicament they were in. I have always seen the US as a bit of a trail-blazer and the ultimate modern country but on this issue it seemed miles behind! As I said earlier, this is by no means meant as offence – just the view of an outsider looking in. Our NHS is by no means perfect (it’s always being bitched about over here) but when there is an emergency you can not knock it.
    Incidentally, our healthcare workers (surgeons through to nurses) have their training paid for by the NHS and work for the NHS on qualification for a set period of time before making the decision to go private, stay as they are or combine the two. A lot of private clinics have an NHS contract where they commit to seeing a certain amount of “free” cases (which they are paid to do by the NHS, which is paid for by us, through the NI).
    A couple of people above made the comment that you should not expect professionals to give their time and skills away for free which I agree with to an extent… but I have always felt that if someone was embarking on a career in healthcare, then you’d like to think they didn’t have money as their primary motivation. Everyone deserves to be compensated for their time/services but if the system Obama is proposing is anything like ours, they will be!

    Welshcaveman wrote on September 20th, 2009
  37. There are several issues with your post. One, the United States is not the U.K. I doubt you can get Americans to pay 70 – 90 percent or more in taxes. Two, Health care is a profession that many, especially physicians pay exorbitant amounts out of pocket to become qualified for. An MD can spend anywhere from $300,00 to a million for a good education, and then then malpractice will eat up a good chunck of your yearly salary after that (over $100,000 a year). You also have to take into consideration that they spend anywhere from 6-12 years on their education so the time investment is considerable as well. My brother is a physician. He spend 8 years in school, then residency and paid $600,000 for his education. He is now paying over $100,00 a year for malpractice insurance in private practice. It is ludicrous for anyone to feel that a person who invests so heavily of his personal time and finances receive little to no compensation by way of their efforts. As it is qualified doctors are becoming harder to find. I would only expect to see fewer and fewer qualified doctors if they were expected to work even more for less. Simple math. And frankly, to expect any professional to be completely selfless is well, selfish. Do you also expect plumbers to work for free out of love of their profession and dedication to providing service to the public? I don’t see Obama shying away from his yearly salary even though he is independently wealthy and should as a generous human being be grateful just for the opportunity to be of service to his country. I see how that works, let health care professional be selfless in their pursuit while everyone else receives whatever their profession can generate. On top of all this, the free health care is not free, it will cost tax payers about $2500 a year to receive substandard service which most who have any means will opt out of and be forced to pay another 3-600.00 a month for adequate health care. You will pay more than what you pay now for the same care. I was in Dublin Ireland two years ago and experienced socialized health care first hand. We were taken to emergency when I injured my eye. We waited for 5 hours to get in to see a physician. The facility was incredibly depressing and run down and the staff was disorganized and rude. I still shudder when I recall the experience. And I know that wait periods for operations can be as long as two years. Socialized health care costs in many ways. It is hardly a bargain or a good option when you really do the math and take the consequences into consideration.

    Bigger government mean more legislation. If the government had it’s way, supplements would only be administered through a physician, and no preventative health care would even be allowed (Chiropractors fought for years to get what small amount of coverage they receive now). I doubt we would have access to Mark’s supplements either. These are only accessible because of persons like myself who actively fight against government regulation and control of natural health care. As it is now, the real cancer clinics who offer real cures are forced to operate outside our borders in Mexico. The problem with quality health care in this country has always been the limited access to it, not the cost of it. It’s not the government waging campaigns to get and keep raw milk on the selves. The longest living people on the planet live in villages with virtually no health care or health care facilities. Good health is all about taking responsibility for one’s own health. Medicine, socialized or not, should not be the solution to our health woes. Sorry for any errors as I typed this up quickly.

    Suzanne wrote on September 20th, 2009
  38. yeah,You also have to take into consideration that they spend anywhere from 6-12 years on their education so the time investment is considerable as well.

    tax marketing and operations coaching wrote on November 21st, 2009
  39. Mark, I sympathize with you greatly. I see the problems with the our health care system…but you are mistaken. Just as you constantly criticize CW in relation to primal living, I must criticize the type of CW that you have shared in this article. As a bit of an economists, I suggest looking at the source of a problem before attempting to fix it.

    Why are patients irresponsible? Because they either have government health insurance or they have insurance that is very highly regulated by government. People pay for less than a fifth of their healthcare out of their pocket. Consider the implications of this. Remember that the corporate stranglehold over insurance is only possible because of lobbying. You yourself just said,
    “It’s not often you’ll hear me suggest that government could do a better job than for-profit industry, but there are so many players in the current healthcare system that require a profit at the expense of the sick – and who have so shamelessly lobbied Congress to allow them to continue this charade – that the concept of “free-market forces” left the building with Elvis decades ago.”
    Can you not see that your problem is not freely acting individuals, but the vehicle of the state? You have identified the source of the problem: Congress and its capacity for being lobbied.

    Why are there not enough doctors? Because the AMA was founded for the specific purpose of controlling/reducing the supply of doctors to guarantee higher incomes. They were only able to do this, surprise, through the vehicle of the state. I am not saying we should get rid of the AMA. But I am saying (as you point out) that there are plenty of smart premeds who could do better than spend 20yrs in school. Get rid of the legal power of the AMA and there will be (as there were before) a greater variety of training for medical professionals.

    Why won’t people change their habits? Because they aren’t responsible. The corporate/state control of healthcare ensures that individuals have little reason for making those good choices (and the undue corporate power comes from its use of the state).

    What’s the problem with drugs? Intellectual property is artificial scarcity. A tangible thing is scarce because by some using it, others are precluded from using it. A system of property rights is the natural response to dealing with the issue of scarcity. In no way do designs (for drugs or anything else) fit this criterion. Thus Big Pharma owes its power to patents, which only exist through the vehicle of the state. Moreover, the FDA is terrible at regulating. It is its nature to approve/not pull drugs like Vioxx (Tylenol, statins, …the list of bad drugs goes on forever), while denying people access to experimental drugs (e.g. a cancer patient who is dying anyway) or other drugs that would anger those who lobby/pad the wallets of FDA people by hurting their profits(e.g. cocaine, MDMA, marijuana, etc.).

    I can go on about this. You really would do better to continue trusting your less than pro-government gut on the issue of health care. If you’re interested, I will email you a paper I’ve just written on how to fix healthcare. I also have knowledge of an enormous variety of sources on many specific things related to healthcare (essentially any question you can pose).

    ChaseW wrote on December 26th, 2009
  40. Just my 2 cents – as a teacher, I find it offensive that it is okay that we work for lower-than-average salaries, compared to others with similar qualifications, but no one cares about that! Doctors can’t get reasonable salaries, but we can underpay the people who provide education to our children?
    Maybe we should fix the socialized systems already in place before trying to add another one. I agree that health care should be socialized, but I think this government has a LONG way to go before it can handle it. Our children are undereducated when they leave public schools, our teachers are underpaid, and I personally don’t want a health care system that is based on similar inefficiency.
    As for all those talking about “6-12 years of education, they should be paid for it” – they should be. If health care was socialized, I think a great idea would be to put any loans on deferral until the completion of a certain term of public service, and the *bam* no more loans. Also, the cost of malpractice insurance would be gone, since the government would be responsible. Doctors would take home what they make, since the gov would pay for the supplies, building, employees, and so on. It really isn’t that bad of a deal.
    Just another point of view. Personally, I wish teachers had such strong advocates as all of you are for doctors. Maybe then we could attract the kind of teacher that would be effective for our children.

    lady_daraine wrote on January 12th, 2010
    • Teachers only work 25 – 35 hours a week and they don’t even work all year long. They are PART TIME workers, and for a part time job, teaching pays pretty dang well.

      When the teachers in my high school went on strike, the only teachers who showed up for work were from china/japan.

      We all asked why they didn’t strike for higher wages too, and they told us that in their countries teaching is a full time job, and that its ridiculous to get paid more for doing way less work. If you need more money, tutor kids or get a second job during the summer.

      On average school teachers in the US are paid $34 an hour, which is comparable to other white collar workers.

      I’m sorry but teachers in the US are not underpaid.

      Lola wrote on August 21st, 2010
      • You are grossly mistaken about how much teachers work. Generally their day begins at 7, and ends at 4. If they have to do after school activities, that can be until 6-7. So just right there is between 9 and 12 hours per day. Then they come home, grade papers, write lesson plans, and continue to have to work. Anyone who thinks teaching is just like any “9-5″ job has no idea what they’re talking about.

        Tim wrote on January 25th, 2012

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