Healthcare Options for the Elderly

by: William Deskin, Ph.D., and Robert E. Hoye, Ph.D., Faculty, Walden University

As published in the American Academy of Medical Administrators, EXECUTIVE, May/June 2010

The health care policy discussions continue across the country, many asking what we should do with the elderly. There isn’t enough health care to go around, it is said, and we can’t sustain what we’re doing – spending lots of money and not getting the return we’d anticipated. We’ve got to figure out who’s spending the most money, it would seem, and tell them to stop it. The question seems to be what to do with grandpa and grandma. As grandpa’s, this is quite disconcerting. There are many unanswered questions regarding health care for the elderly including who should be covered, for how long they should be covered, for what kinds of illnesses, who should pay for these services, and on what basis should decisions regarding their care be made. Some might question whether the decision should be made on some random or arbitrary basis or should some ethical base be used to help assure a modicum of fairness or equity. Others might question whether fairness is possible with scarce resources, or whether equity applies, or could be applied. While a discussion regarding the elderly may center on the most elderly, the old-old over 85 years of age, policy decisions seem to start around the age of graduating to Medicare with the young–old at 65 years of age.
Some would suggest that the idea of aging is an antiquated idea itself, that the scientific and biotechnological era heralds a new age of defeating chronic pain, illness, and aging as it moves forward (Mykytyn, 2006). With this perspective the emphasis is not on rationing, rather it is on eliminating chronic conditions and reducing the time a person is aged. There are those who disagree. They suggest that a certain amount of illness, wear and tear on the body and mind, goes along with the process of aging; that “the price we pay for long life is debility” (Lachs, 2004, p. 176). Within this last idea is a suggestion that many [perhaps all?] of us both earn and wear our debilities through aging as mementos of an earlier age and afflictions.
The aging or aged body is different from the young or youthful body and the health care resources needed to sustain/maintain it are also different. A natural law perspective suggests that after using our bodies for a prolonged period, the elderly should be required to relinquish any remaining or retained youthfulness (Post, 2004), and with that relinquishing, prepare themselves for a so-called natural end; without prolonging the aging process or altering it. Viewed from a different vantage, others suggest that human nature is an obstacle to be overcome (Hook, C.C. as cited in Post, 2004, p. 535) and that nature is what is unnatural in considering the elderly. What was natural in 1900 is markedly different than 2000. We had less sanitation, no antibiotics, pasteurization, we died earlier, and that was natural.
Much of the discussion regarding scarce resources in health care focuses on how to allocate those resources. After all, “in 2006, the median annual health care expenditure for persons age 65 and over was $4,032,with about one-quarter of the elderly having no expenses or expenses under $1,752 (25th percentile) and one-quarter having expenses over $9,289 (75th percentile) (Machlin, 2009). Maybe all that we need to do to save money is find those in the 75th percentile and tell them to stop being sick! Or stop them from using scarce resources.
Recognizing that nothing is free, “costless benefits are not only unattainable, [but that is] a misleading ideal (Lachs, 2004, p. 175), we also recognize that age is not simply about health, we must have usefulness as well or it becomes empty. Usefulness does not necessarily mean productivity. We can mechanize the process of determining who gets what health care by calculating quality-adjusted life years (QALYs) and comparing perfect health and then reducing debilities to arrive at a score. Comparing QALYs against perfect health (Persad, Wertheimer & Emanual, 2009, p. 427) is inherently ageist. To do the calculation requires value judgment at the beginning and value cannot adequately be determined from outside the individual dispassionately or without bias. So how do we decide about how much we’ll allow for the elderly, call it what it really is - rationing or limiting health care to the elderly – if there is an unequal allocation based on something other than illness or disease. Rationing can occur by allowing payment for certain medical procedures based on age or disallowing them using the same rationale.
Another method of calculation is to view the person, and whatever their illness or debility, and to make a determination of how long they might live, considering all that. If they have less than a certain number of years, they aren’t allowed more than palliative care. Or, in an actuarially determined mode, an elderly person could be given an average determination of expected longevity based on their prognosis and after their cohort average has been attained, no additional health care would be given. This method might even parallel the quality adjusted life years mode. Do we really want to give determination for health care services to the accountants?
A variation might be to provide health care only to those who could benefit, that is, extend their actuarially determined life span by treatment. If one has a genetic predisposition to be sicker than the actuarial tables might suggest or recommend, they might receive services until they attain their cohort average and then services would stop. If one has the genetic predisposition to live less sick they would be allowed to continue without healthcare services because they wouldn’t be needed. After surpassing the average for their cohort, however, they would not be able to receive additional services. This method of deciding when to allow and when to withhold health care assumes that age, by itself, can determine the value of an individual – beyond a certain age point the value is not worth maintaining.
Others have put together combinations of ethical or allocation principles in order to suggest a “complete lives system” (Persad, Werthiemer & Emanuel, 2009, p. 428). This system, very well presented, also “produces a priority curve on which individuals aged between roughly 15 and 40 years get the most substantial change, whereas the youngest and oldest people get chances that are attenuated” (p. 428). Part of the argument is that those younger than 15 haven’t had enough “personal investment that people are morally entitled to have received at a particular age” (p. 428). This recommends, in part, that health care services should be less for the young and elderly – or in this case, those over 40 years old.
A fiscally responsible method of determining which elderly should receive health care might be based on the potential outcome. If risk of medical success is below a particular percent or probability, then care would be withheld. It is not in society’s interest to waste health care resources, and that top 25th percent are very expensive. But perhaps it is best to provide health care only to those who are the sickest and leave those who only have chronic illness alone, after all, natural law will take care of them in due time.
Perhaps one of the most easily determined methods to select who obtains health care’s scarce resources is simply to draw a line in the aging sand – beyond a particular age, no additional health care is provided. While it may seem harsh, it may have merit on the basis of equity. Since everyone is checked into Medicare at the same age, why not have everyone begin the process of checking out using the same logic. It might make for an uneven playing field if those with wealth could obtain care while those without couldn’t, much like inclusion in Medicare without a means test, but it’s an idea. Another method might be to allow those who have access to health care through insurance to obtain it, however, that also seems to favor the wealthy over the less wealthy and the employed or retired with benefits over those without. That seems to be without merit on the basis of equity. It also seems to be one of the main sources of discrimination that politicians seek to remedy at the moment. An alternative is to increase taxes for those that have in order to distribute them to those who have much less. A major issue down the road is when the haves and have not’s arrive at the same point.
What’s fair in the mix? There is health care rationing in the U.K. (Giordano, 2005) and a call for governmental rationing in Australia as well (Johnstone & Kanitsaki, 2009) and a feeling that without rationing that “public services will ultimately collapse under the strain of the ever increasing demands placed on these services” (p. 86). The discussion, it seems, may be mostly about how much a society wishes to pay for the health care services for their elderly, rather than whether it should feel obligated to do so. After all, some may say, the elderly are the ones to blame for the world’s ills anyway. While the percent of gross domestic product that health care represents is considered high, no central planning has determined how much, what percent, is appropriate to meet the needs of citizens, only that what we’re experiencing is too much. What to cover, what to pay for with collected taxes, has not been determined either. As single illness support groups have approached Congress, the elected representatives have repeatedly sought to include everything and everyone. Perhaps that is admirable. Indeed, discussions regarding health care seem to include non-citizens within the same moral stance. The EMTALA laws don’t allow an emergency room to turn away patients or to ask for their legal status before treatment. Fair, in that case, is certainly in the eyes of the beholder.
The so-called fair innings argument suggests that those who have lived beyond a particular point have a responsibility to those who haven’t yet lived equal innings to step aside; to assure that those younger have the opportunity to complete at least a minimum number of innings. This argument suggests that “the value of life can be measured in units of lifetime” (Harris, 2005, p. 95). It also assumes that each measure is the same for each person, that age is the only pertinent discriminating factor, more so than experience or education or genetic make-up, or relative success or failure or illness. To continue the metaphor, once someone has the bases loaded and has done well with their life, up to a point, we bring in a rookie because the rookie needs playing time. Whose game is it, anyway? What is a fair inning?
Normal is a word with various meanings that can be applied when ever advantageous for the sake of an argument. Here, the normal death for animals and plants can be used to suggest that there is a normal life span, and normal does not include extensions to that life span (Mykytyn, 2006). Life happens, death happens – it’s all normal. But is it considered normal to take beta-blockers and ace inhibitors, as an example, or is it a subversive act or implicit support for prolongevity? Certainly, many individuals would have died much earlier and with great health care savings had they not taken anti-aging pharmaceuticals or, perhaps, not acquiesced to by-pass surgeries and used so many resources. Is that prolongevity or is it bad social policy to consider it is anti-aging? There are those who suggest that if only we prevent chronic disease we save health care expenses, however, that appears to be an incorrect assumption since, “less than 20 percent of the preventive options (and a similar percentage for treatment) fall in the cost-saving category-80 percent add more to medical costs than they save” (Russell, 2009, p. 45). The cost of chronic disease causes such a “disproportionate burden” that it may “discourage adherence to drugs that prevent disease progression” (Paez, Zhao, & Hwang, 2009, p. 15). “In 2005, 133 million Americans were living with at least one chronic condition” (Bodenheimer, Chen & Bennett, 2009, p. 64).
Aging, by itself, isn’t the problem, but the pain and suffering from illnesses is the problem. The whole notion of anti-aging medicine challenges the notion of aging as a disease. It certainly makes sense that “what is costly is not “old age” but disability and poor health” (Giordano, 2005, p. 88). If only we, through science and technology, can find remedies or cures for the ailments that align with aging, once they are eliminated or greatly diminished then aging can be a period of time to be desired and enjoyed. Nonsense, suggests others, the idea shouldn’t be about eradicating disease and illnesses for the purpose of extending the human lifespan (Chapman, 2004). Instead, society should use money otherwise spent for the purpose of “providing basic medical services to everyone in our own country and ameliorating basic health needs elsewhere in the world” (Chapman, 2004, p. 488). Without basic health care for all, prolonging the life span or curing chronic ailments is viewed, from this vantage, as inappropriate. Just as convinced are those who feel there is an obligation to eliminate illness and extend the natural life span.
Distributive justice requires a fair distribution of life-years (Persad, 2009), the idea being that young people have a right to a particular number of years of life, very similar to the fair innings argument, although few suggest what the number of years or length of the innings might be. Distributive justice is based on equality; however, equality is not possible if the playing field is uneven to begin with. Consider the person who is born with medical maladies, Does equality suggest that they forego health care since their age cohorts don’t need that same, or similar, health care? Suggesting the use of age as a basis for rationing is discriminatory and yet it is that very discrimination that is encouraged in the elderly through distributive justice, and rationing. Through this consideration of equality rests an assumption that every person is born with an innate ability, provided in some utilitarian sense. What do we do with the less than perfect individuals who, early in life, require life-sustaining support because of illness or accident or genetic disposition? If we eliminate health care for these because of their supposed lack of ability to contribute to society in the same manner or level as those who have not yet been ill or had an accident, money is saved but at a terrible cost. Does it apply to the premature infant, the spina bifida, the one with a hole in their just born heart – fixable, but at a cost? Which illness do we suggest is not worth saving, for whom, and at what cost? Which of the many illnesses, diseases, chronic maladies, or accidents will we consider to lessen the value of the individual to the point that their continued care is not worth the price? This does not consider those who are in a vegetative state, only those who are “less” than those around them. Maybe you’re one of them.
Priority must be given to younger people for health care based on their years, or lack of years, and the potential they have, it has been suggested. If the elderly don’t get out of the way, the natural balance of things will be upset. In other words, the limits on longevity are natural and therefore should be respected. People should only live a fixed period of life. If you’ve lived a period of time, say 65 years, then you owe it to someone who has lived, say 25 years, to let go, get out of the way, don’t use costly health care that should be saved for or used on them. It is an argument for the oldest to step aside and let the younger come forward. One problem is that “once the old, however defined, had been ruled out of account; the middle-aged would become the old. They would after all have the greater elapsed time “in the bank” and shorter life expectancy ahead than the rest of society and the cycle of argument and discrimination would have a tendency to extend indefinitely, a tendency moreover that would be difficult to restrain” (Harris, 2005, p. 97). At some point the young and the old merge and there are no older to be rid of. This also assumes that all elderly have the same conditions and lack potential and all young lack health problems and have potential. There is little room for variation, although variation is evident everywhere.
Consider the story of the elderly person who lives in the frozen tundra and finds that there is not enough food for the extended family to make it through the winter. Dutifully, so the story goes, the person walks into the extreme cold to die, thus saving their portion of food for the younger people in the family. So, is it really the responsibility of the elderly to give up their seat and move towards the exit sign at a particular point? Intergenerational equity suggests that an elderly person should do exactly that, after all, “human societies currently are built around expectations of a lifecycle of more limited durations” (Chapman, 2004, p. 479) and the elderly must abide by them. What if they don’t want to? Can it be argued that a utilitarian approach might be more equitable or that Rawlsian ethics (Lebacqz, 1986) will find a different distribution that will “improve the position of the least advantaged in society” (p. 37) by reducing health care to the elderly? If we consider “anti-aging technologies will disrupt all the delicate demographic balanced between the young and the old, and exacerbate the gap between the haves and the have not’s” (Post, 2004, p. 536), we know that historically there have been different expectations in the role of the elderly to the young. The elderly train, provide cultural knowledge, help financially, yet the change in average expected life from less than 50 years in 1900 to almost 80 years in 2000 hasn’t seemed to disrupt this supposedly delicate balance. Can’t the same thing be said about the difference between almost any two periods of time? In 1900 everyone aged along with their cohorts, at the same rate. It can be argued that if science and technology allow for an expanded life expectancy that it will not be in parallel but will widen the gap between those who can afford cutting edge technology and those who can’t. That can’t be fair even though it has been that way for millennia that those with money and influence can purchase more than those with less. But problems are to fix and if “aging is a problem for us, so fixing aging is natural” (Kennedy, 2009, p. 28).
The argument that the elderly should get out of the way and allow younger people to take their place may be an argument spawned, in part, because of the potential tsunami effect that Baby Boomers might have on health care. What is of concern is the consideration that “youth will be displaced rather than elevated” (Post, 2004, p. 536) and that the many Baby Boomers will hold onto jobs and work positions much longer than they might have. Certainly the recent economic times would suggest this is probable anyway. As Baby Boomer retirement savings were reduced with the strong economic downturn, they found a financial need to remain in jobs longer than they might have otherwise. But within this argument is the contention that the elderly owe intergenerational equity to those younger, and it is paid by leaving. Perhaps this notion is not totally incorrect, but it also has a reverse perspective as well. The younger generations owe to the older generations what exists when the younger generation steps into the job market, and into society. The platform has been built even though a younger generation might have built it differently. Don’t all younger generations say that? The older generations have made choices, some of which may have elevated them to positions of power or authority – some of which have relegated them to losing those same positions. Their choices were economic, familial, political, educational, religious, and many others. They have built the businesses that the young wish to step into. To simply say that they should step aside because someone else wants their position is not founded in equity. It may be founded, in part, in a history where some had the audacity to die at an early age and thus leave vacant positions they had previously held, but science and technology, public health and medical care have lengthened the life span so that the average life expectancy is has been greatly extended. Using this same logic of too many people and too few positions, younger Baby Boomers should have been able to kill-off many of their older cohorts simply because there were too many of them to allow each of the younger to climb the ladder of success. This argument screams with unbridled egoism. To each, it may be that we owe equity in terms of making whatever opportunities available to all in a fair manner. This is hard to argue. Added to this, though, is the pretense that there are no cultural barriers or economic status issues that make some more able to succeed than others. Working to eliminate this imbalance is certainly morally honorable.
Science and technology have made the idea of the compression of morbidity a reality, where chronic or acute illnesses are minimized until life is finally taken quickly by some terminal illness. At what age should this illness not be treated because of age or infirmity because the individual is perceived as less valuable to society? Which method of understanding should we make health care policy, knowing that someone will not receive health care? To what do we owe the young, or the elderly, and what do we wish to preserve of each? Those who wish to prolong life may feel that it is a natural wish to do so. Those who wish to maintain a natural life may also feel that it is natural to do so. Spending health care is not like building interest in a bank account. We do not know when our health will be drawn upon and reduced by illness. The amount replenished to society cannot be considered equitable or even between the participants. What genetic make-up we are born with, what choices we make along the way, and what accidents we are lucky enough to avoid all help to determine how long we live.
So what do we do with grandpa and grandma? It’s probable that they’ve lived long enough that they may be in extra innings. The value to their family is extreme. They know the history of the clan, the names that go with pictures, maybe how to wire the house, plumb the water lines, replace the roof, change diapers, calm wounded emotions. They’ve has abided by the rules for decades, paid taxes, scooped snow, raised kids, washed clothes and kids. What does society require of them that they haven’t paid? To encourage them to step aside is to suggest that they owe more to the next generation and the next, when it can also be argued that the next generations owe them. Although it is easy to pit one generation against another, it serves no purpose (Sawhill & Monea, 2008). Entitlements of the type and at the level they now are cannot sustain themselves. The nation has to make some decisions regarding what to allow into the large governmental pot of self-insufficiency, and determine what is reasonable rather than what is politically advantageous. Every illness, every malady, cannot be cured. We should try. If there is evidence-based medicine, there is evidence of what can be done and what can’t. We have no nationally centralized planning process to determine the boundaries of what we, as a nation, can provide. Loy & Chi (2005) are correct to point out that “the present generation has mastered the art of pushing the costs of shortsighted decisions onto future generations” (p. 458) when they include Social Security, the National Debt, and Global Warming and to that add Medicare and Medicaid. But the present generation didn’t begin or significantly alter Social Security. The National Debt has grown, in part, because of continued war around the globe that has not been put to a litmus test through voting by this or any other generation. The idea of Medicare as a cushion for the elderly has never bended to the politically difficult position of including a means test even though most recognize the inherent fairness of doing so. Politicians have bent over backwards to accommodate expanding Medicare beyond its beginning boundaries to include any health care issues that can be seen on the open horizon. National health policies do not address what is fair or equitable or honorable. It has been suggested that once Congress has to find health care insurance coverage in the open market like their constituents that perhaps something new will happen. We should find out; “the test of every institution or policy is whether it enhances or threatens human life and dignity” (U.S. Catholic Conference, 1990).
Giordano (2005) declared, “no age-based rationing may be considered coherent with universal ethical principles and that there is no valid reason, either theoretical or empirical, to deny the elderly full membership to the human family” (p. 90). Full membership includes those younger than 15 and older than 40. Let the debate continue, trying to find an ethical base that supports the people being harmed or helped – an ethical base of fair distribution suggests a supply chain rather than medical care. To determine what health care can be provided based on age – too young or too old - is wrong.












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©2010 American Academy of Medical Administrators - All Rights Reserved.

Government Run Health Care

With complete credit to author and futurist, Ian Morrison, I recommend this thoughtful article.

Government Run Health Care
By Ian Morrison
Powerful forces will expand public funding of health care no matter what.

About the time you read this column we will have Government Run Health Care. No, it's not what you think. While Obamacare has just passed in Congress, the full effect of the legislation will not be felt until 2014 and beyond. No, what I mean is that even if health care reform is repealed, or blocked in implementation, the public sector share of health spending will exceed 50 percent in 2010 for the first time.

Wait, you wonks say, the recent official CMS projections say that doesn't happen until 2012. (See "Health Spending Projections Through 2019: The Recession's Impact Continues," by Christopher J. Truffer, Sean Keehan, Sheila Smith, Jonathan Cylus, Andrea Sisko, John A. Poisal, Joseph Lizonitz and M. Kent Clemens, in Health Affairs, vol. 29, no. 3 [March/April 2010], http://content.healthaffairs.org/cgi/reprint/29/3/522.pdf.) True, but read the fine print. That forecast assumes that Medicare follows current law and cuts Medicare physicians' fees by 20 percent in March because of the sustainable growth rate (SGR) provisions. Since SGR is set to get its annual stay of execution extended for another year, if you follow the authors' own math, then sometime in mid-2010 public payment will exceed private payment in American health care for the first time.

Demography and Recession

As the CMS projections show, this is a result of relentless demographic change, coupled to the lingering effects of the massive economic downturn, which raised Medicaid burdens by a record annual increase of 3.3 million eligibles (to a total of 46.3 million), swollen the ranks of the COBRA-subsidized, and reduced the total number of privately insured by 1.2 percent. But, this is no short-term phenomenon. CMS' current law projection has the public sector growing more than the private sector as far as its eye can see (which is up until 2019). Beyond that, you don't need to be an actuary or futurist to realize that the private sector is unlikely to make a late-breaking comeback in the fourth quarter because of the aging of the baby boom. (By the way, one of my working definitions of a futurist is an actuary who doesn't like numbers.)

Remember, the baby boomers have just started to become Medicare eligible. We are on our way! We boomers can't wait to convert from the uncertainty and capriciousness of private-sector health insurance coverage—especially those of us buying individual coverage from Anthem in California (as my family does)—and get our hands on one of those Magic Kingdom cards that is Medicare, which guarantee we can see pretty much any doctor and that Medicare will at least pay them something. Sounds pretty good to me, even though the benefit consultants and financial planners tell us we also will each need to save $500,000 for our lifetime out-of-pocket medical costs not covered by Medicare. That still may be a better deal than a lifelong relationship with Anthem, trust me.

Higher Taxes Are Inevitable

Republicans are not the mean-spirited rubes that so many sneering progressive intellectuals make them out to be. They understand this math perfectly, and they do not want any part of the massive tax increases that this inexorable, demographically induced march implies.

Republicans were therefore not exactly big fans of the Obama administration wanting to expand coverage to the poor and middle class through government subsidies (albeit that the administration plans are in part financed by provider rate cuts in Medicare). Plus, all of the Democratic legislation expands Medicaid by 16 million enrollees. Medicaid is another publicly financed program, not particularly near and dear to the core Republican voter (or, as the polls show, it is not particularly popular with Independents).

The Republican Plan

So the demographic inevitability of higher taxes for health care motivates Republicans to fight any health care coverage expansion that is funded through public financing.

This partly explains what happened at the exquisite Kabuki Theater of the Health Care Summit at Blair House. The Republicans' goal was to stop this rollercoaster; better yet, reverse it. Step 1 was to stop Obamacare. The Republicans had exactly the same cue cards—some Republican leaders read them better than others—but they all said, "Start over, clean sheet of paper, step by step." It could be a top-40 electro-pop lyric that would make the Black-Eyed Peas proud.

Step 2 is to propose sensible, reasonable, American alternatives. (By the way, clue me in here, who gets to decide what are sensible, reasonable, American alternatives?)

The Republican plan was estimated to reduce the uninsured by 3 million and this was achieved, as follows:

Say "free market" a lot. Government health care is bad, free market health care is good. (I graduated from Edinburgh University 200 years to the day after Adam Smith went there to write The Wealth of Nations, and we still see each other at alumni meetings. He would be appalled that the term free market was applied to anything in American health care. Even private-sector health care bears little resemblance to a free market.)

Create high-risk pools at the state level so you can turbo-charge the death spiral in the insurance market. A high-risk pool makes health insurance cheaper for healthy people and more expensive for sick people. Whenever high-risk pools have been established at the state level, they rapidly death-spiral out of control.

Provide tiny wee tax credits for "affordable insurance." The polls show Americans like tax credits, particularly for small business. What the polls don't always measure is that the tax credits would not be sufficient to pay for the insurance; getting a tiny wee tax credit toward a very big expensive health insurance bill doesn't sound so good.

Create "affordable insurance policies" that don't cover anything. We know how to make health insurance premiums cheaper. It's simple: Limit what's covered and raise the cost-sharing. But wait, isn't that what everyone's mad about?

Encourage consumers to buy "affordable insurance" from an insurance company in another state that has no consumer protection and no contractual relationship with local doctors and hospitals. Practically, insurance executives tell me, there really are no states with significantly cheaper policies that could be sold in other states, unless of course they are trying to eliminate consumer protection. Or maybe it's because of the bargaining clout that an insurer in Alabama has over my doctor in Palo Alto, Calif.

Reform malpractice caps to reduce defensive medicine and let doctors focus on offensive medicine. Policy wonks dismiss malpractice as a driver of health care costs, but it is a big issue to doctors and to Republicans. (Personally, I believe the Obama administration missed a huge opportunity from the beginning by not embracing comprehensive medical malpractice coupled to patient safety reform.)

Increase personal responsibility. Successful surgeon senators advocate for "skin in the game"; community organizer presidents empathize more with $40,000-a-year families who can't pay for food or gas, let alone health insurance. These families have more than enough "skin in the game."

Borrow more money from the Chinese so we can cut taxes. Deficits would remain large and growing even if all these "sensible, step by step" plans were pursued. Therefore any tax cuts would have to be financed by borrowing from the Chinese, just as we have over the last decade.

The Democratic Plan

In the interest of being fair and balanced, we need to scrutinize the health reform legislation that just passed in Congress with the same degree of "vitriolic sardonicism" as Monty Python called it. Democrats will cover 30-plus million of the uninsured (10 times the Republican number) and they achieve this as follows:

Expand Medicaid by 16 million because it is such a swell program. The bill expands Medicaid by 16 million enrollees. When did Medicaid become such a great program? Did I miss a class? I thought it was horribly inefficient from an enrollment point of view and provided such pathetic levels of reimbursement that most mainstream providers won't accept Medicaid patients. Yet it has become the vehicle for half of the newly covered. Maybe that is why so many moderates liked the Wyden-Bennet proposal where people get a voucher. And there's your answer to why the Wyden-Bennet plan had no traction: It's pretty easy to stop printing little vouchers under a change in administration; it's a little more difficult to dismantle an entitlement program for 60 million people.

Have taxpayers in the states with generous Medicaid programs subsidize the Medicaid expansion in the states with less generous Medicaid. I spent the week of the Kabuki Summit, not in Washington, New York or California, but in Oklahoma and South Dakota. And I heard about, and experienced directly, entire local state legislatures and majorities of individuals in the community committed to sending back Obamacare money to Washington if it passed, refusing to accept the rule of the federal government if reform passed, and pleas of "Liberty or death."

Whoa! The delicious irony is that the greatest potential beneficiaries of Obamacare are the very states with the most tight-fisted Medicaid programs. Liberal California software executives and closet lefty Goldman Sachs partners would be paying increased federal taxes to support the Medicaid programs for the less than munificent taxpayers of Texas and Alabama. The Massachusetts voters figured this out in their vote for Scott Brown; they already had Obamacare and like it, so why did they need to pay twice?

Mandate that most other uninsured Americans buy health insurance that they can't really afford. Under Obamacare you must have health insurance, unless you really can't afford it, or you work for a very small business (where most of the uninsured are) or you are a Christian Scientist, or you take a free ride because you can do first-grade arithmetic and figure out that paying the fine is way cheaper than buying insurance. Apart from those limited exceptions, you must have insurance.

And then subsidize them so they can. Did we tell you that we are subsidizing you to buy unaffordable insurance? (Ben Stein, the noted economist, columnist and media celebrity, said on CNN after the summit that we should just give poor people the money to buy health insurance in the private market.) Here's the conversation you would have with a typical uninsured family with two kids, making $40,000 a year:

"Hey folks. I am from the government. Here's $12,000, but we would like you to buy health insurance with it."

"This is Candid Camera, right?"

Regulate insurance companies to take all comers even though all comers are not going to come. There is this pesky little problem with private health insurance markets. Insurers want to make sure that the people who sign up are not just sick people. And if they sign up only sick people, they want to be able to charge what it costs to treat those sick people, plus a fee for administration. Come on now. Be reasonable.

Raise fees and taxes on stakeholders who will pass it on in higher costs to the end consumer. Tax drug companies, medical device manufacturers, insurers and providers. These taxes will be passed on immediately to the end user in higher prices.

Start the taxes now; add the coverage later so in the next 10 years it actually reduces the deficit. Gather in all the taxes, now, so you can pay for expanded coverage later. If you have new revenues for a few years before the costs start, it makes it easier to make it budget neutral and in fact actually reduce the deficit. But…

In the long run, hold your breath and be prepared to borrow even more money from the Chinese. Once we get to a true run rate of the costs of reform, it may be difficult to say we are reducing the deficit because of reform.

We now know who really won the Kabuki Summit. Rahm Emanuel and the Democratic leaders in Congress have "persuaded" enough blue dog Democrats to vote for the good of the party for health reform with this parting comment:

"We know you are going to lose your seat over this, but you have to vote for this; otherwise we won't have health reform for another decade, and then it's too late. We're sorry it didn't work out for you here. But we have some parting gifts for you. Thanks for playing."

This is historic, important and directionally correct legislation that will change health care dramatically when it is fully implemented in 2014. But even in the interim, we will have Government Run Health Care no matter what. We just have to learn how to make it all work better.

Ian Morrison is an author, consultant and futurist based in Menlo Park, Calif. He is also a regular contributor to H&HN Weekly and a member of Health Forum's Forum Faculty Speaker Service.

This article 1st appeared on May 3, 2010 in HHN Magazine online site.