"docdano. com Live" Protesting in Wisconsin: Is Obamacare at the root of the debate?

I spoke last night to a group of young physicians at a venue across the street from the Wisconsin State Capitol at the height of the protest against the state government.

Amid the drum beats and screams of union organizers chanting how workers' rights would be eternally devastated because of the loss of collective bargaining, I lectured to a group of resident physicians on the benefits that await patients with the explosion in health care technology.

The root of the problem centers around a state, like almost all in the country, that is saddled with loss of tax revenues due to the downturn in the economy. This has resulted in massive budget deficits and hard choices.

Many states including Wisconsin have ushered in a flurry of Republicans who ran on campaigns of no new taxes, the need to cut waste and spending, and more state's rights.

So that's what the Republican Governor did from day one in office.

He first attempted to limit spending on education to trim the budget, but because of collective bargaining the negotiation of this type of decrease in the state spending was not palatable to the unions.

It didn't matter, really, because the Republicans had the votes to pass it anyway.

But instead of voting on this budgetary issue, the Democrats chose to flee to the land of Obama in Illinois to prevent the state legislature from reaching the critical number of votes to make a quorum.

For three weeks this stalled the debate and decision on the issue, until the Republicans decided to pull out the budget issues (which require the quorum) and vote instead on non-budgetary items - like collective bargaining.

So this lead to more protests.

I literally visited with hundreds of people in Wisconsin over the past week and different opinions abound from every direction.

Clearly if you are a member of the "haves" then you have no desire to give up a benefit.

That's normal.

One person told me that his daughter is a unionized teacher and she pays a whopping $23 a month for health care insurance with no deductible. Even if you factor in that there might be some requirements for her to see certain physicians in network or limitations on formulary and specialist access, this is still a bargain.

He went on tell me that the Governor's proposal would have raised this to $123 per month. I don't know if these numbers are accurate, but the change in benefit structure certainly spurred part of the protest that had national attention.

If you've read this blog before, you know that I'm not a fan of the Obamacare bill. And I think you are seeing in Wisconsin one end of the spectrum of the problems with the bill.

Let me show you why.

To pay for the extra benefits offered under the bill (like no pre-existing illness exclusion, limitations on the right of rescission of insurance if you're too sick to be in the plan, or extended coverage for children), then there will have to be either more money (read tax dollars or higher premiums) or a decline in benefits for those that are members of the "haves."

It's really that simple.

State governments who have been charged with implementing many of the provisions of the federal health care bill don't have the ability to print money or sell treasury bonds. Their only source of revenue is tax dollars.

A significant part of Obama's plan was to provide health insurance for "all Americans." And, unfortunately, a large number of the uninsured were to be covered with the under funded, limited access Medicaid system -- much of which is paid for by the states.

Finding revenue for Medicaid means that other state funded services - like education, or health benefits for teachers - have to be cut and shifted.

That is the only possible way to fund insurance for the "have nots."

I've been derided for one of my statements in the past, but I stand by it: the Obamacare health regulation was the largest transfer of wealth in American history.

So the union supported President now finds himself supporting the union backed protesters who are fighting against changes in state government that would be used to pay for the health care bill that he (and the unions) supported.

Wisconsin is only a microcosm of what is happening in every state that is now grappling with implementing the federal health legislation in a time of budget crisis.

It is an expensive bill, and now we are starting to pay the price.

I'm a big fan of expanding health care access and coverage for the "have nots." A country like the United States should be ashamed for having citizens that don't have access to quality health care. I'm just not a supporter of the big, expensive, inefficient and over-reaching federal health care bill that was passed last year.

Let's face it: the bill cost the taxpayers almost $1 trillion.

The payment for the bill is due now.

And lest you think that non-government workers will get a free ride and this is just an issue for state employees - it will filter down to every American.

As health plans shift to include the new benefits, pay the taxes and fees that are now required by the IRS, and see declining membership due to employees shifting to government subsidized insurance products there will no doubt either be an increase in your health care premiums or a reduction in your benefits.

The problem is that for many insured Americans there is no union to fight for your corporate benefits.

It will be left up to you.

One Wisconsin young man told me that maybe the Republicans should have left Congress when the health care bill was passed.

I reminded him that democracy doesn't work this way. We elect people to represent us and sometimes we win, and sometimes we lose.

I think the Obamacare bill is failure, but I believe strongly that we can keep what's good and fix what's broken. We just have to continue the debate, make compromises, and yes, probably make some sacrifices.

So it probably won't be the last protest I'll attend. Maybe next time I'll get to carry a sign...I'm not much of a drum beater.


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Location:State Capitol, Madison, Wisconsin

End of Life: What to expect, what it will cost, and what you can do about it

When anyone brings up the idea of end of life care, you are thrown a political football. Yet, the failure to have these discussions with your loved ones creates an expensive and emotional mess.

I can't tell you the number of times I've been sitting at a table with friends and this issue has surfaced with almost unanimous consent: they all want to die with minimal terminal intervention.

Then why do we spend the majority of our Medicare health care expenditures on end of life interventions?

The answer is probably one of political correctness and emotional attachment -- both of which can cloud the decision making process.

This is making the assumption that we could even make the right decision if we wanted to.

Case in point: my father.

Seven years ago when my father was 83 years old he casually asked me to feel a "knot in his belly" on one of my trips to his cattle ranch deep in central Texas.

And, even as a dermatologist, I could tell that he had a pulsatile mass about the size of a navel orange under that cutaneous organ by the same name.

And sure enough, after a trip to the VA medical center, a sonogram and a CT scan, we correctly determined that he had an abdominal aortic aneurysm. And, without intervention, it most certainly would be his death sentence.

So we talked.

I think this is the first of many steps in dealing with elderly parents and end of life decisions. He wanted to know how serious was the surgery, would there be a risk he would end up disabled in the nursing home, or would it change his lifestyle?

As an octogenarian rancher who feeds cows every day, drinks a pot of black coffee, and has smoked at least a half-a-pack of Winston's since WWII, these were certainly concerns.

So we made a decision: no surgery.

If it ruptured and he died an instantaneous death then that would be the way he would leave our world.

We took this opportunity to also discuss asset management of his household possessions, land, cattle, and bank accounts so that my mother would not be a bankrupt widow in the event of an end of life event for either of them.

Time passed and my father lived in constant fear that the rupture could come at any moment.

Fast forward two years: I was attending a medical meeting in Austin, Texas and my father calls at 7 a.m. This is not his normal routine so I was immediately concerned.

He quickly told me that he was having abdominal pain, pain in his legs, and was feeling dizzy. He was rupturing his aneurysm.

I told him to get in the car with my 80 year old mother and drive straight to Providence Hospital in Waco -- 90 miles away.

I was hoping I could temper the dangerous caravan of my mother's driving by calling ahead and warning the emergency room. Within 20 minutes of his arrival we had confirmed that he was dissecting his aneurysm and death or surgery was imminent.

So, we talked.

The doctor suggested surgery and since he had made it to the ER, I encouraged him that he needed to give it a try -- my mother was concerned about the cost. (She is very frugal).

So he had the surgery, was in the ICU for four hours, and checked out back to home in 5 days. That was five years ago.

Now my 90 year old father still feeds and takes care of the ranch, drinks a pot of black coffee every day, and yes, still smokes a half-a-pack of Winstons. Very happy, very productive. No other health complaints.

So did we make the right decision 7 years ago when we agreed not to pursue treatment?

To our family, it was the right decision at the time. So when people make statements that make it sound like end of life care is easy, they are dead wrong. It never is.

But, there are probably some lessons here that we can learn from.

First, you must have the "discussion." It is imperative that you talk to your parents or older loved ones early -- while they still have all of their faculties and can participate in the decision making process.

These discussions are never easy. But it puts the wishes and desires of the parent in concert with those of the siblings. My discussion was easy with my parents, and my sister and I get along so well that there was really no differences of opinion. But it doesn't always work out that way.

You most certainly should formalize a living will. This puts pen to paper and makes the end of life time event easier because there is less opportunity for confusion on what was decided during the "discussion."

And finally, everyone needs to consider the financial impact of any end of life decision. This time is almost always the most expensive health care experience for any patient.

It is not uncommon for spouses to be left bankrupt with years of bills to pay There is also the issue of sitters, home nursing, and medications that also can feed the final costs of someones life.

The government has gotten much stricter on families using their own assets to manage the end of life -- even if it will be detrimental to the surviving spouse. So don't think you can just "transfer assets" into your kids accounts and that will satisfy the requirements to get the nursing home expenses paid for by the state (Medicaid).

You should enlist the help of a knowledgable attorney on all of these end of life decisions. That information can go a long way to making it more understandable for all the parties involved and that the older person's wishes are maintained.

Unfortunately there is no book in the mainstream press on how to deal with elderly parents like we have with pregnancy (such as: What to Expect when You are Expecting).

So, everyone has to write their own conclusion.


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Location:Wolf Island, Galapagos, Ecuador