In the last entry I suggested that perhaps Medicare could be expanded gradually to eventually provide something like universal health care coverage. After all, there is nothing that says that they've got to cover every single person immediately. Why not just start slow? Why not work your way down from the top? Provide coverage to age 62, then 60, then perhaps drop it to age 55. I'd guess that there would be some savings gleaned from having people go to the doctor younger, perhaps catching conditions, especially cancer, that could result in even more expensive treatment later on. And perhaps an emphasis on prevention at an earlier age (not that Medicare encourages prevention now, but that could be changed if it were expanded) might allow for healthier people as they age. Of course, it could be that it would spend more treating those earlier detected conditions than if many of those people just ended up dying (crass, perhaps, but a consideration...).

I don't really know what the numbers would play out to be. But it would certainly seem to be more doable than attempting to provide health care for everyone in the country all at once. The cost of doing that boggles the mind.

So getting back to something I mentioned in a couple of other entries: the paradigm shift that maybe is needed in medicine. A retired orthopedic surgeon friend of mine once suggested that the type of applicant to medical school had changed (regrettably, in his view). Now suddenly med schools are producing physicians with more an eye on their potential income than on their patients' best interests. (Not that they aren't concerned with their patients' welfare and with doing things right - just that they also have an eye on the bottom line.) The "best and brightest" minds seem to be more business oriented than science oriented. He told me that it used to be that the scientific types ended up in the specialties, and the humanitarian types ended up in primary care fields. Now there's a much more financial mindset.

Would someone commit 7 to 10 years of his/her life to learning a skill that didn't allow them to live a rather comfortable lifestyle? And just what the heck is a "comfortable lifestyle"? Would someone commit to that rigorous program knowing that they were going to come out of school and residency and basically to continue to be an employee of a government bureaucracy?

A neurosurgeon I know says that Medicare reimbursements hardly support the overhead in the office. I don't know if that's true, but if it is, then what businessperson in their right mind would accept Medicare?

Should a physician be a businessperson? Should they need to concern themselves with running a business (their practice) and dealing with the headaches and pressures that come with that? I'm a dentist, and I know I certainly have to deal with headaches sometimes, even after 21 years and having excellent staff that I can trust almost completely. Would *I* want it any other way? What if the government told me that they were going to "buy me out" and pay me a salary to do dentistry out of the same facility I'm in now? Would I like to cede control of my facility to a third party? What if I wasn't productive enough for them? Do they fire me? Send me somewhere else? What if they feel my facility is underutilized? Do they try to maximize their investment? Bring in another dentist?

It would be nice to have a guaranteed paycheck, to have paid vacations and not have to worry about the emergency patients when I'm gone, to not have to look every year for health care coverage, to have someone else perhaps fund a part of my retirement. But do I want that at the expense of giving up control?

I don't think I'd really like it that much. The way it is now, I can charge whatever I like. I can work whenever I like. I can hire someone else, or not. If I really want to make more, I can treatment plan differently (if I can sleep at night with my recommendations), I can work more, I can raise fees. Or not. I have a great deal of freedom and autonomy to go with the headaches.

But what if that was the model I came out of dental school to find in the real world? I think you go with it, then. But I think also that the people who want to do this are probably a different breed of student, when it comes to getting applicants. I think it's going to be less the entrepreneurial types, more the types wanting security.

Hopefully they have good hands. And good minds.

The thing that most discussions seem to leave out when talking about controlling health care costs is that there are PEOPLE providing the health care, as well as people needing access to it. In the end, you have to have smart, creative, technically skilled people to do this. And you better have a way to attract those people to this field instead of, say, aspiring to become a CEO of a Fortune 500 company...