So far, where I am  (for the past 20+ years) ... has worked very well.

 - Smaller, nearly rural city,
 - located in the Pacific NW,
 - ~50,000 people,
 - surrounded by diverse agriculture,
 - real four seasons (but, much milder than many 4 season locations in the US),
 - 20 minutes to nearby trout streams to fly-fish,
 - 45 minutes by car from genuine wilderness hiking and the Cascade mountains,
 - 90 minutes from Paradise (Mt. Rainier's largest Lodge and visitor center),
 - 2-3 hours from the ocean,
 - and a slow growth rate since it isn't yet a 'destination.'

We enjoyed one final warm weather hike this last weekend, just east of Mt. Rainier Park. Warm sun, clear skies, fall colors (red berries, orange leaves and red huckleberry plants), mountain lakes and the mountain itself were spectacular. A week later, and the area is covered in snow ...

Uwe Reinhardt wrote an editorial in the NY Times about the perception of what many people actually hope, expect etc. about health care reform. Although the term 'common sense' is frequently used, there are a number striking contradictions which he points out in his (tongue in cheek) wish list. Alas, the fact that we are so poorly informed and don't understand our current system of health care, means we are particularly susceptible to being mislead about any proposed new changes.

 * A 'Common Sense' American Health Reform Plan*

____________________________________________

The All-American Wish List for Health Reform

1. Only patients and their own doctors should decide what clinical response is appropriate for a given medical condition, even if that response involves unproven clinical procedures or technology.
2. Neither government bureaucrats nor private insurance bureaucrats should ever refuse to pay for whatever patients and their doctors have decided to do in response to a given medical condition. An insurer’s refusal to pay for a medical procedure is tantamount to rationing health care.
3. Rationing health care is un-American.
4. Cost-effectiveness analysis should never be the basis of any coverage decision by public or private third-party payers in health care, for to do so would put a price on human life — which, in America, unlike everywhere else, is priceless.
5. Government should not require individuals to purchase health insurance. Such a mandate would violate the constitutional rights of freedom-loving Americans.
6. Americans have a moral right to life-saving and potentially highly expensive medical care, should they fall critically ill, even if they are uninsured and could not possibly pay for that care with their own financial resources. (Why else would God have created hospitals and their emergency rooms?)
7. Government should stay out of health care. Specifically, government should not control health care prices, nor should it increase its spending on health care, which is out of control.
8. Even small reductions to the future growth of Medicare spending — called “cuts” in Washington parlance — unfairly burden the elderly, along with the doctors and hospitals that serve them and the manufacturers of health products, lest the pace of technical innovation be impaired.

OK, so before I start, I have a lot of opinions on the topic. But, I should, after practicing as a physician for the past 24 years. I have actually delivered cost effective care in the most difficult of circumstances, unlike the overwhelming majority of the Health care ‘wonks’ in the current administration (or the last two administrations). So, first a disclaimer:

-    My bias is that Republicans would fix healthcare by assembling a group of CEOs from Pharma and HMOs to put together a plan. The Democrats would get together the Trial Attorneys lobby to fix the problem. You may remember that Hillary Clinton’s Health Care Panel in the 90’s had more lawyers than doctors …hmm!
-    My experience of actually delivering care comes from practicing as a Medical Oncologist and Hematologist in a small city and the surrounding rural region of Central Washington. I set up outreach clinics to get high quality care to smaller towns in the region and I spearheaded research efforts to bring the earliest treatment trials to our rural setting.
-    I perceive that we as Americans have become progressively willing to expect someone else to pay for our indulgences: we smoke, become obese, don’t exercise, then we feel that the world ‘owes’ us some medical care. We no longer seem to feel that we are first responsible for our own health.
-    In the U.S., we have begun to move a large number of ‘social issues’ into the health care expense column: domestic violence, unplanned pregnancy, gang violence, homelessness, illegal immigration, etc.
-    Finally, is is very clear that our current system is not sustainable. A combination of confusing regulations, unnnecessary rules, excessive profiteering, an underregulated drug industry, stunning governmental inefficiency, perverse infuences of lobbying, an abusive tort system and lack of leadership, have all led to the current gridlock and exorbitant in healthcare.

So, I have tried to understand the proposals taking place on Capital Hill.  It is not easy. Most are cloaked in political bargaining and back-room deals. The players are Congressmen (and woman), their aides, the lobbyists, the trial lawyers, the HMOs, the Hospital organizations, big Pharma, AARP, etc. These groups are far removed from actual care of people at the bedside, the outpatient clinic, the small town or the home. I get depressed when I recognize that these are many of the same organizations who are responsible for the current mess we are in:

-    Congress has largely been responsible for the morass of rules which have made Medicare and Medicaid the unwieldy programs they have become (conflicting mandates, micromanaging what they do not understand, creating poorly thought out rules which never get changed, creating additional programs to fix problems with other programs, creating new bureaucracies, and most often doing these things as the result of politically expedient compromises). Examples of the programs created and now failing include: Medicare, Medicaid, Postal Service, Army Corps of Engineers, … shall I continue?

-    Lobbyists are of course just as pervasive now as ever. Nothing really seems to have changed – just different lobbies have the inside track compared to two years ago. But, in some instances the same people are representing the ‘new’ interests.

-    Trial lawyers have been assured, by Obama, that he will do nothing to address meaningful reform for the pervasive medical-legal costs we all must pay. In a statement that I felt showed he had no real spine, Mr. Obama stated, “I recognize that … doctors feel like they are constantly looking over their shoulder for fear of lawsuits.” However, “… I’m not advocating caps on malpractice awards.”(in his meeting with the AMA).” Unfortunately, tort reform is ignored by the current administration apparently because it would limit what lawyers would earn on lawsuits and trial lawyers are the biggest contributor to the Democratic Party. As a result, we all pay the extra cost, as physicians, hospitals and health care systems ‘do everything’ to limit there medical-legal exposure – DEFENSIVE MEDICINE. There are no other countries in the world with so pervasive a trial lawyer influence forcing up the unnecessary healthcare costs which America experiences (all the countries sited by the administration as having improved health care outcomes or systems have much less unnecessary costs experienced from defensive medicine).

-    HMOs have for years had a selective tendency to pick and chose what they want to cover. Often, under the guise of ‘evidence-based guidelines’ (commonly made up in-house by physician panels who are not expert in the diseases or conditions which they oversee) they paint themselves on the moral high ground and fail to acknowledge that they are really interested in the ‘cheapest care.’  Oh, and did I forget to mention the extremely high salaries and bonuses for their CEOs (and returns for their investors).

-    Pharma has always had a pervasive influence in Congress. Even when physicians and hospitals had to cope with cutbacks on a year to year basis, Congress refused to ‘control’ the prices pharmaceutical companies could charge. A drug that offered a 5% improvement over an existing drug would cost 500% more than the drug it replaced – no questions asked! Virtually all other countries (including those the backers of the current reform efforts site) do negotiate prices. The recent articles about the ‘side deals' between the Obama administration and ‘big Pharma’ leave me angry!*

-    Hospitals are often portrayed as the do-gooders in the community. In many communities (including mine) physicians can no longer stay afloat financially as a result of the excessive regulations imposed by state and federal governments. More and more doctors are becoming ‘hospital employed.’ An unfortunate result is that the charges for the doctors services go up dramatically once they are in the hospital setting. These same hospitals (some under the ‘not-for –profit’ umbrella) drive other small practices out of business. The hospital can enjoy preferential tax treatment while competing with the small practice. The hospital lobby is also very powerful.

-    AARP several years ago was responsible for side deals with the Insurance industry and created a nightmare for physicians and other health care providers in the late ‘90s. They are at it again, in their current lobbying. AARP wants to allow a blatantly age discriminatory policy to go forward in Congress. True, they would limit it to maybe having 50-somethings pay no more than twice the premium of younger people for the same coverage. Of course, AARP rakes in an enormous income from its supplemental insurance business. It only makes sense for them to help gouge the 50 and over crowd before they are eligible for Medicare … you figure it out. Profits over people - it's the American way.

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This is what is being proposed as the areas of reform by Congress and the Administration:

• Expanding access to coverage
• Individual mandate
• Employer requirements
• Expansion of public programs
• Premium subsidies to individuals
• Premium subsidies to employers
• Tax changes related  to health insurance
• Creation of insurance pooling mechanisms
• Benefit design
• Changes to private insurance
• State role
• Cost containment
• Improving quality/health system performance
• Prevention/wellness
• Long-term care
• Other investments
• Financing

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These reform areas sorta sound innocuous,. However, I just don't think that, given their track record, the above parties are really up to the task of setting aside what is in their own best interest and instead doing what is best for the entire country. All of these groups are best at spending other peoples money!!

After a marvelous week in the coastal waters off the west coast of Vancouver Island, I am struggling with our 'reality.' Perhaps you can tell why. Another few days of brain numbing work and interactions with our own cumbersome Federal Bureaucracy, I might again become a stable cog in the big wheels of our civilization, but ...

... of apple blossums bursting open in the past few days. Walking in the orchard, last Sunday at 8 AM while inhaling that pervasive subtle fragrance of apple trees in full bloom, made me regret their transient nature.

A couple nights ago as I went out for a water change (changing the irrigation lines in the orchard) I took along a camera to try to capture some of the late day beauty as the sun driopped over the cascade range to the west:

The pears (Bartlett above) were in full bloom. The honey crisp apple graft growth is visible prior to the trees fully leafing out (below).



The Anjou pears tend to have the fullest blooms in early spring:


Of course the rented bee hives enhance to low levels of natural pollination.


The light late in the day is magnificent under the Bosc pear trees.


Even the sprinklers spraying iirrigation water in the late day sun are mesmerizing.


And after a 25 minute working stroll ... the tulips provide another reward:

I am with you in the worst of times.
When even your friends scatter, I am there.
I will boldly challenge the dread disease,
... and hold your hand if I should fail.

And tomorrow, I start anew, with new weapons and tactics.
For if I don't succeed, then perhaps soon my partners will ...

from my limited view:

A few recent experiences caused me to consider how we, as a civilization try to fix 'things' ... especially things we screwed up in the first place. I just returned from New Zealand, where man's introduction in a variety of mammalian species (which were not native the those beautiful islands) have created many environmental catastrophes. In each case a well intentioned effort, led to unexpected adverse consequence. As an approach to the unexpected problems, often the New Zealanders attempted to 'fix' the unintended problems, by introducing yet another non-native species (in a poorly thought plan to control the first species). As a result of these actions, today there are populations of stoats, possums, and rats which threaten the survival of many of the rare native bird species.

Now, we in the USA are trying to 'fix' the economy of our great land. The problems seem to have largely resulted from the previous fixes, that have gone badly wrong. Like the introduction of alien animal species, the 'creative' financial instruments and the greed of our people has combined to disrupt and nearly destroy the basic financial fabric of our lives.

So, do you get nervous when people are willing to spend your hard earned income to 'fix' the whole thing with a few more financial packages which were probably no more intelligently designed than those old plans for introduction of species to New Zealand. So, today the Congress puts forth a plan to tax back some of the bonuses of AIG and other executives who received 'bali-out bonuses ... I smell rats everywhere.