So what is a cost effective medical care system solution for all of United States?

Well, everyone is debating about Obamacare and universal health care.  Obamacare [universal health care] tries to do two things --- provide everyone with medical care access and secondly, it attempts to bring private insurance costs under control.  The rest of the anticipated reforms are in the 'on-hold' bin!  A glance at the Patient Protection and Affordable Act, H.R. 3590 reveals the following:

No reference is made to reform the many subsidies in farming that are suspected of contributing to chronic diseases and poor health. An attempt is made to require some transparency in the FDA, as in requiring limited labeling on food products. Carrying out childhood obesity demonstration projects is not directly attacking the already known issues related to obesity. Instead of enacting better anti-toxic environmental laws, Obamacare is going to provide more medicare coverage for certain individuals exposed to environmental health hazards. Obamacare will develop a plan for promoting healthy lifestyles and chronic disease self-management for Medicare beneficiaries; evaluate community prevention and wellness programs that have demonstrated a potential to help Medicare beneficiaries reduce their risk of disease, disability, and injury by making healthy lifestyle choices. But non-Medicare persons appear to be overlooked! No mention of cultural reinforcements to help individuals adopt good life style habits. And Obamacare will allow the broken medical care system house to wrought!   Obamacare 2012

Overlooked are the long-term cultural values of how medicine is practiced and how government subsidies in agriculture and industry contribute to faulty life style habits that create a sick culture. There’s a near-universal sense that the U.S. health-care system is an expensive heaving mess, rife with errors and injustices. The sensitive, unpopular and controversial things that need fixing are not being discussed. This article identifies the sensitive issues that need reform and suggests cost effective ways of fixing both the medical care system and the personal health care system. 

 Need a fresh philosophy of medical care and life:   Philosophy is a way of life --- how we live.  And how we live is directed by our values and morals.  It is our values that help guide us to make good decisions. We need to re-examine our values in order to fix our medical care system, our government and how we live as a society. 

We need to fix what all previous presidents were unable to do and what President Obama was trying to do!  We need to fix our dysfunctional government, the broken medical care system, change our philosophy of health-medical care and how we live. The question is which should we fix first? The chicken or the egg --- fix the dysfunctional government or the total medical-health care system? The entire country needs to adopt a fresh new philosophy of medical care and personal health care. As a country, we are living in an economic-social system that does not advocate a healthy life style. Unless we reform the many other aspects of how we live and practice medicine, the current attempts to fix our medical system will fail in the long run. We are running around free, like a boat drifting in an ocean, without a rudder to steer it!

Below are the many values of our life style that need to be fixed!

 Obamacare fails to fix the broken medical care house of 1910.   Attempts to fix the medical care system since 1910 have been band aid approaches that were stifled by poor original design. Current amendments are nothing more than a camouflage for an old medical house with rotting floors and a crumbling foundation.  We need to salvage the good aspects of the existing system and start from the beginning with an entirely new health-medical care foundation that can support a functional, efficient and cost-effective quality medical care system. We are bolstered by recent medical-technology advancements to build a new medical care house! Obamacare postpones doing this!

 Intent of medical Care:  Seldom if ever discussed is the intent of medical care!  Is it to provide medical care for the sick, those in emergency need of care, prevent diseases, keep costs down, or make money for the insurance providers?

The current medical model is modeled on the outdated 1948 WHO model of health and profiting off the sick. Medical doctors apply battlefield  trench injury care instead of preventive care for out-of-control chronic diseases.

Is it proper or just for a medical care provider to profit from serving a sick or dying person? Is doing so any different from a funeral director selling a funeral casket to a distraught and mourning relative of a dead person, thereby taking advantage of the relative’s emotionally vulnerable status? A sick person grasps for straws while struggling to make informed decisions and stay alive. Where is the justice in profiting from a sick person? Is it just to ignore giving health care when the sick person cannot pay for it; thereby perhaps infecting others with his/her malady?

Obamacare temporarily overlooks the issue of whether it is just to make money from sick persons!

  Competition in a free market:    There have been arguments made that the existing mix of over 400 private medical care insurance companies are a free market system. Also that universal medical care is not a free market system and does not allow supply-demand system to work. This section offers some information on both of these issues.

Market failure is at the root of the medical care system’s dysfunction.  Kelly: myth of free med market 2011   Krugman: markets can't cure healthcare 2009  The American Medical Association [AMA] and the federal government, with good intentions to improve the quality of medical care, created an unequal playing field for the medical market as early as 1910. Since 1910, the relationship between providers and consumers gradually drifted into a monopoly non-free medical market that today is manipulated by medical care corporations.

Markets work well for goods and services that can be comparison shopped, be easily packaged and sold, which is not the case for health care. Even under competitive conditions, markets may fail to produce socially optimal quantities of a commodity or service. Hence, in the face of these realities it is more appropriate to view medical care differently than a typical consumer product.   Karsten: private vs public good 1995   This kind of thinking will no doubt be challenged. Hyde: creating hea reform market 2009

"One illusion which exists is that "medical care" can be most efficiently provided by the competitive market. This is hardly the case. Providers of medical care services do not operate like firms in settings of market structures resembling perfect or monopolistic competition."  Karsten: private vs public good 1995  Kelly: myth of free med market 2011  

"Health care laws function differently than in other supply industries. Demand is relatively elastic in response to supply growth and, when patients are insured, is largely price-sensitive. Furthermore, scarcity of price information in the public domain, and information asymmetry with physicians make it difficult for patients to base decisions on value for money. On the supply side, providers of health care largely dictate the quality of services offered, and, given largely elastic and price-insensitive demand, suppliers tend to innovate at the high end of the market rather than introduce innovations that could lower cost." 

In 1963, Kenneth Arrow, a Stanford University economist, later a Nobel laureate, decisively demonstrated in a groundbreaking paper that the usual rules of the market can never govern medical care.  Krugman: markets can't cure healthcare 2009 The subject is the medical-care industry, not health. The causal factors in health are many, and the provision of medical care is only one. Particularly at low levels of income, other commodities such as nutrition, shelter, clothing, and sanitation may be much more significant. It is the complex of services that center about the physician, private and group practice, hospitals, and public. Arrow argued that doctors and patients interact as highly atypical buyers and sellers; thus the price and extent of care provided to the sick should be determined according to standards intrinsic to medicine and not those of business. Since an individual’s health is so variable and largely unpredictable, it should follow that attempting to value and insure it as a commodity, like a car or a house, is antithetical to the practice of medical care and, therefore, is not an appropriate model.

Medical care is not a commodity or product:  Ancient China provides us with an example that medical care is not a commodity.  Ancient China doctors were paid a fee once a year to keep a family well and actually lost their salaries when the patient got sick. Doctors were not paid when treating sick persons.  In the earliest acupuncture text, the Yellow Emperor's Inner Classic, written circa 500 B.C., it is stated that the superior physician prevents the family from getting sick. Ancient Chinese doctors did not make money on sick persons! We need to explore such a medical care system.  The philosophy of how we practice medicine and healing is reflected in the cost of medical care and how we manage our medical care system.

Conclusion: Based on the current medical care system, even with President Obama's reforms of 2012, there is no free market for medical care.  An individual's demand for medical services is not steady in origin as, for example, for food or clothing, but irregular and unpredictable. Illness itself is unpredictable. Medical services, apart from preventive services, afford satisfaction only in the event of illness, a departure from the normal state of free commodity market affairs. Most patients, as consumers of medical care, choose their physicians and not the care they receive. Consumers of medical help have very little knowledge about appropriate medical treatment compared to care providers or the supposed 'real' expertise of the available pool of doctors. This makes it impossible for consumer patients to be able to make good informed decisions about finding low cost and appropriate medical care. With all these unknown circumstances of illness, the patient who may get sick, and the medical care needed, it is impossible to have a free medical market. There is no equal playing field in the Obamacare medical care market --- the medical care market is tilted toward the providers. Budetti: Market justice in US Hea Care 2008  Krugman: markets can't cure healthcare 2009

 Health as public good:    There is controversy about the idea that individual health is a public good!  Do people prosper as a society, as individuals or both?

This is a complex idea. Basically the point being made is that someone has to provide an infrastructure that all members of society use to function as children, adults and entrepreneurs. In economics, a public good is a good that is both non-excludable and non-rivalrous in that individuals cannot be effectively excluded from use and where use by one individual does not reduce availability to others.Wiki: public good Examples of public goods include fresh air, clean water, knowledge, lighthouses, open source software, radio and television broadcasts, roads, street lighting. As Adam Smith, J. B. Say, and others recognized, people are prosperous not as individuals but as members of a prosperous society. Gordon: health care a public good  Karsten: private vs public good 1995

This is a complex idea. Basically the point being made is that someone has to provide an infrastructure that all members of society use to function as children, adults and entrepreneurs. In economics, a public good is a good that is both non-excludable and non-rivalry in that individuals cannot be effectively excluded from use and where use by one individual does not reduce availability to others. Public good

A good medical care system can be categorized as a tax supported public good because it provides opportunities for healthy individuals who can use the infrastructure as a place to prosper and do business. The result is that individuals use the conveniences of public goods to prosper, thereby making society more prosperous. The successful Warren Buffets and Bill Gates' of this country are successful because they had access to public infrastructure and also access to healthy consumers of their goods ---- in a healthy environment.  Entrepreneurs share the infrastructure --- clean water, roads, education, good food and sanitation much of which has been paid for by public taxes.

The bigger issue in medical care that is related to cost of the delivery system is a philosophical one: who should be served by the medical care system: the masses, the healers or the profiteers? This is a philosophical issue and it has been overlooked by Obamacare. 

The medical care system debate needs to start with some common sense philosophy and not trivial tad-bits! character and health The ancient Greek philosophers would have an entirely different approach to this debate. They would define the terms and seek to find strength in the justice of a medical care system.

The Greek Philosopher's Nature of Justice. "The question which opens this immense dialogue is: what is justice? Several inadequate definitions are put forward, but the most emphatically presented definition is given by a young Sophist, Thrasymachus. He defines justice as whatever the strongest decide it is, and that the strong decide that whatever is in their best interest is just. Socrates dismisses this argument by proving that the strong rarely figure out what is in their best interest, and this can't be just since justice is a good thing." For more info: Plato: justice justice Analysis:Plato on justice

So what is the substance in health care? I would argue that the substance is justice and fairness of a health care system. In the case of this health care system debate, the economic, medical and political aspects of the health care system would be without real strength, or Greek substance, for no concern was made about whether either health care system functioned in a justifiable and fair manner. Such substance would ask the hierarchical questions of who the system would serve? Is it a just health care system for the few or the many? Who takes priority …. the few or the many? These questions need to be answered first before dealing with the cost issues! The realistic approach to medical care has to be a philosophical basis of doing the most good for the most persons. This approach carries more weight and is more important than the minor points in a debate about a good medical care system.

Blaming a political system for a failing medical care system, whether it be democracy, socialism or dictatorship, is a moot one. From a Greek point of view, the need is to focus on the country’s civic responsibility for its people. The state’s responsibility to its populace is similar to that of a parent to its children. Is taking care of a family’s children any different than a government taking care of it’s people? The state, like a parent, has a parallel obligation to protect the health of its citizens.

Now let us put the shoe on the other foot: Should a citizen have the right to expect good medical care from society? Does a worker need good health to be productive? Does a country benefit from a healthy citizenry? What are the justifications for such expectations? The ancient Greeks would love this part of the debate! So what is the real incentive for a country to maintain a healthy society? The answer is very simple: Healthy workers produce more goods for a longer time, pay taxes and in turn, have money to buy the necessities of life and bolster a healthy national economy. The masses need to practice preventive disease habits that warrant being considered a good and worthy citizen. The Gross Developmental Product [ GDP ], a measure of the wealth of a country, needs to go up.

 Find causes of health problems:   We need to really focus on identifying the causes of our problems and less so on the symptoms!  Our doctors relieve symptoms by prescribing medication for most of our health problems. This does not fix the medical problems; instead it is driving health costs up.

 Fix medical-doctoring system:    The philosophy of how doctors heal needs to be changed!  Doctors learn the art and science of medicine from their peers in medical school.  It would be prudent to overhaul the medical school curriculum,  Mayer: overhaul med curriculum 2012  although most curriculum upgrades are more concerned about accreditation and keeping the status quo than focusing on relevant patient health. 

Medical schools and the AMA have created a monopoly --- a lop-sided medical market in favor of providers. For example, the restrictions on entry o medical schools is itself not part of a free market supply-demand system. The high cost of medical education in the United States is itself a reflection of the quality standards imposed by the American Medical Association since the Flexner Report. This has resulted in a high cost of medical education that has been subsidized and both the quality and the quantity of the supply of medical care have been strongly influenced by this none free market.    Medical schools and the AMA have both imposed licensing laws and standards on medical-school training that limit the possibilities of alternative qualities of medical care and the number of practitioners. The practice of drug companies providing medical scholarships is well recognized in drug companies having a favorable market tof influence on perspective medical doctors. Theoretically, a supply of more doctors would increase the pool of available doctors competing for medical care jobs and thereby lower the cost of physician care services. But this is not the case in United States. Indeed, medical schools also control the number of students allowed to enter medical schools so graduate MDs can get high salaries. These type of restrictions do not meet the criteria of a free supply-demand medical market system. Obama care deferred reforming this aspect of medical care at this time.

Some aspects of the medical curriculum itself are questionable, like the glaring lack of legitimate courses on nutrition.  A survey of medical doctors by Anderson revealed that physicians believe their training did not adequately prepare them to:

• Coordinate in-home and community services (66 percent)


• Educate patients with chronic conditions (66 percent)


• Manage the psychological and social aspects of chronic care (64 percent)


• Provide effective nutritional guidance (63 percent)


• Manage chronic pain (63 percent)

Most of today's medical practitioners did not take a 'real' nutrition class as a medical requirement to get a medical degree, Huff: MDs lack nutrition 2012  yet display their ignorance about vitamins and minerals while attempting to advise their patients on nutrition and health.  Many patients know more about nutrition than their doctors.  Knowing medicine is not the same as knowing about health! Obamacare overlooked this.

 Doctors change habits:  The medical system is also dragging behind the computer-internet technology. Most doctors and hospital systems are still without patient electronic medical records [EMR] that have been available for over 20 years. The CDC reported that the EMR adoption rate had steadily risen to 48.3 percent at the end of 2009. Wiki: EMR  Obamacare has no mandate to provide electronic record keeping incentives to motivate instant adoptions of EMR.

In an attempt to control costs, managed-care organizations have attempted to measure the process of medical-care delivery, rather than identifying physicians who keep their patients healthy. Managed care has failed to contain costs or improve doctor care.  

Doctors need to focus less on defensive practice and more on making the patient well.  e.g. Doctors also need to change the small habits of how they practice medicine ---- by minimizing patient waiting time to see a doctor and sharing information directly with patients via e-mails.  Doctors need to do a better job of monitoring their patients who are on prescribed medications. Young: 100,000 die from drug 

 Streamline Lab tests:  Lab tests being ordered as defensive liability medicine [ to protect the doctor ] need to be supplemented or replaced by body information relevant to patient health [ such as vitamin-mineral-pH levels, co-factors and mineral ratios ].  Medical technology is now available to help patients instantly monitor their health status [ blood pressure, nutritional status, diabetes, heart rate ] at home instead of traveling to doctor's offices.  Lab tests need to focus more on health promotion --- keeping patients healthy than on treatment tests. We need a test that confirms bioavailability of nutrients being delivered to somatic cells and not just presence in the blood stream.   Obamacare does not have economic incentives for implementing new patient oriented health technology that would save money. 

 Fix FDA:   Many experts who advise the government on drugs often have financial conflicts that may sway some of their votes on approving drugs and other health-medical care issues.  The classic example is the revolving door connection between  Michael Taylor , current head of the FDA and his previous employment at Monsanto, the company that has engineered genetic plants. Taylor exemplifies the revolving door between the food industry and the government agencies that regulate it. Kenfield: Michael Taylor revolving door 2009   Another example, a JAMA study underscored how pervasive the conflicts are: In 73 percent of drug advisory committee meetings, at least one panelist reported a financial conflict of interest.  NBCNews: FDA conflict of interests 2008

Research data submissions from drug companies to the US Food and Drug Administration (FDA) may be worse than in other countries, since the agency doesn’t actually require any data. Their policy says that biotech companies can determine if their own foods are safe.  Anything submitted is voluntary and, according to former Environmental Protection Agency scientist Doug Gurian-Sherman, PhD, “often lack[s]sufficient detail, such as necessary statistical analyses needed for an adequate safety evaluation.”  Health risks of genetically modified foods

Obama needed to overhaul how the FDA selects persons with no vested drug interests and how the FDA works!

 Need real research on consumer health and not drugs: 

Much of the research done at universities and funded by the federal government is questionable research.  It subsidizes university professor's salaries, often discovers little useful information and seldom benefits society.  We need more research on how healthy bodies should work. We need to do more preventive research that is useful for patient-consumers.  Rothbard: Gov med insurance 2012

Obamacare needed to redirect research funding. The U.S. is the world’s leader in medical innovation because our government pumps tens of billions of dollars into health research each year through the National Institutes of Health [ NIH ]. In fact, many of the drugs, medical devices, and clinical tests that ultimately get marketed and sold by private sector medical companies originated in NIH-funded labs across the country.

But the funding for products that cannot be patented and copyrighted, like vitamin and mineral supplements, and how nutritional co-factors work, get almost no funding.

Drug companies have a huge influence over what gets researched, how it is researched, how the results are reported, how they are analyzed, and how they are interpreted. NBCNews: FDA conflict of interests 2008   Obamacare needed to take drug research out of the hands of drug corporations. We need to focus more on funding independent research, outside the realm of drug corporations, to find out how the very young and the elderly can take better care of themselves, with a minimum of help from the health care system; thereby reducing dependence on the medical care system.  Perhaps the most significant need is for someone finding the time and funding to research on how benefits from common everyday lifestyle affect health; like how foods and proper eating habits may more effectively enhance the individual biochemistry of individuals than medications. Such focus needs government reinforcement for health promotion as well.  Medicine knows very little about maximizing the nutritional well-being of all age groups.

 Dealing with the terminal last days of life:  

We need the government [ NIH, CDC, FDA ] to focus on where the largest amount of health care money is spent in the shortest period of time on people.  This would be on the terminally ill.  Public health measures like improved sanitation and housing, better nutrition and safer drinking water have eradicated many communicable diseases and allowed all of us to live longer. Living longer brings us face to face with the diseases of age. It isn't lifestyle changes and drugs that are keeping senior citizens alive – it is machines and doctors doing a lot of the heavy lifting in order to grant us those precious extra days or months. These extra few months of extended life are very, very expensive. We need more and better research and incentives on how to help terminal elderly live out their lives in dignity.  We need to change our perceptions about how and where to die. And yes, we need to fix how we all deal with "end of life!"  Since 2000, we have much new scientific human body information, most important being plasticity. This is providing exciting first time experiences for all .... young and old, that stimulate the brain to learn.  The brain needs continuous new learning to stay well.  This is an especially critical need in order to prevent Alzheimer's disease and extending life in a qualitative manner. 

Obamacare did not do thisand neither are Trump's politicians!

 Update water treatment facilities: 

The treatment and distribution of water for safe use is one of the greatest achievements of the twentieth century. Before cities began routinely treating drinking water with chlorine [ starting with Chicago and Jersey City in 1908 ], cholera, typhoid fever, dysentery and hepatitis killed thousands of U.S. residents annually. Drinking water chlorination and filtration have helped to virtually eliminate these water borne diseases in the U.S. and other developed countries.  

Chlorine was chosen in the early 1900 as the best way at that time to purify water for drinking purposes.  As with many novel chemical innovations, however, what was once thought perfectly harmless has turned out to be poisonous. Over the past 25 years, scientists have discovered that while chlorine is killing microbes, it is also reacting with organic matter already in the water to form toxic chemicals called organochlorines [ also known as disinfection by-products or DBPs ].

To date, several hundred known organochlorines have been found in drinking water but many times that number are chemically unidentified. Federal government monitoring programs show that many U.S. cities have elevated levels of organochlorines at the tap --- concentrations substantially higher than most public water systems. This is especially disconcerting because many of these organochlorines [ DBPs ] are known carcinogens and mutagens. Epidemiological research by Morris has directly linked chlorinated drinking water to cancer and possibly miscarriages.   Fleckenstein: unsafe drinking water 2001

Although chlorine kills all germs, it is a poison to our bodies. Chlorine is a goitrogen ---- it interferes with iodine absorption in the body. Iodine is an essential nutrient for not just the thyroid gland but every cell on the body. The halogens chlorine, as well as fluoride [ added to drinking water to prevent dental caries ] and bromide [ used as herbicide in agriculture] easily interfere with iodine absorption. When iodine is replaced by the more active chlorine, fluoride and bromide, the body absorbs less iodine and the population is then at increased risk to goiter and other diseases and disorders --- including silent chronic health problems.  Abraham: Orthiodinesupplementation  Drinking Water Chlorination

Finally, the U.S. General Accounting Office reports that there are serious deficiencies in water treatment plants in 75% of the states. According to a study conducted by the Natural Resources Defense Council, more than 120 million people may get unsafe drinking water.  Pure eEarth technologies 

Several alternatives to traditional chlorination exist, and are being used today in many countries. Ozonation is used by many European countries and also in a few municipalities in the United States. Due to current regulations, systems employing ozonation in the United States still must maintain chlorine residuals comparable to systems without ozonation.   Wiki: chlorination

Municipal water treatment plants are part of our deteriorating infrastructure. Our people cannot live without a supply of safe drinking water. Obamacare had postponed and Trump ignored fixing the outdated public water system that may be contributing to illnesses and diseases.

 REDUCING ADMINISTRATIVE COSTS 

Spending on medical care administration is much higher in the United States than in other countries, and is much greater than any analyst suggests is needed. For every office based physician in the United States, there are 2.2 administrative workers; in Canada, there are half as many. U.S. hospitals have 1.5 administrative workers per bed; that is 40 percent more than in Canada.

Our medical care system is driven by a profit motive rather than a focus on helping people prevent chronic diseases, get well and stay well.  Independent journalists recently compared the number of staff in the billing department of a hospital in Massachusetts and another in Toronto, Canada. The US hospital had 300; the Canadian facility had just three.  Changing the idea of making money from medical care to helping people stay well would cut administrative costs!  Alberti: Admin price differences 2012

Poor-quality problems in the United States health-care system cost an additional $700 billion per year in wasted payments.  Jarvis: no hea care fix 2012

 Regulating medical care providers to control health care costs:   Medical care providers should be more realistically viewed as enterprises which exercise "monopoly power." Today insurance and drug corporations not only buy politicians with their campaign monies and lobbying influences, they are also in a position to significantly influence supply and demand conditions, pricing and output decisions, excess profits, and also tend to generate inefficiencies.  These entities disrupt an equal playing field for consumers!

Consumer Reports estimates that "roughly 20 percent of the money we now spend could be saved with no loss in quality of care" and also save about 50 percent of administrative costs.   Karsten: private vs public good 1995

The General Accounting Office found that those prescription drugs that were marketed and made in the U.S. but also marketed in Great Britain, tended to carry a 60 percent higher price tag, on the average, in the U.S., with some drugs selling at five, or even eighteen times the prices charged in England.  Karsten: private vs public good 1995

 How much profit should private insurance companies make?    According to a study by a pro-medical reform group, the nation's largest five medical insurance companies posted a 56 percent gain in 2009 profits over 2008. The insurers [ Wellpoint, UnitedHealth, Cigna, Aetna and Humana ] cover the majority of Americans with medical insurance; not health care which is health promotion.  Wiki: Hea insur in USA  This excessive amount of profit, when compared to less than 10% profit that other businesses expect in order to stay in business, is a good reason to bring private medical insurance companies under control!  Thank President Obama for trying to do just that!

 Paying for health care: 

All the above issues would be incomplete without addressing how medical care should be paid for. Obamacare inherited a dysfunctional insurance system, and stumbles in a mix of insurance sponsored schemes that contribute to confusion, controversy and continued expensive coverage. The implementation of employer sponsored insurance happened more or less by accident, without good planning nor design.  

The system of employer-sponsored insurance is not well designed to deal with the problems of the costs and quality of medical care in the United States and certainly not with the most epidemic chronic diseases.    This is a complex issue and we need to briefly review how we pay for medical insurance.

 Employer-sponsored medical insurance  is paid for by businesses on behalf of their employees as part of an employee benefit package. Most private [non-government] medical coverage in the US is employment-based. Nearly all large employers in America have been forced to offer group medical insurance to their employees.

Typically, employers pay about 85% of the insurance premium for their employees, and about 75% of the premium for their employees' dependents. The employee pays the remaining fraction of the premium, usually with pre-tax/tax-exempt earnings. Wiki: Hea insur in USA 

According to a 2007 study, about 59% of employers at small firms [3-199 workers] in the US provide employee medical insurance.  Most of the businesses employ fewer than 50 persons and the initial plan had difficulties covering such wage earners. Also this plan did not provide medical insurance to those who were not working. In spite of all the legal adjustments to make this plan work, it sputters today.   Wiki: Hea insur in USA

Effective by January 1, 2014, the Patient Protection and Affordable Care Act will impose a $2000 per employee tax penalty on employers with over 50 employees who do not offer medical insurance to their full-time workers. In 2008, over 95% of employers with at least 50 employees offered medical insurance. Wiki: Hea insur in USA

Buchmueller and Monheit studied the “goodness of fit” of Employer Sponsored Insurance [ ESI ] in the current economic and medical insurance environments. Their findings:

Summary of the weaknesses of ESI system:   "There are four longstanding areas of concern which warrant important consideration. The first is portability. Particularly in a time or recession, it is clear that a weakness of the current system is the way the gaps in coverage that occur when persons lose or change jobs or otherwise..... sever employment relationships. Second, economists have long noted that the current tax treatment of ESI is both inefficient—because it encourages the purchase of more generous coverage — and inequitable — because the tax subsidy is distributed in a regressive fashion. While this remains a difficult political issue, there appears to be a growing willingness among policy makers to consider alternatives to the current tax exclusion policy. Third, currently small employers are at a disadvantage with regard to the costs and types of insurance products they can offer compared to their large-firm counterparts. Finally, the ability to maintain a prominent and sustainable role for ESI in health [medical] insurance expansions, and more generally, to ensure access to such coverage through sustainable income-related subsidies, will hinge critically on the ability of employers, insurers, and providers to actively work to contain health [medical] care costs."

Although Obamacare attempted to avoid "rocking the boat" and continue using the mix of existing employer insurance systems, the problems of such a convoluted way to provide medical insurance coverage will continue. There is doubt that employer insurance systems will survive or that these may even reduce costs of medical care.   Kelton: Hea care crisis 2007  The major problem of employer based medical insurance that is overlooked is that the employers pass on the cost of medical insurance to the products they make. This makes their products less competitive on the global market and something that President trump is oblivious to.

“It is a well-known fact that the U.S. automobile industry spends more per car on health care than on steel,” said Lee Iacocca, the retired chairman of the Chrysler Corporation, who is one of the few business leaders to advocate openly for national health insurance. 

National medical insurance dramatically lowers costs of medical care and in turn, allows US businesses to be more competitive in the global market.

 Adopt from other systems:   Although there is no single best medical care system in the world today, some systems work better than others and these are cost effective.  We can learn from rich [ Canada, Germany, Switzerland ] and poor countries on how to best reform the medical care system. Contrary to common perceptions, the German health insurance system, "is not government run, in either its financing or its delivery. "The government prescribes policy but private parties finance and deliver services."  It functions "to mandate, specify, authorize, referee, consult, collaborate, regulate, monitor, and supervise."   Karsten: private vs public good 1995

 Summary on reforming the medical care system: 

There is no shortage of ideas about fixing the medical care system. By now you, the reader, have your own suggestions about fixing our broken medical care system. The cartoon below also has a suggestion!

Almost every president since President Roosevelt in the early 1930's has failed to provide medical care legislation. We need to commend President Obama for attempting to do the impossible with a dysfunctional congress and senate. Although Obamacare has many empty holes in it, getting everyone insured would be a gigantic step toward a sustainable medical care system.

The nature of the medical care system aside, the real medical problems are not medical doctors, medical care providers or hospitals. Instead, we have an invisible cultural problem of faltering morality in politics and how we live --- about doing harm instead of good. Other sensitive problems are the out of control medical - industrial complex and the behaviors of people --- their lack of self discipline to exercise and eat properly. Seventy percent of all health-medical expenditures in the United States are devoted to treating chronic diseases; only 4% of the medical care budget is focused on primary prevention. Cohen: Making health care healthy 2010

It should be evident by now that the majority of people have bad behaviors and habits and lack the acumen to make wise choices. Our American culture has spawned a disease culture and poor life style.

The real solution lies in reforming our screwed-up civilization.  The current health care and medical system is based on the old-model Flexnir's proposal for improving healthcare in 1910. It got further reinforcement from the 1948 WHO definition of health. Both ideas foster treating battlefield injuries. As of 1995, our health problems are not battlefield injuries but instead chronic diseases.  Unfortunately, the health care system and medicine are still using an outdated paradigm that will never fix the broken health care system. We need a wholesale culture change that also includes a medical, political, moral and economic upheaval as well.

 There will be no real success in real medical care reform until the political system is reformed and congress and senate begin to function on behalf of the people.  Government attempt to “reform medical insurance for all or Obamacare” before fixing the dysfunctional congress and senate is putting the cart before the horse.