The Healthcare System

I will write something up as a .doc or .docx. Or .rtf. Just let me know what you prefer. Might take a couple of days. Lived in Canada and the US and my parents were in science and my husband is a psychologist.

.doc format is fine, Kathryn. Thank you.

I think the medical care provided is excellent in the USA. But the unbelievably high financial costs associated with that care is truly abysmal. So, too, the cost of purchasing health insurance. In short, the American Healthcare system is schizophrenic - a mix of the excellent and the abysmal. You have no universal healthcare - what you have is a disgraceful third-world system grounded in a person's ability to pay; and God help you if you cannot afford it. Your pursuit of health and thus happiness is directly related to how much money you have got. There is no inherent equality, in reality.

That is so true and it is another case in point about the US that we have extremes.

Thank you, Magi and Kathryn. It's those kinds of issues which I'm aware need to be addressed.

They are pressing issues! They go to the heart of what democracy is ... is democracy for the few who can afford health care or the human right of all, regardless of their ability to pay?

Even the health care of a affluent needs to be addressed, Magi, but there are a lot more people at the other end of the spectrum whose needs are not being met. Thanks.

Australia on the other hand has universal Medicare, paid for (in theory) by a 1% tax surcharge. Doctor's visits are free, but Pharmacy prescription charges are expensive. Medicare funds 75% of theatre costs for operations, to a scale set by the Medicare Benefits Schedule in which the Health department sets the estimated reasonable cost for each operation. Hospital room fees are not covered unless you have private Health insurance. Private Health insurance covers the room rental at the Hospital, and the 25% surgical fees not covered by Medicare. It sounds perfect, but the MBS has gone up by an average of 1% per year for the last 20 years. Actual charges have gone up by 4% or more each year. I need knee reconstruction surgery due to a water skiing accident: Medicare pays $800, Health insurance pays $200, Surgeon charges $2500, which I must pay in advance, then claim the 1/3 back from Medicare & Health Insurance later. In other words we have a perfect system except that it is 2/3 under-funded.
Maybe this is the best we can do?
Medical advances present us with ever increasing but very expensive treatments, and if the Government funded 100% of them, demand would be infinite and the system would bankrupt the country. There has to be a rationing system to keep demand and supply in reasonable balance, but I'd like to see the Medicare Benefits Schedule doubled immediately, then indexed to inflation.
David is having Laser eye surgery on Tuesday - because it is "elective surgery", Medicare pays zero, Health Insurance pays $1000, cost is $6800.
It all adds up, and I need to plan my surgery around when I can fund it rather than when I need it. Democracy give you a right to vote: Healthcare is always a balance between what the voters want, and how much they are prepared to pay in taxes, so democracy is for all, healthcare is for those who can afford it. Everyone in Australia gets for free what the health system could deliver in 1950, it is all the expensive procedures invented since then that are unaffordable by many people, and funding universal access is unaffordable by society.

Thank you for your very thoughtful response, Allen. In addition to increased funding, cost containment has to be part of the approach I feel. Some of the interventions used by our government and insurance carriers have probably actually added layers of cost to the overall system. If we could eliminate the need for those layers, then eliminate them, that might be part of the solution.

I have a ton of medical bills right now, as my kids have had quite a few medical issues lately. I find it sad that it's over $1300 for me to take Angela to the ER for her broken wrist. She would have gotten better care if I had waited 12 hrs and taken her straight to the orthopedic....and the cost would have been around $300. (Though if I had waited, DFACS would probably have gotten on my case).

One broken wrist has cost us over $3000 so far. Our share is over $500.

Thanks, Jax.

I'm terrified of doctors. All I know is my monthly insurance bill is way high.

Thank you, Pam. Back when I was in full time practice I had several patients who were terrified of physicians, sometimes with good cause. It is very rewarding to win their trust.

I don't ever go to the doctor. I've never had one. When I'm sick I just go to bed. If something really bad happened I'd go, of course. I'm not afraid of them or anything like that. I love the downtown hospital - it's like walking into a grand science fiction movie.

Thanks, Peter. Many articles have been written about how men resist seeking medical attention unless they're in health crisis.

I did go to the Target clinic once when I thought I had ringworm on my foot and I couldn't get it to go away by myself (and one would never go to the emergency room for ringworm!!!). They told me it was actually eczema and I could stop pouring bleach on it, LOL. I got a $4 prescription for a generic cream that worked right away and that was that ...

Thanks, Peter. We don't have store clinics around here, but I saw a comparison recently with costs from an emergency room, a private physician, an urgent care "doc in a box", and a store clinic. The store clinic was the cheapest.

It was just two nurses running the whole thing but it was very nice and for once I had some of my vitals checked as part of their routine even though I was just there for the skin on my foot, and they told me I was fine! That's always nice to know.

(They even clamped an odd little clip thing on my finger and told me I was at 100 % and looked happy about that! Woo-hoo)

"I had some of my vitals checked as part of their routine even though I was just there for the skin on my foot..." That's standard of care, but wasn't always. The pulse oxymetry is standard of care for many things, but is not always done for some skin problems.

I have had so many experiences with doctors and hospitals, for myself and loved ones. I have to say, I have Medicare as primary, and NYShip Blue Cross , Blue Shield, from my husbands job. I have had cancer twice,, both major and one with chemo , and never had to pay more than 200.00 co pay. I can't complain there. I do complain with some of the mistakes hospitals make, one that I think caused both my husbands passing, and one for my son. Bad judgment. Even my primary care doctors agree with me, but it was not their doing. I may have to have to go to a hospital soon myself, and am afraid out of my skin because of those experiences. Hopefully , it won't happen. Otherwise I have always had the best of care from my Primary care doctors and my surgeons, Good luck
on figuring out how to fix this Obama care which is already causing me higher co pays
and notices on my doctors wall that they will be able to treat me if I am ill, but not get
the tests I have done regularly Also my co pays on drugs have gone up:), Great work John, love, Elsie

Thanks, Elsie. Errors in the hospital setting are being addressed but much more needs to be done.

What would you say is the third leading cause of death in America, John?

This is a good article a Gather member recently wrote, sharing his experience. I think it's a great addition to your invitation to share.

Thank you for the link and for directing me there. Certainly there are several lessons to be learned from his experience.

You're welcome. I was wondering whether any of the committees on which you serve address the iatrogenic events described in that post, Elsie's comment, and what Orbus Argentum alludes to in his comment. If so, what measures are being taken to reduce the massive number of these types of events. If not, why not?

And Bill Allin is in Canada!

Yes, that's a good point a bit ahead of itself here. :)

Although my post is a request for input, Sue, I'm aware of the article to which your first question refers. As I stated, I am not in a position to fix everything. In terms of technology and procedures, many efforts are being made to reduce errors and to provide physicians and other professionals with immediate and pertinent information, recognizing that there is too much information for physicians to practice on the basis of their memories. Technology and procedures are being put in place to catch errors before they happen. Some institutions are farther along than others. Wrong site surgery should never occur, for example, and is one of a number of "sentinal events" designated by Medicare to cause hefty penalties to be imposed when they occur, yet some hospitals don't adopt those safeguards and wrong site surgery continues to occur in some places.

I wouldn't expect any one individual to be in a position to "fix everything," John. That would be foolish of me to expect, and just as foolish for someone to think I would expect.

I said I was wondering whether any of the committees on which you serve address these iatrogenic events. I guess they don't because your answer is only a general one, that "many efforts are being made to reduce errors and provide...information. Since you're familiar with Death by Medicine, then you know that these events are not limited to surgical procedures and wrong site surgery. The over-prescription and mis-prescription of antibiotics alone for viral infections that are not bacterial and so should not be treated with antibiotics costs billions of unnecessary dollars, not to mention the immunity they build so that the antibiotics are ineffective when someone really does need them for a bacterial infection. That's just one of the many problems, as you well know. I won't even begin to address all of them. The iatrogenic causes of the costs of health care, both monetarily and to people's lives and well being must be the major issues of concern when considering reduction of costs in insurance premiums and in any government sponsored programs before any real change to the system of health care can be addressed and executed. Without those considerations seriously in the major talks about health care reform, there can be no reduction of cost, and that seems to be the major concern of people who do use the available avenues of traditional medicine on a regular basis.

Sue, we agree more than you can imagine. I didn't post this to defend the health care system or the actions of "providers", I'm hoping to help address solutions. The examples I gave regarding surgery were only that--examples of procedures which have not been adopted as widely as they should have been. Organizations have fought the overuse and inappropriate use of antibiotics for literally decades, yet the practice continues. One way this is being addressed is by linking information to symptoms, problems and findings. Another is standards of practice where deviations must be justified and are reviewed, in some cases linked to remuneration and other penalties and "carrots". I agree that the concerns you have identified are real, serious, and among the issues I want to hear (read). Thank you for your thoughtful contributions to this effort.

Then I should thank you very much, John, because it's essentially important that someone who has authority on this issue recognizes the scope of its significance in the health care debate. The answer you just gave me about the fight for misuse of antibiotics and the ways it's being addressed is what I was going for. I'm so glad to see that someone like yourself isn't going to try to minimize the problems if only to help make the general public aware that the debate about whether the same health care is administered through the government or private enterprise is only secondary in the issue of quality care and cost for that care. The problems cannot begin to be solved without a recognition of the cause. Moreover, if two vendors are selling the exact same candy bar on two different street corners, it doesn't make any difference from which vendor you purchase them, and their cost is not going to be significantly different. I'll check back in time to see where this discussion you've begun leads. I hope there will be a lot more to read about how these iatrogenic problems are being addressed and what we can do to help put this issue in the forefront of the health care debate where it belongs.

I might do that, Sue. I'm not really in a position of authority but I do have input here and there. I'll admit that I've mentioned a few things which are being done to minimize or correct problems but that is a topic in itself. I'm trying not to muddy the water of this post, which is intended as information and opinion gathering from Gather friends like you, and I very much appreciate your input. I have seen patients prescribed a medication for fainting which aggravates the problem. I have seen patients prescribed medications which interfere with kidney or liver function when those functions were already impaired, and appropriate alternatives are available. Partly through technology and partly through process changes, these kinds of problems can and must be reduced and eliminated.

Until I turned 65 a year ago February 14, I had Blue Cross Blue Shield. Now I have Medicare and the supplementary MedEx from BC/BS. Over the years, I have experienced wonderful coverage from BC/BS and so far under Medicare, everything has been fine. (The ten month battle of my son's with aplastic anemia cost BC/BS 1.6 million dollars. We paid nothing.)

This year I've only had a routine visit to my primary care doctor and a colonoscopy last spring.

Thanks, Bob. I admit that when I had my first colonoscopy it was when we were going to present a program on colon cancer prevention and I feared that someone in the audience would ask when I had last had a colonoscopy. Actually they removed an adenomatous polyp and my followup was clear. I was constantly after one of my patients to have one but he declined until it was too late. Another patient I had repeatedly recommended a colonoscopy and he refused until one of my medical students (a bright girl from Estonia) somehow convinced him to have a colonoscopy and he had cancer, but at a stage early enough to cure; she saved his life.

After arriving in Perth on the 17 Feb., both Magi and I developed bad colds (long air flights as you well known can do this)...Mag went to Doctors last week and it cost him nothing; I finally went today because I couldn't get over sore throat, headache, stuffy nose and cough. It cost me $55 for 22 minute doctor visit (not bad, huh?) and $ 17.25 for prescription drug (Roximycin). Dr. McNamara said to save receipt because I probably could submit it to Medicare when I got home. I have no idea whether this is true or not.

Although I have told Mag he needs a colonoscopy, so far he has refused. I will show your comment to him when he gets up from his nap.

I was polyp free. I was told I didn't have to have another for 10 years but I think I would feel better having one every five years.

I had a minor injury in Brisbane - the pointed toilet seat jabbed me in the kidney area. The hotel called the doctor and the doctor came and wrote me a script for a pain medicine and to get a truss from the chemist's and to wear it for a week, blood in the urine for a few days and after a couple of weeks, it will be better. The hotel paid the doctor and I paid a few bucks for a truss and pills. In England, when I was 19, I had to go to a doctor and she didn't charge me. Not because I lived in Canada, just...

I tend to think that when a person eats mostly a plant diet, that they are a lot less likely to get polyps or colon cancer. When I came to Boston in 79, I was living with a first year resident at one of the hospitals here. He brought me the transcript to the results of the Framingham Heart Study that Dr. William Castelli directed. The study discussed not only the heart, but that vegetarians have less cancer as well as less diabetes and fewer incidences of cardiac illness. Noting that colon cancer is epidemic among the heavily meat-eating cultures in the US but is not so among vegetarian cultures.

Yes.

I've been wanting to write up an article about some of the misadventures my mother had last year when she fractured her hip. There are a mixture of elements and a couple may not pertain to what you want, but I think they all need to be aired. The weekend is coming so I will make an effort to get you your own document and maybe even post it as an article. I think this is a very important thing that you are doing and asking of us. I just wish it would happen more often. Thank you John

Thank you, Orb. If you want to post it as a Gather article, I'm sure to see it. If you prefer to send it to me, that's fine too.

Dr. Mark Vonnegut (son of Kurt Vonnegut) in his memoir "Exactly Like People Without Mental Illness But More So" - Dr. Mark has bipolar illness and practices pediatrics in MA - Dr. Mark wrote that if someone were to say, 'you'll wait hours in the ER for not so good care and weeks for an OP appt for not-so good care, I would ask 'what third world country are you talking about?'

Thanks, Kathryn. Several issues need to be addressed in that regard, including why should there be a wait for emergency room care, why is the care not so good (if that's the case), and why should there be a wait for outpatient appointments? Advanced access attempts to make available to the patient the doctor of their choice when the patient wants to be seen, including same day if appropriate.

That would be an improvement, yes...

It's done in some areas. It's not easy.

Today I went to Mag's Clinic at 9 AM and explained why I needed to see a Doctor and she asked how close I was to the Clinic. When I said "less then a mile",she asked if I could come back at 10:30 for an appointment. I couldn't believe it....be seen on the same day? Wow!

that is interesting. Also, we have 300M and Aus has ?25? Canada 30M. But we could manage things differently and better if we were not tied to a capitalist model.

Well, maybe I will write more later when I have more time... but let's just say for now that I am pretty d*rn glad to live in Germany. Some Americans consider our health care system to be socialist (know that from Gather), but at least it is SOCIAL.

Thanks, Christine. I'll be looking for your comments about what you like and don't like about your system, and any encounters you have had, positive or otherwise.

Ok, will try to get some of my thoughts to digital paper now. It's a difficult topic in English *lol*

Anyway, the German system - like many European health care systems - is definitely very social compared to other countries.
We Germans pay a fixed percentage from our salary. Had to look it up: We employees pay 8.5% from our income and the employer pays an additional 7%.
Up until a few years ago, the percentage was 50/50 for employer and employee PLUS the percentage was varying depending on which insurance you were member of. But this system started too collapse and expensice insurances got less and less members (logical, if you ask me!) and *bam* we all have to pay the same percentage now :-( Hubby and me now pay more as our insurance was 3% less expensive. Grrr...
[numbers from http://de.wikipedia.org/wiki/Gesetzliche_Krankenversicherung]



The big advantage I see compared to the American system, is that we usually do not need to pay much out of our own pocket. Unless you are member of a "private insurance" (e.g. as civil servant) and your insurance wants you to pay a certain percentage yourself.
So, when I am sick and go to the doctor, the visit does not cause a cost BESIDES a €10.00 fee I have to pay every quarter. That fee is a horrible invention they implemented a few years ago. The purpose was to stop people from "doctor hopping". So I have to pay this fee cash at the first doctor I see in a current quarter. When I need to see another doctor in the same quarter, the first doctor has to give me a referral. As I need thyroid hormons every three to four months, I am really annoyed that I need to pay that d*rn fee just to get my receipt!

Medicine is also not really included anymore. On some you have to pay a certain percentage, e.g. €5 but most you have to pay yourself. It depends on what the stuff is for.
My thyroid hormones cost me the flat €5 per pack and the contraceptive pill was either totally on me or I had to pay a percentage - I do not know what's correct, but I know I had to pay around €60 per 6 months. I guess that this is not the full price though.
My mum has some chronic illnesses and her insurance pays most of it.

At the dentist, the regular stuff is included (check ups) but anything extra (bleaching, professional cleaning or any prostheses) needs to be paid by ourselves.


We also do get a lot of check ups to prevent illnesses. I recently discussed this with Amber over on Mylot (she is also here). The topic was a check up for cervical cancer. I think she wrote that she needs to pay for it. Mine is free TWICE a year ^^
And with 30 or older we can have a check for skin cancer regularly.



We often whine about our system and that we have to pay a lot. But I try not to. I try to be happy that we have it and that it is better compared to many other countries.

Of course, a social system like this has disadvantages for people like my hubby who are sick maybe once in a blue moon, but on the other hand he supports me *lol*

Thank you, Christine.

Here is an interesting article from the NYT on the health care systems (15) of them in Canada. Not much info, but an interesting perspective. I'd forgotten that each province and territory administers its own provincial system. We in the USA never mention that.

http://economix.blogs.nytimes.com/2009/07/07/how-does-canadas-health-system-actually-work/

Canada's personal income tax is about 40 percent, which goes for the health care system, vastly lower educational costs and other goodies.

McGill or any university in Canada has a multi-tiered tuition structure. A few years ago (about 4 years ago) for American and other non-Canadian citizens worldwide, tuition was about

$15K a year, not including room and board.

For Canadians outside of the province in which the University is:

$6K a year, not including room and board.

For Quebec residents,

$3K a year.

Northwestern's Medill graduate program was 12K tuition for 12 months when I went there 30 years ago; now, it is $48K tuition one year.

I mention the tuition because, tuition and health care, both so important for a civilized society, are both out of reach for many more Americans than before.

At UMass-Amherst, the total tuition bill for 4 years for a MA resident:

$12K tuition, total cost $25K

Out of state:

$25K tuition, total cost, $35K

It is the availability or lack of healthcare and the availability or lack of education that makes a country a leader or behind in the pack.

In the USA, both healthcare and education are increasingly forcing US citizens to be behind the pack. This trend will continue.

Interesting, Kathryn. Thank you.

I live in the UK, where we have a national health service. Nowadays, the NHS is creaking, but not yet broken!

Medical care is given at the point of need - no insurance forms, no 'can I afford this procedure'... If an emergency, then you are treated very quickly.

I have a couple of conditions which necessitate me taking medications for the rest of my life. Because of the nature of ONE of those conditions, I get all prescriptions FREE. My asthma meds alone used to cost me about 20 GBP per month (heavily subsidised by the NHS).

People over retirement age, those still at school and other conditions such as coeliac disease get all meds free.

Thanks, Ishbel.

I have had numerous experiences — some good and some awful. Suffice it to say that I've told all my friends and family (when asked) that as soon as our mighty government officials (from the President on down) are in line to receive the medical care they want everyone else to have, I'll be the next one in line. However, as long as they have their own plan, I'll never support it... Thanks for asking, John and for doing what you do.

Thank you, Marilyn.

I want to feature this for you, John.


Featured in Issues in Healthcare in the Triple Name Club.

Thank you kindly for the feature, Kathryn.

I just stopped by to let you know I miss you on Fox.

I am in no way related to Glen Beck.

I've been a Kaiser member since 1964. I don't mind it at all. You have to be assertive and look out for your interests but you can get decent care at low out of pocket cost. It's not a good system for people who are unable to be their own advocate. OTOH knowing that a major medical experience will cost a few hundred dollars in copays with no problems with disputed claims after the fact is reassuring.

There are two interesting aspects to Kaiser. It's a nonprofit and it's run by the doctors.

Thanks, NK. Kaiser played a significant role in the conference I attended last week.

Harvard Community Health Care that started in the 80s was based on Kaiser. It morphed into Harvard Pilgrim and such. HCHP was the first HMO we had here. They are okay, but I preferred when we had double coverage with the Commonwealth of Mass.'s Blue Cross plan, which was excellent.

Thanks, Kathryn.

If you have a weirdo disease (I have post-Lyme issues) it's only the most expensive and flexible health insurance plans that will truly take care of you. When I was under Fallon Health Care, a highly-rated HMO, there were only one or two specialists available in each field, and if they thought my disorder was in my head, I was out of luck.

Now that I have Blue Cross through the State of CT (and I'm sure the State pays through the nose for this insurance), I can see any doctor I want anywhere in the country, and my health care has improved tremendously.

One last comment-- the malpractice laws are so strict in the Northeast that they scare many doctors. I've received better treatment in New Mexico due the fact that there is a cap on malpractice settlements and the doctors feel freer to experiment.

Interesting points. Thanks, Ann.
Where was the Fallon Health Care?

I think Fallon is New England based only. I've been and it is not bad.

Fallon is in Massachusetts only. It's been rated #1 HMO in the country more than once on national surveys. It still does a poor job with little-known diseases, though. That's a downfall of HMOs.

My mother in law had a choice between a Medicare HMO and another Medicare program. She chose the HMO because her medications would be paid for. The setup is that physicians are financially rewarded for denying care. Her doctor prescribed toxic doses of cheap medications instead of the thorough evaluation she needed. I advised her to get out of the HMO if she could. She did and received appropriate care. That's not to say that all HMO's are bad or that all physicians working in HMO's are greedy.

Fallon is owned by doctors and generally okay. It's supposedly non-profit, but they pulled a barely legal maneuver a few years ago when they SOLD a public hospital that the city of Worcester had given them for free. The senior Fallon doctors banked over $100,000 each from that sleight of hand, which was uncovered by The Boston Globe.

I have no suggestions. I seldom get sick and it's been years since I've been to a doctor. At my age that's a miracle. I have Medicare but have never used it. I think they only pay part of a bill anyway.

Thanks, Lee.

Looks like you pushed a "hot button" here...more to come, I'm sure.

Thank you submitting to Gathers Luminous Writers and Artists.

Thank you, Stephen. There's a lot that needs to be done.

Having seen various healthcare systems, I have some ideas that would bring down costs.

I would be most appreciative if you would share them, Bill. Thank you.

I did write a full page, but I want to edit it before posting.

I could write more than a few pages on this, John, but I decided to focus on one issue, and that is that it appears that the federal government is making it extremely hard for family doctors to survive in individual practices. I believe that having a family doctor that knows you is very important in keeping each one of us proactive in our own health. If government health care rules and payments undermine the business of our local doctors, I think we will all pay a price both monetarily and in a degradation of our health

Thanks, Richard. Your comment is well taken. My "right hand", Jayne, knew our patents well also, and I feel that helped in their care.

First of all I would like to say I think personal choice should be respected in a free society and that includes all fields of medicine. I understand situational protocols, but these should be looked upon with only the necessary restrictions.

My experience with the VA here & in Germany and 16 years of excellent Japanese ‘social’ medicine gives me a different perspective. I do not like many of Prez Obama’s policies, but Obamacare will eventually change medicine availability for the better with price stability, but in the short term it is going to cause an economic pinch.

What the GOP should be doing is to focus on getting rid of the penalty for those wanting to opt out and let the average citizen decide with ‘freedom’ what they wish to do. In Japan, the socialized medical bill isn’t cheap. I believe my family of four paid about $14,000 a year in the 90’s.

Many in Japan opted out, with no penalty, and there were plenty of alternative medical practices. These were not fly by night practitioners, but people who practiced ancient medical therapy. I would like to see people in the ’Land of the Free’ be able to decide if they want to try or apply to an alternative medical therapy/belief. I would like these alternative medicine therapies to not face Big Parma driven FDA close down. The FDA in doing this (documented many times) shames our Constitution, in my & many opinions.

However, not all was/is rosy glasses for the Japanese person opting out. Just like in the ’Land of Freedom,’ people lost their houses and went into debt to pay for a life threatening disease or crisis. This is sad, but the Japanese seem to have more freedom than we under Obamacare.

We have to get hospitals out of the GP business, so they can focus on patients with serious needs and do research. Hospitals once made discoveries often by real caring documented research. We need many more clinics in the USA with a GP who cares and has not sold his soul to Big Pharma. We need many clones of Michael Fox.

This means more Federal/State funding of hospitals with hopefully only the more brilliant, eclectic and freedom loving doctors, who should be honored and looked upon as National Treasures. Not just any doctor should be allowed in this elite circle. Only those doctors who have written research papers, positively commented on by at least thirteen hospital doctors, performed with excellence at an ER or GP clinic.

Under our current system, this sounds like pie in the sky and is why we need public positive changes in how we train our doctors. The Residency requirements are nothing more than indentured servitude. Again, FREEDOM! As an American I insist freedom that causes no harm be respected. The AMA or some venture business should set up many clinics in every town and village in the USA and have an ER or GP clinic staffed by Residents. (They should be immune from lawsuits unless proved criminal behavior).

Clinics will have long waiting times making a change in how people look at whether or not they actually need health care. This should drive prices down. You might say there are not even doctors for clinics, but yes there are, if you toughen the licensing standards to get say a Plastic Surgery degree. Just a few thoughts.

Basic healthcare. Basic right. Free choice paying insurance for the extras.

Important principles. Thanks, Sheila.

The discussion here is good.

And I thank you, John, for all your efforts toward helping improve health care.

Thank you, Barbary. It will take many, keeping what works well, rejecting what doesn't, and innovating constructively with careful evaluation of the consequences.