I spent about two hours this morning talking to one of the young doctors that did his fellowship here a few years ago, did phenomenally well and now is climbing quickly climbing up the vines toward a stellar career here at UPMC. I respect him a lot and I am proud to have been a part of his professional nurturing. He spends most of his time at one of the other UPMC hospitals and drops by to see me now and then when he’s around.

Like most doctors, he’s a voting Republican. I think he is clearly more on the moderate end of the spectrum, which I suspect a greater percentage of advertised Republicans are. He claims to be a “conservative”, but he differs radically from most of what I’m hearing other (said to be) conservatives are saying on “Events”.

At any rate, we had a long conversation about a lot of things and I think his opinions are very interesting and worth relating to you. Here are some of his expressed opinions as best I can interpret them.

1.  Being “conservative” doesn’t necessarily mean being a nut.

There are some politicians out there that use the “conservative” angle as a platform to extol their social theories that are not necessarily what a lot of other “conservative” voters believe.  In fact, many conservatives think of Sarah Palin as a self promoting opportunist who happens to stand on a conservative platform because it tends to gather a bigger crowd. Rick Santorum is a radical evangelical purist who calls himself a conservative because it resonates to a smaller but more vocal crowd.  Newt Gingrich is a cold blooded politician that has been working the system for many years and has figured out how to use conservative angles for his own financial and political benefit.

But in fact, a conservative is just a reasonable person who is concerned about reasonable things. Fiscal responsibility. Treating people as you would like to be treated. Some degree of personal autonomy in a world full of regimented political mandates. Things most reasonable folks subscribe to (Gasp….even some Democrats). The problem is that those principles have been hijacked by self-serving, self-promoting persons using them as a base for their own social restructuring programs in the name of all conservatives. The current sitting President is not Satan incarnate. He is a person whose policies are perceived as contra-productive to the GOP ideal, and therefore they oppose his policies, not the man.

The reality is that the majority of Republicans don’t subscribe to the Sarah Palin brand which is why after all the hoopla, she is sitting in a cabin in Alaska instead of being intimately involved in Republican issues.  If she thought she’s get more mileage from the American Nazi Party, she’d be wearing jack boots tomorrow on Fox. It is also why Santorum is getting about 10% of the vote anywhere but in States infested with evangelicals. And “most” responsible Republicans are appalled and embarrassed by Newt Gingrich and this will be a self correcting issue in time.  In the end, the GOP will do the best they can with what they have to work with, just like everyone else. Time smooths all wrinkles.

2.  Some of his VERY interesting observations about the Affordable Health Care Act of 2008 (AHCA/2008).

He thinks the AHCA/2008 is unconstitutional because it allows the Federal Government to MANDATE what amounts to a tax by some other name without calling it a tax. There is no precedent for the Government doing that. It is extra-constitutional for the States to do exactly that (Mass), but not the Federales. The most effective way to afford health care for all citizens is simply to create a tax to support it (just like Medicare/Medicaid). The reason that was not done is as soon as any voter hears or sees the word “tax”, they immediately vote against it as a knee jerk. Residents of affluent townships routinely vote against school tax increases that benefit their own children.

So the theory of the AHCA/2008 is technically correct as far as it goes. It definitely does good things for the population. Contrary to some highly biased sources, there is no language in it creating “death panels” and no specific restrictions as to who will be treated. However, there is a 600 lb gorilla sitting in the room. The fact that under current regulations COBRA and EMTALA, everyone presenting for medical care has to be seen and treated to their satisfaction regardless of their ability to pay. So that means there is no incentive for younger, lower risk patients to purchase indemnification and virtually no practical way to make them if they refuse. You can’t get much blood out of turnips. And if they don’t, then the point of spreading the risk to lower the cost is lost.

So, unless the law mandates that anyone that didn’t purchase the plan will be REFUSED medical care if they get sick, the plan can’t work in practice even though it’s technically right minded. And the voters will never sit still for any refusal of service no matter how it’s applied.  So, if the AHCA/2008 is trashed by the SCOTUS in March, we then go back to a system that is very rapidly and reliably going broke. Even if it’s implemented on time in 2013, it’s probably already too late to save our current Medicare/Medicaid system, and the private insurers are already in the process of pricing themselves out of the market.

The reality is that there is only one way to provide health indemnification for all comers in the USA, and that’s where it’s applied in virtually every other country- a straight up National Health Care Service just like the UK does it, with an option for the well-off to purchase more if they can. This from the mouth of a Republican(who knows the system). Traditionally, private indemnification has been a GOP hallmark, but it suffers from a double whammy: 1)  They cannot keep up with the never-ending escalation in cost, and 2) the coming laws disallowing them from cherry picking only low risk patients will finish them, just like it would finish a car insurance agency that was forced to charge drunk drivers the same as safe drivers.

The voters (and the GOP) want it both ways. They want cheap, efficient health care without Government input and they also want unlimited benefits. The Government can’t afford that and neither can the private insurance companies. We will continue on that course until the system we have now collapses, and it will…..in my lifetime. When it collapses, there will be only one way to re-build it. That will be with restrictions as to how much money is spent on non-viable resources, and it will be tied to a GNP. There will be no dialysis after age X, no unlimited ICU stays awaiting the pie-in-the-sky-bye-and-bye-long-shot-cure, no instant MRI for trivial complaints, extremely limited transplantation, no unrestricted ED admission for convenience complaints, and on and on and on. It will be that or it will be nothing. Pay or die.