John Mackey's Suggestions (Health Care)

[Pangloss]

Interesting op/ed piece in the Wall Street Journal today by John Mackey, the CEO of Whole Foods, which runs a chain of natural-oriented grocery stores around the country.

 

http://online.wsj.com/article/SB10001424052970204251404574342170072865070.html?mod=googlenews_wsj

 

He mentions several suggestions for overhauling the industry that would be an alternative to the Obamacare or single-payer approaches, costing less and focusing more on cost reform and less on universal coverage, which he denies is either a right or a necessity (I agree, though I am willing to spend SOME to cover more, but not at a cost of a trillion dollar deficit for the forseeable future).

 

Let's take a look at some of his specific suggestions:

 

• Remove the legal obstacles that slow the creation of high-deductible health insurance plans and health savings accounts (HSAs). The combination of high-deductible health insurance and HSAs is one solution that could solve many of our health-care problems.

 

Perhaps. I'm not sure what obstacles he means here and he's somewhat vague with this, instead just giving an example of an HSA (his own). Anybody know anything about this?

 

• Equalize the tax laws so that employer-provided health insurance and individually owned health insurance have the same tax benefits. Now employer health insurance benefits are fully tax deductible, but individual health insurance is not. This is unfair.

 

I agree with this. It's not the central problem with private health insurance, but it would help.

 

• Repeal all state laws which prevent insurance companies from competing across state lines. We should all have the legal right to purchase health insurance from any insurance company in any state and we should be able use that insurance wherever we live. Health insurance should be portable.

 

I agree with this as well. I'm not sure I understand why this isn't already the case, but it's probably as he says -- state laws differ too much to allow portability. This would seem to be an obvious thing to fix.

 

• Repeal government mandates regarding what insurance companies must cover. These mandates have increased the cost of health insurance by billions of dollars. What is insured and what is not insured should be determined by individual customer preferences and not through special-interest lobbying.

 

Well he has a point at the end there, but what he's covering up is the fact that his suggestion just favors a different special interest lobby -- the insurance industry. And those mandates didn't go in under a vacuum -- they were put in because those things weren't being covered.

 

This is the part that partisans on either side never quite seem to get. It ultimately doesn't matter why it isn't working, at least in terms of leveling blame at Democrats, Republicans, liberals, conservatives, socialists or free-marketers. What matters is that it isn't working. Which is why people don't ultimately care whether the fix is "socialist" or "capitalist". They care about whether it's going to work, and they understand that cost, both individual and national, is important, just as care and coverage are.

 

• Enact tort reform to end the ruinous lawsuits that force doctors to pay insurance costs of hundreds of thousands of dollars per year. These costs are passed back to us through much higher prices for health care.

 

I am always very leery of tort reform, but I am keeping an open mind about it, given the advantages of some kind of limits. This is something that's going to have to be looked under any of the three systems being considered.

 

• Make costs transparent so that consumers understand what health-care treatments cost. How many people know the total cost of their last doctor's visit and how that total breaks down? What other goods or services do we buy without knowing how much they will cost us?

 

I agree, though I thought that was already happening. Have any of you guys seen how a lot of hospitals do it now, where they print out all of the costs line-by-line and make sure that you see the bill, even though your insurance is ultimately the payer? I think it's quite fascinating that they do it that way, and I'm surprised they do it because it says as much about the hospital as it does about the insurance industry. Maybe it's a HIPPA thing.

 

• Enact Medicare reform. We need to face up to the actuarial fact that Medicare is heading towards bankruptcy and enact reforms that create greater patient empowerment, choice and responsibility.

 

I agree, unfortunately the only proposed model that actually seems to solve this problem is single-payer. Yes, Medicare is already single payer and it has this problem, but that's because it can't control costs the way Canada does, because the private sector still exists.

 

But if we go single-payer then we adopt all the problems faced by Canada, France, etc, too (e.g. wait times). So maybe it would make more sense to try a reform based on backing off and regulating correctly.

 

• Finally, revise tax forms to make it easier for individuals to make a voluntary, tax-deductible donation to help the millions of people who have no insurance and aren't covered by Medicare, Medicaid or the State Children's Health Insurance Program.

 

Interesting. Seems unlikely to solve the problem of the 47 million uninsured, though.

 

What do you all think? Is there any chance for reform under a fully privatized system?

[iNow]

Perhaps. I'm not sure what obstacles he means here and he's somewhat vague with this, instead just giving an example of an HSA (his own). Anybody know anything about this?

I'm not sure, but my initial impression is that these "obstacles" have more to do with the need to ensure that insurers keep enough money on hand to actually cover claims... That's just a guess, though.

 

 

 

This is the part that partisans on either side never quite seem to get. It ultimately doesn't matter why it isn't working, at least in terms of leveling blame at Democrats, Republicans, liberals, conservatives, socialists or free-marketers. What matters is that it isn't working.

Well, yes and no. I certainly agree with you that it has nothing to do with party affiliation, but it absolutely matters why it isn't working. If you do not understand the root of your problems, then you cannot implement a fix which will adequately resolve them.

 

I deal with this all of the time in my operations work. Problems appear ALWAYS. The first step... before practically anything else... is to understand the root cause... do an 8D analysis using some sort of six sigma techniques... and focus on that. However, trying to fix a problem before you know why you have that problem is futile.

 

Again, though... I fully agree that it has nothing to do with party affiliation or ideology.

 

 

I agree, unfortunately the only proposed model that actually seems to solve this problem is single-payer.

It may be seen as unfortunate, but I do think it's true. I tend to support single payer... at least, if it's done right, you know?

 

 

But if we go single-payer then we adopt all the problems faced by Canada, France, etc, too (e.g. wait times). So maybe it would make more sense to try a reform based on backing off and regulating correctly.

Argg... the old Canada canard. Listen... it works... and it works in lots of places, and wait times are not a freakin' deal breaker.

 

This program was outstanding, and shows how it's done in other countries:

http://www.pbs.org/wgbh/pages/frontline/video/flv/generic.html?s=frol02p101&continuous=1

 

 

Is there any chance for reform under a fully privatized system?

I think that it's certain we can reform under a fully privatized system (and also that such reform is unquestionably necessary). However, I don't think those reforms can ever go far enough, and that we need to break free of this inherently flawed model.

 

Thanks for asking, bro.

[bascule]

Remove the legal obstacles that slow the creation of high-deductible health insurance plans and health savings accounts (HSAs). The combination of high-deductible health insurance and HSAs is one solution that could solve many of our health-care problems.

 

For what it's worth, as an affluent individual I think my combination of an HSA and a high deductible health insurance plan is fairly effective, but a substantial portion of my HSA is financed by my employer and I do not believe this is a solution acceptable to the general public.

 

I also have great concerns that my high deductible plan my even still drop me in the event of catastrophic care. To be completely comfortable with my current plan I would like government oversight which ensures that private insurers must pay out in the event of catastrophic care, leaving no room for loopholes. If I need my insurance to live they better damn well be there.

[Pangloss]

For what it's worth, as an affluent individual I think my combination of an HSA and a high deductible health insurance plan is fairly effective

 

It always seems to a trade-off between money and care, doesn't it? As you said in the other thread, our overall care rating amongst nations is low, but that's because the poor don't get great care -- the rich certainly do. The Canadian PM put it succinctly after the "Three Amigos" summit the other day, saying something along the lines of "it's easy to provide good health care if you only throw enough money at it -- the problem is that there's never enough money to throw at it". (I'm paraphrasing.)

 

iNow I agree with what you're saying about the waiting time not being a deal breaker -- in itself the fact that people sometimes have to wait is not going to stop me from supporting single payer. But the problem in Canada appears to be more serious than just waiting to see a doctor. I have colleagues who've watched people die while waiting. That's not the progressive ideal, killing people just to save a little money. Yes I know, people die waiting for care here too, and it's not much better that they have their lives ruined by bankruptcy. I'm just saying that single payer is not inherently superior or any kind of automatic win. The best we can definitively say seems to be that it might be better than what we're doing now.

 

I don't mean to put all this on you and bascule to defend. I'm just saying these are good questions, and I don't think they've been fully answered by any discussion or input we've seen. We see lots of opinions, but conclusive evidence that any system is absolutely, unequivocally better is non-existent. (BTW, if I remember correctly that Frontline didn't even look at Canada.)

 

Single payer may simply be the best of a bad set of choices. At least that's how it seems to me at the moment.

[iNow]

The Canadian PM...

 

<...>

 

But the problem in Canada appears to be more serious...

 

Yeah, but I called the mention of Canada a canard for a reason. It's always what people say when they're trying to support their position that single payer won't work.

 

It's not like we're going to do things exactly the same as Canada, so come off it already, ya know? If we were going to setup our system exactly as the Canadian system then this would be a valid criticism, but we're not, so it's not. There are plenty of nations out there right now doing it correctly, and I suspect we'll borrow the bits from each which actually work...

 

That is, of course, if we manage to do anything at all and get past the blind unfocused rage everyone continues to express in these discussions.

[Skye]

Maybe I am missing something here but the main issue is Medicare costs. He writes this:

 

• Enact Medicare reform. We need to face up to the actuarial fact that Medicare is heading towards bankruptcy and enact reforms that create greater patient empowerment, choice and responsibility.

 

I think what it means is reduce spending in the ways his company has with employee plans. Ok, fine but it's not going to solve the problem. This is about hard nosed rationing of services for aged health care, not efficiency dividends unfortunately.

[padren]

It's not like we're going to do things exactly the same as Canada, so come off it already, ya know? If we were going to setup our system exactly as the Canadian system then this would be a valid criticism, but we're not, so it's not.

 

To play devil's advocate, if we model Canada's system while trying to ensure we make it different enough to avoid their problems, we have to have a pretty good understanding of what those problems are and how we will avoid them.

Without a clear understanding of that, we are setting ourselves up to fall into the same set of problems they do.

[Pangloss]

I agree with iNow's point and Padren's reply, and I think I can even give an example of government learning from its mistakes, albeit not in the health care industry.

 

Florida organized its state lottery in 1988, but it made a lot of mistakes. The biggest problem it ran into was that lottery funding that was fed into education resulted in educational spending being decreased from other sources, resulting in a net balance or even decrease in overall education funding. There were other issues as well.

 

So when Georgia started its lottery in 1992, it learned from Florida's mistakes. Amongst other things it included as part of the constitutional amendment a provision that made it impossible for the legislature to reduce educational spending due to lottery spending. Essentially lottery-generated educational spending was never added to the general education budget. This produced a few interesting problems of its own, such as an amusing situation one year where every school was presented with a satellite dish but no equipment to connect it to (the opposition party made great hay over this). But over time these mistakes were learned-from and corrected, and produced an eventual situation that is today almost universally hailed as a success. And the Hope Scholarship program, which allows every Georgia student with at least a 3.0 GPA to go to college for free, wouldn't exist without lottery money. (Important points for liberals to consider before they roast Zell Miller for being a turncoat.)

 

Even better, those learning experiences were passed back to Florida, who not only changed how it handles educational spending, but even ultimately changed its constitutional amendment process, in no small part because of the lottery. Those changes are now also almost universally hailed as positive, even though many were vehemently opposed.

 

We have to look at Canada, but as iNow says it can't just be a canard (Canadard? maybe not). We can't just run away from problems because they are hard. Conversely, that also means not necessarily running away from private health care just because fixing it is hard. But the point about facing problems and learning from mistakes is a good one.

[bascule]

It always seems to a trade-off between money and care, doesn't it? As you said in the other thread, our overall care rating amongst nations is low, but that's because the poor don't get great care -- the rich certainly do.

 

There's still a lot of edge cases with my HSA. My HSA is currently configured to accrue a value equal to my deductible, but that's over the course of a year. It's also my only recourse for *everything*, doctors visits, lab work, etc, at least until I've paid up to my deductible.

 

Any healthcare costs which exceed the value presently in my HSA end up getting paid out of pocket, up to my deductible. Ouch.

[Theophrastus]

The Canadian PM put it succinctly after the "Three Amigos" summit the other day' date=' saying something along the lines of "it's easy to provide good health care if you only throw enough money at it -- the problem is that there's never enough money to throw at it". (I'm paraphrasing.)

[/quote']

 

Stevie Harper said what? Goddamn it, how did the conservatives win office again? Oh yeah, the Stephane Dion smear campaign.

 

iNow I agree with what you're saying about the waiting time not being a deal breaker -- in itself the fact that people sometimes have to wait is not going to stop me from supporting single payer. But the problem in Canada appears to be more serious than just waiting to see a doctor. I have colleagues who've watched people die while waiting. That's not the progressive ideal' date=' killing people just to save a little money. Yes I know, people die waiting for care here too, and it's not much better that they have their lives ruined by bankruptcy. I'm just saying that single payer is not inherently superior or any kind of automatic win. The best we can definitively say seems to be that it might be better than what we're doing now.

[/quote']

 

To the contrary, I myself am Canadian, and from personal experience, and that of parents, friends and family, I can tell you, that waiting at a doctor's clinic only occurs in the case of minor infections and their diagnosis. If someone feels severe pains and the like, or has a serious medical condition, that requires immediate attention, they are admitted right away. There is no wait.

 

The only case, in likeness to this, I've ever heard of, is in the death of an aboriginal man, who died in the E.R., following which his family claimed that he was not admitted to the hospital as promptly as he could have been, due to racial discrimination. Whether there is truth in the claims, I suppose is irrelevant, as it does relate to the discussion at hand.

 

As for effectiveness, while I personally believe the concept of the single- payer system, is superior to pure privatization, or a hybrid of the two, there does exist much differentiation, between the various single- payer systems in terms of regulation, and methods and means of execution. These are the factors that define these systems, (single- payer) which, in contrast are stereotyped to be exactly the same, however there are key differences. Single payer or not, there is a lot of key regulation that is being put in place, and I think that this, aside form the basic skeletal structure, also definitely deserves some public analysis.

 

It's not like we're going to do things exactly the same as Canada, so come off it already, ya know? If we were going to setup our system exactly as the Canadian system then this would be a valid criticism, but we're not, so it's not. There are plenty of nations out there right now doing it correctly, and I suspect we'll borrow the bits from each which actually work...

 

Actually, that sounds a lot like something Obama said during the "Three Amigos Meet" in Mexico, in response to some questioning .

Edited August 13, 2009 by Theophrastus

[iNow]

To the contrary, I myself am Canadian, and from personal experience, and that of parents, friends and family, I can tell you, that waiting at a doctor's clinic only occurs in the case of minor infections and their diagnosis. If someone feels severe pains and the like, or has a serious medical condition, that requires immediate attention, they are admitted right away. There is no wait.

Thanks for that, Theo. There is a pretty rampant rumor in the US right now going around about how the Canadians (because they have universal care) have to wait like 3 weeks to see a GP, and that people die while they wait, and that's why we can't mirror your system here in the US.

 

It's nice to see someone sharing, based on first hand experience, that this simply isn't the case. Thanks for sharing that.

[Pangloss]

To the contrary, I myself am Canadian, and from personal experience, and that of parents, friends and family, I can tell you, that waiting at a doctor's clinic only occurs in the case of minor infections and their diagnosis. If someone feels severe pains and the like, or has a serious medical condition, that requires immediate attention, they are admitted right away. There is no wait.

 

This is different from what I was talking about. I spoke with one Canadian colleague and asked her specifically what happens if the ambulance brings you in from a car crash, and she completely agreed with what you say above -- you get attention right away. This seems to be more or less universal in Canada. I was glad to hear this.

 

What I'm talking about is long-term treatment for serious illnesses such as cancer (e.g. chemotherapy). This was the example specifically stated by my colleague, saying she lost two family members who were waiting for therapy and didn't get it in time, and has another old friend back in Canada now who is on a waiting list (but could very well get it in time -- I'm trying to be objective here). Also in the interest of objectivity, it's certainly possible that my colleagues family members who died might have died anyway, etc. I do understand that.

 

Thanks for the reply.

[iNow]

Maybe I am missing something here but the main issue is Medicare costs. He writes this:

 

• Enact Medicare reform. We need to face up to the actuarial fact that Medicare is heading towards bankruptcy and enact reforms that create greater patient empowerment, choice and responsibility.

 

I think what it means is reduce spending in the ways his company has with employee plans. Ok, fine but it's not going to solve the problem. This is about hard nosed rationing of services for aged health care, not efficiency dividends unfortunately.

 

Good call, Skye. I completely missed that point on my first read.

[Pangloss]

Yes, but there's a very good reason not to call it "rationing", even if it's just a perception point. It's apparently more a matter of helping people make informed choices about end-of-life care, which according to recent stories I've seen can have a profound impact on lowering costs per capita.

 

I'm not actually disagreeing with your word choice, Skye -- rationing is exactly what it is, and it's not necessarily inhumane. For example, it might make sense to make 15 heart transplants available to people over the age of 75 per year, but no more, and then applicants will be weighed on the merits. Or there may be a different number of a different mechanical process involved that amounts to the same thing. But it's not automatically bad to do it that way.

 

But perception is a funny beast, and we need not only the support of older Americans on this, but also their wisdom and perspective.

 

 

(Perhaps that's what my Canadian colleague saw.)

[Theophrastus]

In terms of cancer treatment key diagnostic testing and the like, you are right Pangloss, that Canada has and is still having a lot of trouble, (I know, quite an understatement) in the past 2-3 years, with numerous people still waiting for things as simple as diagnostic tests, and even more serious matters of treatment. Why you ask? Well, in response, I have two words: Chalk River.

 

It's mostly because our primary source of radioisotopes for medical use, (by our, I mean that of Canadian hospitals, and the medical community in Canada) was Chalk River Reactor, in Ontario, northwest of Ottawa, however, not long ago, there was a radioactive leak. The reactor in turn got a lot of negative publicity from environmentalists, and was closed down, for maintenance, as a result.

 

This radioisotope shortage has left many patients without the opportunity of treatment. This problem was constantly featured on CBC last year, and I admit that for many people waiting for diagnosis, and treatment, this has been a very difficult time. I have heard however, that in goodwill, some universities, have been using their equipment, to try and produce small quantities of these radioisotopes, for patients' to use, however, certainly this remains a serious problem, in Canada, for the treatment of numerous "lifelong" diseases.

 

I see what you're going at, but this is not so much a problem of the system, but more of circumstance. I suppose that systematically, such a thing could have been avoided by diversifying our source of radioisotopes, importing from other countries like Holland and France, in case of a leak (while this would likely lead to higher costs; with all things, there are pros and cons).

 

It is true that there are problems in the Canadian system; it is not flawless, but as for the model itself, there can be no denying, it has potential, and is able to cover everyone, and still pay for it, by making your payment indirect.

Edited August 14, 2009 by Theophrastus

[Severian]

I don't understand why people keep saying that Universal Coverage would cost too much. The UK has universal coverage, but pays a lot less on healthcare per capita than the US currently does (about half I think).

[bascule]

I don't understand why people keep saying that Universal Coverage would cost too much. The UK has universal coverage, but pays a lot less on healthcare per capita than the US currently does (about half I think).

 

It's because it's a statement not based on evidence, analysis, or observation of other universal single payer systems worldwide, but on an ignorant and quaint assumption that the government can't do anything right and anything done by the private sector instead of the government will be cheaper.

 

Frankly I'm sick of hearing this nonsense bandied about, but these people are stubborn and set in their ways and simply refuse to acknowledge that there are some things that can be done better by the government than the private sector.

[Skye]

Yes, but there's a very good reason not to call it "rationing", even if it's just a perception point. It's apparently more a matter of helping people make informed choices about end-of-life care, which according to recent stories I've seen can have a profound impact on lowering costs per capita.

 

I'm not actually disagreeing with your word choice, Skye -- rationing is exactly what it is, and it's not necessarily inhumane. For example, it might make sense to make 15 heart transplants available to people over the age of 75 per year, but no more, and then applicants will be weighed on the merits. Or there may be a different number of a different mechanical process involved that amounts to the same thing. But it's not automatically bad to do it that way.

 

But perception is a funny beast, and we need not only the support of older Americans on this, but also their wisdom and perspective.

 

 

(Perhaps that's what my Canadian colleague saw.)

I was being blunt there deliberately to be in contrast with the author. If I was a politician trying to sell health care reform I wouldn't use the term rationing. But then if I was a politician I might use language to side step the issue like Mackey did.

 

I agree that you can get better, cheaper health care by giving people choice and responsibility. That responsibility is to the government who will be footing the bill though, and can only occur if the government takes their responsibility to taxpayers seriously and limits spending. Which in the case of Medicare will mean rationing since (I think) it will need fairly heavy handed treatment to be brought under control.

[bascule]

My problem with "rationing" is that people pretend it doesn't exist under the present private insurance system. It just takes a different form: healthcare providers trying to maximize the number of expensive claims they deny.

[iNow]

My problem with "rationing" is that people pretend it doesn't exist under the present private insurance system. It just takes a different form: healthcare providers trying to maximize the number of expensive claims they deny.

 

Indeed, but the current system rations much more than just the "expensive" claims. They try to maximize the number of ALL claims they deny.

[Pangloss]

My problem with "rationing" is that people pretend it doesn't exist under the present private insurance system. It just takes a different form: healthcare providers trying to maximize the number of expensive claims they deny.

 

Absolutely. What is the difference between a health insurer telling you you can't have a heart transplant because you checked the wrong box on the third copy of an unrelated form, and a government telling you you can't have a heart transplant because you're a smoker over the age of 59? Either way you die.

 

It almost seems like sometimes we're holding up both Obamacare/HR3200 and single-payer proposals against an ideal of "capitalist health care" that doesn't actually exist. At least not for the vast, overwhelming majority of this country.

 

This is one of the reasons I continue to struggle so hard with this pressing issue personally. As annoyed as I am about lobbyists and the lack of addressing the cost issue in HR3200, I ultimately will have to support it anyway because it may simply be the best that we're capable of at the moment.

 

 

I don't understand why people keep saying that Universal Coverage would cost too much. The UK has universal coverage, but pays a lot less on healthcare per capita than the US currently does (about half I think).

 

Cost is the only clear advantage of the single-payer model that everyone more or less agrees on. It does have to be paid for, e.g. income taxes, but as you say when you look at the cost of health care per capita the increased taxation is actually a savings. But we're being told that 1.8 million UK citizens are waiting for treatment and (if I remember the article I read last week correctly -- sorry, I can look it up if you want) 400,000 Canadians likewise. Whether that's good or bad, or what the numbers mean, are the subject of much disagreement and debate.

 

The single-payer model is not presently being debated for implmenetation in the United States, though that may happen this fall. The current debate over "Obamacare" is a different approach. Whether or not that approach is more expensive is the subject of great disagreement. The initial cost is about a trillion dollars spread over 10 years. The president says it will ultimately lead to great savings due to decreased costs in Medicare spending and in improved industry efficiency. Opponents say that it will not decrease costs.

 

Neither side really knows anything, but this approach does maintaining the advantages of immediacy and potentially high quality of care available under the current system, which addresses the weaknesses of the UK/Canadian systems.

[ParanoiA]

Well, of course, I like Mackey's suggestions because they deal with the problem of cost, which I believe is central to our Healthcare accessibility problem. They carry a theme of consumer level scrutiny and economizing, particularly high-deductible insurance plans which my man Dr. Paul puts in great perspective:

 

We don’t have insurance for medical care. We have distorted that word. Insurance is supposed to measure risk and you’re supposed to buy that protection. So if you want medical insurance, you would be insuring against bad accidents or major surgeries or against cancer or something like that. But today, people expect prepaid services. They want every penny taken care of. They want the drugs paid for and then that invites abuse. When third parties pay the bills, doctors, labs, and hospital, and everybody else, all of a sudden, they charge the most, not the least.

 

http://www.ronpaul.com/2009-06-19/ron-paul-how-to-solve-the-healthcare-crisis/

 

And this can be seen on your medical bill. The medical insurance billing game. Look at how much your insurance is being charged and how much they actually pay. Imagine being the poor sap that pays the bill out of pocket, without the same discounts. I've seen ads by MRI clinics that offer 40% off if you're paying with cash, in full. Why can they practically halve the cost for cash customers? Why would they?

 

There is a buffer zone of blissful fiscal ignorance with our precious co-pays, low-deductible insurance coverages, medicare and medicaid - the third party payout.

 

I'm curious how socialized medicine handles these concepts:

1) Overuse of medical resources by patients (causing underuse by those who really need it)

 

2) Administrative paper work created by the third party payer patchwork and cost control behavioral monitoring of doctors and patients.

 

3) Defensive medical testing for fear of malpractice suits.

 

 

I would imagine 1 would still be a problem, perhaps lending to the infamous attribute of "excessive wait times", but I'm betting 2 and 3 are far less of an issue.

 

 

Mackey doesn't mention anything about prescription drug freedom. I still don't understand why my freedom to purchase internationally or to import drugs from other countries should be restricted. There has always been an argument to drive down the prices of prescription drugs in the US by allowing this competition.

 

Regardless, Mackey is on the right track, IMO. Cost control first, since it is laughably way off track and at the very heart of healthcare accessibility.