Single payer health care questions

[Loren Pechtel]

I've known one person who reached 100 years old and she was in pretty good shape. After she turned 100, which seemed to be a goal for her, it was a few months later she died. She lived at home until she was about 96 I think. With support of course but she did pretty well. Had a couple falls and had to go into a home. Same with my neighbor, died at 98 I think at home. Took a fall, banged her head and died not long after but she was still driving occasionally in her early 90s. If you look after your health when young I think you will do better as you get older.

One grandfather made it well into his 90s, living with us the last years.

 

[T.G.G. Moogly]

How are end of life issues handled under UHC systems?

For some geographical areas and in some families, it is seen as a duty to 'do everything possible' to extend life because failing to do so means you don't love the patient, or you are 'giving up.' This is an enormous cost driver in the US.

Other cost drivers are frankly, addiction issues, and the health issues that go along with addition, including children born addicted or prematurely or with serious medical issues that will likely persist for years, as well as prematurity and attending health issues born to mothers mostly in poverty but not entirely, again sometimes with long term and expensive medical needs.

The narrative goes that poor women should not have children. Of course they should also not have access to birth control which is affordable. For example. Prenatal care should not be provided at no or low cost. Instead, it is important to attach shame to being poor and to make recipients of medicaid and WIC jump through lots of hoops, which isn't at all stressful and does nothing at all to contribute to increased risks of prematurity, maternal or fetal death or morbidity. (irony here in case anyone has any doubts)

Almost everyone I know of any age would prefer to die at home; few people in the US die at home.

These things are handled in various ways, according to the local medical norms and both hospital and wider societal culture; They are in no way tied to the funding model, so there is no one 'UHC' way to approach them. These things define what a society sets as the minimum expectation for their health care system. The success or failure of the funding model (Single payer; Centrally funded service; Private insurance; Regional funding; Charitable donations; or a combination of two or more of these) at the point of use determines whether they need to compromise those objectives set by societal expectations or not. So for example, a patient in the USA might reasonably expect that a hospital will treat his cancer with the latest and/or most suitable chemo drug, but if his insurance won't pay for it, his expectations won't be met. This can also occur under UHC; The major difference being that the rules are uniform - either the system pays, and anyone can get the treatment; or it doesn't, and only the wealthy can get it (as compared to the bizarre US situation where two people of similar means might be treated completely differently, because one happened to work at a company with a different insurance plan to the other).

Typically, UHC is equivalent to everybody having the same insurance plan, with nobody uninsured or under-insured. How good that plan is depends on the implementation of the UHC system. Most UHC systems provide excellent coverage, driven by expert medical opinion on what is best, rather than by marketing and the averaged opinions of the general public.

Almost all UHC systems have better outcomes overall than the US system, by all reasonable measures.

Right. In a way the argument is because it will not be perfect, only good, it will be a disaster.

 

[fromderinside]

The problem with your solutions are they don't take into account profit demand. Powers that be will charge just as much for comfort as they will for extreme procedures. If only money could be taken out of the situation and actual plans for care by the aging be implemented without cost. People deserve living, even comfortable wages in all professions. Holding one's life hostage for that income is just plane criminal.

As for just so ideas let them be. We all got here so we all deserve care levels to which there is consensus without using money as a gauge.

 

[Loren Pechtel]

The problem with your solutions are they don't take into account profit demand. Powers that be will charge just as much for comfort as they will for extreme procedures. If only money could be taken out of the situation and actual plans for care by the aging be implemented without cost. People deserve living, even comfortable wages in all professions. Holding one's life hostage for that income is just plane criminal.

As for just so ideas let them be. We all got here so we all deserve care levels to which there is consensus without using money as a gauge.

There is no such thing as without cost. The cost may be hidden but it's still there.

 

[T.G.G. Moogly]

The problem with your solutions are they don't take into account profit demand. Powers that be will charge just as much for comfort as they will for extreme procedures. If only money could be taken out of the situation and actual plans for care by the aging be implemented without cost. People deserve living, even comfortable wages in all professions. Holding one's life hostage for that income is just plane criminal.

As for just so ideas let them be. We all got here so we all deserve care levels to which there is consensus without using money as a gauge.

There is no such thing as without cost. The cost may be hidden but it's still there.

I think he means without exorbitant cost, like 18% of GDP, for which you still end up getting a lot less.

People don't deserve anything, and there's always a cost. But people can plan and societies can plan to have things they deem valuable, necessary and decent. Not having to worry that you will become indigent because you break a leg seems worthwhile to me.

 

[Toni]

Do you know the costs of procedures under UHC or single payer systems? Because I think that would be a tremendous advantage. It seems like the costs in the US go something like this:

You "How much for an MRI?"
Doctor "Why don't you tell me how much you/your insurer can afford and then we'll send the bill"

https://www.forbes.com/sites/kateashford/2014/10/31/how-much-mri-cost/#304b4bf48485

It seems like an MRI shouldn't cost between $800 and $2400 within the same zip code. I'm a property and casualty actuary, not a health actuary. But the fact that it is easier for me to predict the range of outcomes of a liability settlement from a slip and fall accident in a restaurant than it is to predict the range of costs for a knee replacement surgery from the exact same accident is ridiculous.

And before I hear the "medicare doesn't cover the costs" refrain, that is an easier fix than the current attempts at getting the medical community on board with standardizing prices.

aa

In all probability the physician doesn't actually know the cost of an MRI, period and definitely not how much your insurance company will pay (if anything) and what, if anything you will be responsible for paying. That is why you are often sent to a business office to ensure that everyone knows costs and coverage.

Here's the other thing: cost should be immaterial to your physician. Your physician should be free to proscribe whatever diagnostic tests and treatment will best treat your ailment and/or best serve your health.

And even more importantly your doctor should not consider or be put into a position of considering whether you are wealthy or poor: it should not affect how you are treated.

Reality is that doctors gave some knowledge of about how much out of pocket certain patients will be, out of necessity and concern for the patient. A doctor does not want to proscribe a treatment or test that s/he knows the patient cannot afford or cannot afford without difficulty. Most doctors I know do look for the most cost effective treatment plan that will work. Not necessarily the one which will work best.

My concerns with Medicare/Medicaid not funding cost of treatment is that they don't and their payment schedule is subject to a political process that determines how much money they have to pay costs for all patients. A bunch of cheap bigoted or ignorant politicians can reck havoc.

 

[bilby]

Do you know the costs of procedures under UHC or single payer systems? Because I think that would be a tremendous advantage. It seems like the costs in the US go something like this:

You "How much for an MRI?"
Doctor "Why don't you tell me how much you/your insurer can afford and then we'll send the bill"

https://www.forbes.com/sites/kateashford/2014/10/31/how-much-mri-cost/#304b4bf48485

It seems like an MRI shouldn't cost between $800 and $2400 within the same zip code. I'm a property and casualty actuary, not a health actuary. But the fact that it is easier for me to predict the range of outcomes of a liability settlement from a slip and fall accident in a restaurant than it is to predict the range of costs for a knee replacement surgery from the exact same accident is ridiculous.

And before I hear the "medicare doesn't cover the costs" refrain, that is an easier fix than the current attempts at getting the medical community on board with standardizing prices.

aa

In all probability the physician doesn't actually know the cost of an MRI, period and definitely not how much your insurance company will pay (if anything) and what, if anything you will be responsible for paying. That is why you are often sent to a business office to ensure that everyone knows costs and coverage.

Here's the other thing: cost should be immaterial to your physician. Your physician should be free to proscribe whatever diagnostic tests and treatment will best treat your ailment and/or best serve your health.

And even more importantly your doctor should not consider or be put into a position of considering whether you are wealthy or poor: it should not affect how you are treated.

Reality is that doctors gave some knowledge of about how much out of pocket certain patients will be, out of necessity and concern for the patient. A doctor does not want to proscribe a treatment or test that s/he knows the patient cannot afford or cannot afford without difficulty. Most doctors I know do look for the most cost effective treatment plan that will work. Not necessarily the one which will work best.

My concerns with Medicare/Medicaid not funding cost of treatment is that they don't and their payment schedule is subject to a political process that determines how much money they have to pay costs for all patients. A bunch of cheap bigoted or ignorant politicians can reck havoc.

Indeed.

Neither doctors nor patients should need to know or care what a treatment or test costs; Doctors should base their decisions solely on what their professional judgment says is best for the patient, and patients should be completely protected from any cost impact of their illness.

Money is a useful tool for rationing scarce resources, when those resources are going to discretionary use by members of a society. If you want cake, you can have it if (and only if) you can afford it. If you can't afford it, then you can't have it.

If you want a tumor removed from your brain, then that's not something you decided one day would be nice; It's not something you can save up for, like a new car, in the hope that one day you will be able to afford it; and it's not something that, by giving it to you without making you pay for it all yourself, the doctor is depriving others from having. There's no queue people who saved all their lives to buy a brain tumor operation, who are going to be upset that you got one and they didn't. The only people who get brain tumor operations are those with operable brain tumors; there are enough such operations for all who need them; and there is no choice - if you need one and don't get one, you don't get to spend the money on a sports car instead, you just DIE.

Civilized societies don't use money to block access to the necessities of life. Money is a tool to prevent people from taking more than they have earned from society. It's an excellent tool, but it is not perfect, and when we pretend that it's the only tool we need, we end up with a very ugly situation indeed. Nobody takes more health care than they need, when doctors are made the arbiters of what patients can or cannot have. If patients demand unnecessary procedures or tests, doctors should say 'no', EVEN IF the patient can afford to pay for whatever he is asking for. And if a patient needs a given procedure or test, doctors should provide it, and be paid BY SOCIETY to do so. Because nobody chooses to get sick.

 

[Loren Pechtel]

Here's the other thing: cost should be immaterial to your physician. Your physician should be free to proscribe whatever diagnostic tests and treatment will best treat your ailment and/or best serve your health.

Disagree--there are times when they should know the cost. Specifically, when test A should be used as a screening before performing test B.

 

[seanie]

In the UK the healthcare systems (which differ in the different countries) try to tackle that through having bodies to assess treatments and their cost effectiveness, and make recommendations on them. They're not absolutely binding, and are a source of controversy in the more emotive areas, but at the end of the day there's no particular reason for doctors to know the cost of a procedure, just what's considered cost-effective, appropriate and available.

 

[Toni]

Here's the other thing: cost should be immaterial to your physician. Your physician should be free to proscribe whatever diagnostic tests and treatment will best treat your ailment and/or best serve your health.

Disagree--there are times when they should know the cost. Specifically, when test A should be used as a screening before performing test B.

That's not a cost issue. In my experience, physicians do know the order to perform tests, i.e. screen before confirmatory. In some cases, there is a cascade of tests which can get more complicated and specific testing order can depend upon a number of variables, aside from results from the previous tests. Also test results are sometimes inconclusive, or even misleading. Which is why any physician would look at test results within the context of patient history (including testing history and test results history) before making a diagnosis and use all of this to determine next steps (testing or treatment).

I've worked in clinical labs where such testing is performed: diagnostic and staging. Certainly there are algorithms to aid in decisions about next steps but it is not always the case that a result for Test A definitively means A, B and/or C. Depending on the test, more than one potential diagnosis could be appropriate and more testing may or may not be needed.

 

[Toni]

In all probability the physician doesn't actually know the cost of an MRI, period and definitely not how much your insurance company will pay (if anything) and what, if anything you will be responsible for paying. That is why you are often sent to a business office to ensure that everyone knows costs and coverage.

Here's the other thing: cost should be immaterial to your physician. Your physician should be free to proscribe whatever diagnostic tests and treatment will best treat your ailment and/or best serve your health.

And even more importantly your doctor should not consider or be put into a position of considering whether you are wealthy or poor: it should not affect how you are treated.

Reality is that doctors gave some knowledge of about how much out of pocket certain patients will be, out of necessity and concern for the patient. A doctor does not want to proscribe a treatment or test that s/he knows the patient cannot afford or cannot afford without difficulty. Most doctors I know do look for the most cost effective treatment plan that will work. Not necessarily the one which will work best.

My concerns with Medicare/Medicaid not funding cost of treatment is that they don't and their payment schedule is subject to a political process that determines how much money they have to pay costs for all patients. A bunch of cheap bigoted or ignorant politicians can reck havoc.

Indeed.

Neither doctors nor patients should need to know or care what a treatment or test costs; Doctors should base their decisions solely on what their professional judgment says is best for the patient, and patients should be completely protected from any cost impact of their illness.

Money is a useful tool for rationing scarce resources, when those resources are going to discretionary use by members of a society. If you want cake, you can have it if (and only if) you can afford it. If you can't afford it, then you can't have it.

If you want a tumor removed from your brain, then that's not something you decided one day would be nice; It's not something you can save up for, like a new car, in the hope that one day you will be able to afford it; and it's not something that, by giving it to you without making you pay for it all yourself, the doctor is depriving others from having. There's no queue people who saved all their lives to buy a brain tumor operation, who are going to be upset that you got one and they didn't. The only people who get brain tumor operations are those with operable brain tumors; there are enough such operations for all who need them; and there is no choice - if you need one and don't get one, you don't get to spend the money on a sports car instead, you just DIE.

Civilized societies don't use money to block access to the necessities of life. Money is a tool to prevent people from taking more than they have earned from society. It's an excellent tool, but it is not perfect, and when we pretend that it's the only tool we need, we end up with a very ugly situation indeed. Nobody takes more health care than they need, when doctors are made the arbiters of what patients can or cannot have. If patients demand unnecessary procedures or tests, doctors should say 'no', EVEN IF the patient can afford to pay for whatever he is asking for. And if a patient needs a given procedure or test, doctors should provide it, and be paid BY SOCIETY to do so. Because nobody chooses to get sick.

Again, the cost of a testing or treatment does not directly affect diagnosis or treatment. However, a doctor treating a medicare patient will know that medicare will only pay for some testing, some treatments in some circumstances. The physician must either get a waiver from the patient who agrees to pay for these or elect to try to diagnose and treat patient without, or come up with another scheme of treatment. Even if the patient is covered by medicare and also by supplemental insurance or or other insurance or no insurance-for (insert reason) likely to be concerned about a test or treatment, the physician will try to assess this before coming up with a treatment plan. It is useless to insist on a plan of action of the patient is unlikely to be willing to try for (insert reason), but often the reason is concern for costs. Note: This can occur with even a pretty well to do patient when the cost of a test is not a huge factor for their budget.

 

[seanie]

In a sensible universal healthcare model individual costs aren't that important. They matter at a higher level of budgeting for what is and isn't cost-effective, and hence what's readily available, but day in and day out costs aren't a big consideration.

 

[bilby]

Indeed.

Neither doctors nor patients should need to know or care what a treatment or test costs; Doctors should base their decisions solely on what their professional judgment says is best for the patient, and patients should be completely protected from any cost impact of their illness.

Money is a useful tool for rationing scarce resources, when those resources are going to discretionary use by members of a society. If you want cake, you can have it if (and only if) you can afford it. If you can't afford it, then you can't have it.

If you want a tumor removed from your brain, then that's not something you decided one day would be nice; It's not something you can save up for, like a new car, in the hope that one day you will be able to afford it; and it's not something that, by giving it to you without making you pay for it all yourself, the doctor is depriving others from having. There's no queue people who saved all their lives to buy a brain tumor operation, who are going to be upset that you got one and they didn't. The only people who get brain tumor operations are those with operable brain tumors; there are enough such operations for all who need them; and there is no choice - if you need one and don't get one, you don't get to spend the money on a sports car instead, you just DIE.

Civilized societies don't use money to block access to the necessities of life. Money is a tool to prevent people from taking more than they have earned from society. It's an excellent tool, but it is not perfect, and when we pretend that it's the only tool we need, we end up with a very ugly situation indeed. Nobody takes more health care than they need, when doctors are made the arbiters of what patients can or cannot have. If patients demand unnecessary procedures or tests, doctors should say 'no', EVEN IF the patient can afford to pay for whatever he is asking for. And if a patient needs a given procedure or test, doctors should provide it, and be paid BY SOCIETY to do so. Because nobody chooses to get sick.

Again, the cost of a testing or treatment does not directly affect diagnosis or treatment. However, a doctor treating a medicare patient will know that medicare will only pay for some testing, some treatments in some circumstances. The physician must either get a waiver from the patient who agrees to pay for these or elect to try to diagnose and treat patient without, or come up with another scheme of treatment. Even if the patient is covered by medicare and also by supplemental insurance or or other insurance or no insurance-for (insert reason) likely to be concerned about a test or treatment, the physician will try to assess this before coming up with a treatment plan. It is useless to insist on a plan of action of the patient is unlikely to be willing to try for (insert reason), but often the reason is concern for costs. Note: This can occur with even a pretty well to do patient when the cost of a test is not a huge factor for their budget.

Yes, I understand that, and I think it is barbaric and inhumane. The phrase, "It is useless to insist on a plan of action of the patient is unlikely to be willing to try for (insert reason), but often the reason is concern for costs", makes me feel rather similarly about your country as would the phrase, "of course, it would only make the slaves miserable if they were to receive an education beyond what is needed for the work they are to perform".

It's a phrase that makes clear that nobody is particularly surprised by a situation that is utterly horrific.

 

[Toni]

To be fair and to be completely honest, a not insignoficant number of those who would forego a test or treatment due to cost can actually afford the care. I understand those who grew up in hard timessich as the Great Depression but they are not the only ones. Yes if the norm were that there were few or only small costs for anyone a great deal of this would eventually disappear. Mostly through attrition.

 

[bilby]

To be fair and to be completely honest, a not insignoficant number of those who would forego a test or treatment due to cost can actually afford the care. I understand those who grew up in hard timessich as the Great Depression but they are not the only ones. Yes if the norm were that there were few or only small costs for anyone a great deal of this would eventually disappear. Mostly through attrition.

And most slaves are treated kindly by their masters, and looked after, if only because they are a valuable commodity in their own right; You don't abuse an expensive car, for the same reason.

But to civilized people, the very concept of slavery (however benign the reality) is abhorrent; As is the concept of having to consider cost when deciding what health care you should or should not seek. Medical necessity should be the only criterion here - ideally based on the expert advice of medical professionals. Patients shouldn't be OK with the cost of treatment because they can afford it, any more than slaves should be OK with being chattels because they are well fed, and infrequently beaten.

 

[Toni]

To be fair and to be completely honest, a not insignoficant number of those who would forego a test or treatment due to cost can actually afford the care. I understand those who grew up in hard timessich as the Great Depression but they are not the only ones. Yes if the norm were that there were few or only small costs for anyone a great deal of this would eventually disappear. Mostly through attrition.

And most slaves are treated kindly by their masters, and looked after, if only because they are a valuable commodity in their own right; You don't abuse an expensive car, for the same reason.

But to civilized people, the very concept of slavery (however benign the reality) is abhorrent; As is the concept of having to consider cost when deciding what health care you should or should not seek. Medical necessity should be the only criterion here - ideally based on the expert advice of medical professionals. Patients shouldn't be OK with the cost of treatment because they can afford it, any more than slaves should be OK with being chattels because they are well fed, and infrequently beaten.

Your comparison to slavery is grotesquely misguided and frankly unworthy of you. You live where government funded healthcare has been the norm for many years. I imagine that there were some older folks who protested govt. paid health care and any and all costs in theBritish Empire as well.

I was recently visiting with an 80 year old relative who was telling the story of an older couple in the largely rural and poverty stricken region where she grew up. Talked about cousins who helped this struggling old couple with some tough manual labor, and were fed pretty watery soup in compensation. Please note: normally it is a point of pride to feed those who help bring in the year's crops well and generously with your very best. The old man died of starvation and his wife did not survive her heart attack in part due to serious malnutrition. They left well over a million dollars --at a time when $1M was really a lot of money!,to various churches in the area some of which disbanded because of disagreements about how to use the windfall. Obviously an extreme case of someone being unwilling to do what they needed to do to live well when they could obviously afford to do so.

 

[bilby]

And most slaves are treated kindly by their masters, and looked after, if only because they are a valuable commodity in their own right; You don't abuse an expensive car, for the same reason.

But to civilized people, the very concept of slavery (however benign the reality) is abhorrent; As is the concept of having to consider cost when deciding what health care you should or should not seek. Medical necessity should be the only criterion here - ideally based on the expert advice of medical professionals. Patients shouldn't be OK with the cost of treatment because they can afford it, any more than slaves should be OK with being chattels because they are well fed, and infrequently beaten.

Your comparison to slavery is grotesquely misguided and frankly unworthy of you. You live where government funded healthcare has been the norm for many years. I imagine that there were some older folks who protested govt. paid health care and any and all costs in theBritish Empire as well.

There were plenty of people who opposed the introduction of the NHS, just as there were plenty who opposed the abolition of slavery (although a civil war wasn't needed in the case of the NHS).

My father had a brother who died in 1938, because his mother couldn't afford to call out the doctor. That experience was far from atypical in South East London before WWII. My father broke his collar bone on VE day - he was eight years old, and had never seen all the street lights lit, and ran outside not looking where he was going. To this day he can't touch his right hand to his right shoulder, because the bone was set by a neighbour - again because a doctor would have been too expensive.

Needless to say, there were very few working class people in the UK who opposed the NHS when it was brought in. But yes, it was opposed.

The comparison to slavery is not misguided nor overblown. Both 'for profit' medical care and slavery are barbaric, both lead to needless death and misery, and both were considered not only normal, but worth fighting for, by many people at the time that they were abolished.

 

[Loren Pechtel]

Disagree--there are times when they should know the cost. Specifically, when test A should be used as a screening before performing test B.

That's not a cost issue. In my experience, physicians do know the order to perform tests, i.e. screen before confirmatory. In some cases, there is a cascade of tests which can get more complicated and specific testing order can depend upon a number of variables, aside from results from the previous tests. Also test results are sometimes inconclusive, or even misleading. Which is why any physician would look at test results within the context of patient history (including testing history and test results history) before making a diagnosis and use all of this to determine next steps (testing or treatment).

I've worked in clinical labs where such testing is performed: diagnostic and staging. Certainly there are algorithms to aid in decisions about next steps but it is not always the case that a result for Test A definitively means A, B and/or C. Depending on the test, more than one potential diagnosis could be appropriate and more testing may or may not be needed.

Yeah, it could be reduce to a flowchart of the order to do things instead of looking at the costs. However, the flowchart approach is going to have a hard time covering cases where the doctor thinks the odds they'll have to do the second test anyway is well above normal.

 

[Loren Pechtel]

Again, the cost of a testing or treatment does not directly affect diagnosis or treatment. However, a doctor treating a medicare patient will know that medicare will only pay for some testing, some treatments in some circumstances. The physician must either get a waiver from the patient who agrees to pay for these or elect to try to diagnose and treat patient without, or come up with another scheme of treatment. Even if the patient is covered by medicare and also by supplemental insurance or or other insurance or no insurance-for (insert reason) likely to be concerned about a test or treatment, the physician will try to assess this before coming up with a treatment plan. It is useless to insist on a plan of action of the patient is unlikely to be willing to try for (insert reason), but often the reason is concern for costs. Note: This can occur with even a pretty well to do patient when the cost of a test is not a huge factor for their budget.

Unfortunately, the guidelines are often poor.

I never found out the end result but there was a dispute between my mother's oncologist and Medicare over some imaging. Medicare was saying there was no evidence of a tumor there, thus the test was not warranted and wouldn't be paid for. I never saw what the doctor was saying about it but the doctor was being pretty through in his imaging because the primary tumor was not found in the first round of imaging.

 

[Toni]

Again, the cost of a testing or treatment does not directly affect diagnosis or treatment. However, a doctor treating a medicare patient will know that medicare will only pay for some testing, some treatments in some circumstances. The physician must either get a waiver from the patient who agrees to pay for these or elect to try to diagnose and treat patient without, or come up with another scheme of treatment. Even if the patient is covered by medicare and also by supplemental insurance or or other insurance or no insurance-for (insert reason) likely to be concerned about a test or treatment, the physician will try to assess this before coming up with a treatment plan. It is useless to insist on a plan of action of the patient is unlikely to be willing to try for (insert reason), but often the reason is concern for costs. Note: This can occur with even a pretty well to do patient when the cost of a test is not a huge factor for their budget.

Unfortunately, the guidelines are often poor.

I never found out the end result but there was a dispute between my mother's oncologist and Medicare over some imaging. Medicare was saying there was no evidence of a tumor there, thus the test was not warranted and wouldn't be paid for. I never saw what the doctor was saying about it but the doctor was being pretty through in his imaging because the primary tumor was not found in the first round of imaging.

I'm not sure it's the guidelines that are poor as it is a system where everything must be fit into a pretty narrow code category. I've had the same experience with Medicare with my mother and with many different insurance companies (working for a medical clinic).

Which brings up the point of the billions of dollars that are spent coordinating, processing, denying and resubmitting (rinse/repeat times infinity) claims, billing, collections, contracting with debt collectors, etc. I have not yet seen any study that attempts to estimate the portion of a medical dollar actually going towards medical care. My suspicion is that it is a very small percentage indeed.