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Lou Schlickman

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Dr. Lou Schlickman likes to talk about our socialist highways and schools and police and fire. It's part of his PowerPoint presentation on health-care reform. Schlickman, a Meridian internist, is a spokesman for Idaho Health Care for All, a group pushing for single-payer health care, or what he calls Medicare for All. Single payer would create one large government insurance company, similar to Medicare, replacing most of the private health insurance industry. Advocates argue this would reduce the cost of insurance through pooling and the elimination of administrative waste and the profit motive.

Schlickman is from Rockford, Ill., went to Rush Medical College in Chicago and has been in private practice since 1998.

Why did you become a doctor?

Well, that's strange. I was younger, and somebody said I was smart enough to become a doctor. I think I probably would have gone into teaching or something if I couldn't do that. Thought I would do OBGYN, didn't like the hours. I wasn't really sure I liked my career choice until I went to the Air Force base in Mountain Home and started taking care of my patients.

When did you realize everything was not right with the medical system?

I was in medical school when Hillarycare was being touted, and I would listen to all the comments in the hallways in the hospital, talking about how ridiculous it would be and not really having any idea about what it was. I had no clue if it was ridiculous or legitimate because I was in medical school. I didn't take the time to learn that stuff. But then I remember telling people who would ask questions: "We've got a safety net, you can always go to the Cook County Hospital, you can always go to the ER." I think I was just one of those people who preferred not to evaluate the real problem.

As time went on, I trained at a residency program in Pittsburgh [Penn.], and any residency has tons of uninsured, indigent, Medicaid patients, and I don't think I really paid attention to that either. They were people, you take care of them, they would go home, maybe they would come back.

Then I was in the Air Force and you don't really have that problem when you're in the Air Force.

And then, finally getting out of the Air Force and going into practice, seeing the frustration of taking care of all of these Medicare people who are the most challenging, the most time-consuming patient population and yet we get reimbursed the least amount of money for. The only way to sort of subsidize your practice is to try to drum up business otherwise through procedures, whether you need 'em or not.

Do you find yourself doing that?

Well, I try to stay away from that, but of course, you've got to wonder how much you might be influenced to do something just because you know it's going to pay more. I do EGDs [upper endoscopy] and colonoscopies on non-complicated cases because it's a procedural skill and it reimburses higher. When people have bad arthritis in the knees, you think, "Should I just give them an injection to help their pain because it will pay more or should we talk about using pills or physical therapy and exercise?" And usually, I will actually put off the shots. You try to do the right thing, and financially, you get penalized for it.

How would single payer look different from Medicare?

You can call it whatever you want. The whole purpose of saying "Medicare For All" is to make people understand that, hey, there's already this really great system and even though it's got its problems, you know it's a really great system because there's 63-year-olds who won't do anything until they're on Medicare. You try to take Medicare away from the country and see what happens. There will be a riot.

I had a guy with blood in the stool, and he was 63 and he didn't want to do the colonoscopy until he was 65. Most of the time blood in the stool is not going to be anything deadly, but sometimes it's cancer, and if he waits two years, it could be too late to cure him, so he puts that off till he's 65. Why? Because he's going to get Medicare. That's a bastion of hope for these people. If he's 63 and he lost his job, how's he going to get another job?

So Medicare is a great system for the patients?

It's certainly not perfect for the doctors, and some doctors are punished more than others, again, based on that procedure-driven care vs. cognitive patient care. But if you would stop under-funding the system so that hospitals got paid appropriately to cover the cost of care and primary care physicians got paid appropriately for the cost of delivering care to them, we wouldn't complain so much. Well, why do we under-fund it? Of course, that's a political issue. Our politicians don't want to raise taxes to prop up Medicare because then they get voted out of office. But at the same time, they turn around and give huge tax breaks to private health insurance companies. They adjust the tax code so that it's far more beneficial for corporate health insurance companies than it is for you and me.

Fix the problems in Medicare and then give it to everybody. We can afford to do that if we help get rid of the waste.

Do you spend time figuring out people's benefits?

They can call and try to figure it out from their insurance, but often times they can't get an answer from the insurance because the insurance has all these cryptic procedures they follow. You know, "You're approved for elective gall bladder surgery." Go down two paragraphs: "This is not a guarantee of payment of benefits." What does that mean? You're approved, but we don't guarantee to pay. And that's their sneaky way of saying, hey, if you get this expensive surgery and later we find out you didn't tell the truth on your application, we'll deny the payment. And those are the examples you heard in Obama's speech. Acne and asymptomatic gallstones.

Did you hear anything new in Obama's speech?

He's a great speaker. He is very motivating and very inspiring and he hits it right on the head what the problems are, and he touches on some of the important components of a solution. But I think where everybody in Washington falls short is thinking that all we need is insurance reform. We need health-care reform. We need to figure out where the waste is so that we can redirect our financial resources to actually provide care, not figure out ways to deny care. You can't treat it as a market because a market implies there's a consumer and somebody providing the service. But they've got somebody right in the middle interfering.

When you buy a car, if you go through Costco, who brokers you a better deal, you're not getting less car because you go through Costco. Costco doesn't make more money because they allowed you to buy a Cadillac and then stripped it of all of its features.

You can buy a car at Costco?

You can buy a car through Costco; they have a purchasing program. That's how I got my Ford Escape hybrid. Put hybrid down... see how much socialist, Communist banter ... when you go through hotels.com, do they make money by trying to stop you from getting a hotel? They don't. Insurance companies penalize you under the guise of options, free market, more choice.

If there was a single payer, wouldn't they have to operate by those same kind of rules? That's the game of insurance.

Thank you for calling it a game, by the way. Any industry needs regulation.

Obama said, my plan is going to make sure that you can't be denied care because of preexisting conditions. My plan is going to make it so that if you get sick, you can't be dumped by the insurance company. My plan is going to make sure that when you lose your job, that you can't be dumped by the insurance company, or if you are, you have an affordable option, the public option, to go to. But those are all of the things that insurance companies do because they are in a competitive market. They don't compete for providing our health care, they compete for getting our premium dollars. And this is also why we say they privatize profits and socialize costs. When you've got your good health insurance plan at Micron, which probably isn't that good anymore, you're healthy and you're working and you think it's a great plan because you're covered. But then when you have a disabling accident or unpredictable illness like lymphoma, you become disabled and then you can't work. And, how long will you get to keep your insurance? Well, that's built into our system. Once you lose your job, you're allowed to do COBRA, which costs three to five times as much, for 18 months, and then you can't even do that anymore. Then you go to the private insurance market where you can't get a policy because you have lymphoma. Where do you end up? That's where the public comes in and pays for your care, when you end up on the public program. So they made all the money from your premiums that you and your employer paid, and right when you need them the most, they dump you and they don't have to pay the high cost of your long-term treatment and, instead, those costs get passed on to the public plan.

We're already paying for a system and then we're paying more. And we pay more because for some reason our country thinks that we need to waste money so that a middle man in conflict with our health-care interests can be profitable.

Give me an example of how a single payer would contain costs.

You got asthma, you get a cold, you don't go get treated, you don't take your inhalers, you end up with bronchitis, you think you'll get over it, you can't see the doctor, you don't want to go wait six hours in the ER. The next thing you know, you've got pneumonia; you're just about dead and the ambulance gets you, takes you to the ER, puts you on a vent, you're in the ICU for two weeks. That costs $50,000 to $100,000. If we just would have paid for that person to have primary care, they could have been fixed long ago—when they just got bronchitis—in the doctor's office for $50. And who pays for the $50 for that person who can't do it themselves? The public. And who pays for that $50,000 when they can't do it for themselves? The public. So the public should be able to decide, do I want to pay $50,000 or do I want to pay $50.

It's the same concept with illegal immigrants. You can tout how you just do not want to pay for their care, but unless you can follow through and stare this dying person in the eye and say, "You know, you're an illegal immigrant, we're not going to care for you, you just have to die over in the corner." We don't do that. They go to the hospital, they get taken care of, they ring up a bill and the taxpayer pays for it somehow. Maybe not directly, but eventually that hospital has to recoup costs.

How do your colleagues view your position on this?

It's variable. And part of the reason you're going to see the high variance is because whether it's single payer or public option or any type of reform which potentially could help the health-care consumer—which is just a stupid way to call a patient—you're going to find that people who make more money with procedures aren't as happy about reform. People who make far less money because of their primary care, cognitive base work are going to be much more interested in reform. People who see more of the indigent and Medicaid and Medicare population are going to see the value of reform.

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