Sweet. One question: what line on your 1040 is used for “tomatoes”?

I am a boutique. A solo practice psychiatrist with a home office, and I am on no insurance plans, including Medicare. A secretary/book-keeper one day/week who needs to know nothing about coding, etc. It works for me. And if patients without money pay me in tomatoes from their gardens, it’s fine with me. It is a kind of freedom, and I love it.

I only need ocasional access so Im not payin!

There was a sign in a business that said “Speed, Quality, Price: Pick Two”. The first rule of the marketplace is that you don’t get something for nothing.

I suppose some principles are universal. Kinda like the laws of physics. Your “unlovely triangle” echoes the same idea for medicine that the restaurant sign did for the food business.

After slogging out a pretty good living in the cafeteria business I have watched helplessly as the old ways of cooking and doing business have been displaced by newer ideas. Often they are less expensive (economy of scale), safer (better sanitation with cutting boards not made of wood, pasteurized eggs, etc.) and even better for you (no MSG, trans-fats, etc.). But there is no way that a factory-made strawberry pie made two or three days ago can compete with its less glamorous, made from scratch cousin put together this morning about three hours before lunch. Especially if the berries are selected for perfection and the topping is made from real whipped cream.

In the case of health care, I don’t worry too much that those with enough financial resources will get a lot of bang for their buck. The marketplace will take care of them. My concern is for those who endure treatable medical and dental conditions and never seek treatment because they are too proud to do so at the price of personal dignity. Some people, those we call the “working poor,” don’t want to admit they cannot afford medical care and delay or deny the need, often to everyone’s expensive peril. (Needless to say, insurance is out of the question for the unemployed, and we are led to believe that any unemployment figure under five percent is considered “good.” For this reason I am in favor of the president’s proposal to uncouple employment from insurance. Only a lame duck administration could advance such an idea, but in that regard he is taking a high road toward resolving this problem.)

At some point some hard decisions must be made and harsh guidelines put into place regarding what will and what will not constitute a universal safety net. Somewhere between elective cosmetic procedures and life-saving emergency care a lot of hard decisions must be made. The time is past due for a spirited public debate about the specifics of what we want to be paid for by individuals (including their many insurers) and what will ultimately be paid for by tax dollars.