It is the best of healthcare spending, it is the worst of healthcare spending. This is the tale of two graphs.
The US spends much more for healthcare than any country in the world, yet it does not have the longest life expectancy, not even close. The following graph makes this startlingly clear. Prepared by statisticians at National Geographic, it shows the relationship between total healthcare spending and average life expectancy.
The US spends more, far more, per capita than the other nations and seems to get a lot less in return. Many pundits (and alternative health advocates) use this graph, and similar data, to support their contention that the American medical care is deficient in some way. But let me show you another graph that may change your mind.
The following was prepared for the Pittsburgh Post Gazette by Professor Paul Fischbeck of Carnegie Mellon University. Prof. Fischbeck runs the website Death Risk Ranking.com.
Until approximately age 60, US per capita health care costs are similarly to Western European countries. A disparity develops after age 60 and that disparity increases rapidly in size. By age 67, the US is spending more than 2.5 times per capita, increasing to 3 times more by age 77 and a whopping 4 times more at age 85.
These graphs impressively demonstrate a reality of healthcare that Americans persist in ignoring. We can't cure stave off death in the elderly, no matter how much we spend trying to do so.
Everyone dies. There hasn't been anyone yet who has lived indefinitely, and there isn't ever going to be anyone who lives indefinitely. Despite the massively increased sums we spend compared to other countries in an attempt to stave off death in the elderly, we accomplish virtually nothing. The inevitable conclusion is that end of life care in the elderly is terribly expensive and essentially useless.
It is not really accurate to say that the US spends more on healthcare and gets lets in return. A more accurate assessment is that the US spends almost the same on healthcare as everyone else throughout childhood and adulthood, but spends dramatically more on end of life care without any return on that investment.
Need more evidence? According to the US Agency for Healthcare Research and Quality (AHRQ), the 5% of people with the greatest healthcare expenses spent 49% of US healthcare dollars. Of that group, 43% are age 65 and over.
This is the "elephant in the room" in the healthcare debate. We are wasting massive amounts of money on unsuccessfully trying to prevent death in elderly people who are going to die anyway. We are offering false hope at an exorbitant price, and no one wants to stop.
The key point is that this care is ineffective. If it succeeded in prolonging life, we would need to ask if the massively increased expenditures are "worth it." We would have to contemplate the value of spending an ever increasing proportion of our gross domestic product on extending the lives of those who have already lived a full life. We would need to consider whether it is worth crippling the competitiveness of American industry in the global marketplace in order to increase life expectancy. And we would probably answer "yes" to all these questions, since the alternative is rationing, the third rail of American healthcare politics.
But the care is not effective. Therefore, denying such care is not "rationing," but merely reigning in waste. It may make people feel better emotionally to believe that they are doing everything possible to postpone the inevitable, but it is an extraordinarily high price to pay for what amounts to nothing more than wishful thinking.
The discrepancy between American healthcare expenditure and life expectancy does not reflect any fault in the quality of American healthcare. Rather it reflects a philosophical distinction between the US and other first world nations. We are willing to pay, and pay dearly, for false hope, while they are not. If we want to know why American healthcare costs so much more than healthcare elsewhere, we should not be looking at the quality of medical care, we should be looking in the mirror.
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Comments
We have such a hard time dealing with the idea that we are all, every one of us, on a one-way trip. Birth at one end, death at the other.
The whole "death panel" debate was such a farce. All it was, was a representative from my state (Oregon's Earl Blumenauer) saying that doctors should get reimbursed for their time for talking to their patients about death.
What do you want? Is it written down anywhere? Do you want full resuscitation? Do you want them to pull the plug? How do you feel about hospice care? Who should make decisions for you if you become incapacitated? Is it written down anywhere? Does your doctor know what you want? Does your family know what you want? Do you know what you want?
That's it. That conversation, and the doctor writes stuff down and gets reimbursed for the time. That's all.
Not thinking about death doesn't make it go away. And, as you've pointed out, spending endless sums of money doesn't make it go away either.
A woman at my work recently passed away suddenly. She went in with pneumonia and received a terminal diagnosis. Apparently in her last few weeks she felt bitter that she had put off so many things for the future (her retirement was one year away) and was regretting the decision to sacrifice so much for a job for so long. Makes one stop and reflect...
Sympathy on the loss of your husband. What a tragic situation.
"The irony of this is that if you asked most random people on the street if they want to die in a hospital hooked up to a thousand machines, or at home peacefully in their own bed, we all know what the answer would be."
That's right. The problem is that when people demand that doctors "do everything," they don't really understand what "everything" means.
"Perhaps elderly Americans are just more unhealthy than elderly Europeans due to a different lifestyle?"
The take home message, though, is that spending more money on the elderly at the end of life doesn't extend lifespan. Therefore, that money could be diverted into caring for those without access to healthcare, or into health education or preventive health without decreasing lifespan.
I'm glad you're not my doctor.
You see, there are some people who find it great that we actually try to treat people after sixty.
We also try to help people with problems in the early stages of life. We have, as you should know, some of the best preemie care in the world.
But, for the Left, it's always about money. Isn't it? See, we who are classical liberals think it is wonderful that people over sixty have a greater chance to live a longer life than they would have had say 100 years ago. On the Left, at least where you live, this is not a good thing.
BTW, all medical care is an attempt to stave off death.
You are a good example of why classical liberals such as myself don't want the government involved in other people's health-care decisions.
My points still stand. Sixty-five is not terribly old and, most people understand, that later, as well as earlier, in life is where we need most medical care. That a lot of it is great care that prolongs life is a GOOD thing for many of us. (Obviously, I'm speaking in general and not referencing people attached to machines at 103.)
That it is not to the Left, is really rather sad. Very sad.
So, would you agree with Obama, who, having had pointed out to him that a questioner's grandmother in her late 90s had treatment that allowed her to live an additional 5 active, good years, basically implied that she should not have had the treatment?
How compassionate! And, in so many ways, how anti-life.
There is certainly a time to die. But all of medical care in later life is not simply triage, and many diseases that caused early death in other generations can be treated. It gives us one of the most active and "alive" (in every sense of the word) older generations in the world. Isn't this a good thing? You seem to think the cost makes it not so. Sure there is a cost trade-off in everything in life. But, if you, and people like you, would stay out of other people's lives, they could decide that trade-off for themselves. And most people, at least those who don't dwell on the Left, choose life, if viable, decent and whole, over "early" death.
Again, I find it sad that you are a doctor.
I'm certainly glad you are not an oncologist.
Obviously, setting a broken arm is not an attempt to stave off death. It is a treatment for an injury. (Although after an age to be determined by the good doctor, it is best to let it go and let nature take its course perhaps?)But, beyond injury and the common illnesses that do not usually kill, all medicine is an attempt to stave off death.
I was speaking in the general sense.
I'd also have a question for the doctor. Is she a practicing Jew or a practicing Christian?
I'm just curious.
Actually, no. We have to distinguish between treatment and palliative care -- comfort care. You never withdraw care. But there is a point at which we transition from treatment to comfort care. I think the point of the post is that in many cases the transition from treatment to comfort care should happen earlier than it does now.
To do so would not only save money; it would be kinder to patients. Treatment is often uncomfortable and painful, and often requires the patient to be hospitalized rather than being at home. So it's not only about money.
Barbara: "You are a good example of why classical liberals such as myself don't want the government involved in other people's health-care decisions."
But we already make these decisions. For example, no one is going to give a 90 year old man a heart transplant.
Medical treatment has to have a goal. Sometimes treatment makes sense, and sometimes it doesn't. Expending vast resources on treatment of little or no value is futile care and makes no sense. We may sometimes disagree on what constitutes futile care. But in a world of scarce resources, we need to start having that conversation sooner rather than later.
Of course we make these decisions already, but the doctor appears to think that care for the elderly, full stop, should be amended based on age alone, not the possibility of a full life of many years after said care.
No, most of us would not choose to have a heart transplant at 90, although I'd contend endlessly that that should be the choice of the patient and his family, not of society.
But what the doctor implies is that treatment for some diseases, let us (it is my choice) say cancer should not be as "full out" after a certain age. Yes, there may come an age at which I or other individuals choose not to have aggressive treatment, but there may be others who, even at 80 for example, feel they have a good 10 years of life ahead and choose to have that treatment.
Where the doctor seems to be going with her post, is toward a society that laments the aggressive treatment of disease among the elderly.
I repeat, a woman told Sen. Obama, he was not yet president, that her grandmother, I believe, in her late 90s had a heart procedure that gave her a life up to 103, I think it was. Sen. Obama, perhaps not understanding her (?), and I don't mean that as an insult - perhaps he merely misheard the comment - pointed out that at that point choosing a "pill" and going home is perhaps best.
If he meant that, especially given that the woman in question had had successful treatment that gave her more years of active life, I find it scary.
At what point do we evaluate all "non-productive" life and withhold care? Should we apply this to the chronically homeless? I would not. I'd fight anything like that.
This is, for me, why other people should stay out of my care, my family's care and why I will stay out of their health decisions.
I think this is something the Left doesn't get.
Don't American elderly, if one wants to call 65 elderly, have better older years in part because of medical care?
And the doctor doesn't dissect, no pun intended, other reasons they may not LIVE as long as the elderly in, say, Japan.
The doctor also speaks as if the American individual is part of some "we". We are not. I know one must speak in general, but my dollars for care are not part of HER dollars for care and so on.
Her thinking, and perhaps her power at some point, is yet another reason we should speak to health care as an individual choice and remember that it is not a "pie" she gets to divide.
Another reason to keep other people out of our live choices.
Great! Pay for any care that you want. Oh, wait, you expect the government to pay for it. You expect me and everyone else to pay for it, because that's what Medicare is.
So what you're really saying is keep handing over the cash, and don't ask me any questions about what I'm going to do with it.
You seem to have entirely missed the point of my post. The point is that spending massive amounts of money does NOT prolong life. That's what the second graph shows.
I'd also ask that you show, since you're the doctor, what this life-expectancy is based on? That is, are Americans being compared to other societies , such as Japan, that have a longer life expectancy for possibly other reasons? (Are we, in a sense, comparing "apples and oranges?")
I find it difficult to believe that, for example, greater cardiac care, - we have one of the best systems in the world - among people over 65 does not prolong their lives. How do you explain that? For that matter, what do you mean when you talk of "prolonging"? (Also, what is the quality of life for those in other countries that live to the length of years those older Americans reach?)
Of course we will not live forever. But surely one should be able to choose, for example, aggressive cancer treatment at at 65, 70, 75 in one wants. Does that mean we'll live forever. Of course not. But it might mean we have more years. Also, have you factored, or have the people who are working with these statistics factored for everything possible that accounts for them? I don't know. Do you? (Whom are they comparing to whom? How do the elderly die? Of what? After what treatment? From what diseases?)
I'd also point out that I don't believe in the government paying for MY CARE. I don't think people should be forced into Medicare for many reasons. What you are suggesting, by implication, the governmental rationing of care based on the outcome and goals you have, is just one of them.
I also think you are not addressing improvement in health with certain care for the older among us. Should people over a certain age NOT be treated for cancer? Do we want to base all medicine on statistics? Do we not want to allow people to choose for themselves whether they want to pursue treatment?
And, by the way, my money is not your money. I don't want the government in my health care and I don't want you to tell me what to do in regard to my health-care decisions.
You seem to have missed the point of my posts as well.
I don't believe in forcing people into systems that the government controls.
Do you deny that advances in medical care overall have had anything to do with longevity? Would you have a cut-off point? Would you have cut off Mr. Kennedy's care? Or will people who are rich always have a way to opt out of the system?
At root, what non-liberals do not realize, is that my care and the care of the elderly I love is none of your business and my money is none of your affair either. And it is "rich" indeed that you accuse me of wanting to take medicare money. No, I want people like you to stop taking MY money. I'll handle my medical needs my own way.
Please research those statistics, see what they are based on, take them apart, and try again to persuade me. You certainly haven't so far.
Many things that cause premature death have nothing do with medical care. We have far more fatal transportation accidents than other countries. That's not a health-care problem.
Similarly, our homicide rate is 10 times higher than in the U.K., eight times higher than in France, and five times greater than in Canada.
When you adjust for these "fatal injury" rates, U.S. life expectancy is actually higher than in nearly every other industrialized nation.
Using international life expectancy statistics as a justification for a government takeover of medicine is misleading and dangerous. Fortunately, some doctors and reporters know better.
To the good doctor. This was just on general life expectancy. Have the compilers of your graph, however, factored in other discriminating circumstances between the U.S. and other countries? Have you researched whether they have?
So you plan to reject Medicare? Then we have no problem. You can pay for whatever care you want, regardless of whether or not it is beneficial.
I, on the other hand, am writing about everybody else who assumes that the government will pay for whatever extraordinary end of life care they desire.
You also haven't answered my questions about the study, the statistics, Mr. Kennedy, the question that was put to Mr. Obama, and such.
You have, however, given a good example of just what a lot of those, including me (and people like Nat Hentoff) worry about when we talk about government-managed health-care.
Take care. And, no disrespect meant, but check out the stats and stay out of my choices.
"Obama's Senior Moment"
Why the elderly are right to worry when the government rations medical care.
You can find on Forbes.com. "Medical Analysis by Milton Friedman" by Peter Robinson.
The issue is not age per se, but the fact that most end of life care occurs with elderly patients.
If all of this cost was in fact significantly extending life, you'd have a point. But it is not working out that way. From a 2001 article in the Journal of the Royal Society of Medicine:
"According to a report from the Medicare Payment Advisory Commission (MedPAC), about a quarter of the total Medicare budget is spent on services for beneficiaries in their last year of life, 40% of it on the last 30 days."
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1282187/
There is a significant variation in end of life care between states. From a 2006 USA Today article:
"If you are dying in Miami, the last six months of your life might well look like this: You'll see doctors, mostly specialists, 46 times; spend more than six days in an intensive care unit and stand a 27% chance of dying in a hospital ICU. The tab for your doctor and hospital care will run just over $23,000.
"But spend those last six months in Portland, Ore., and you'll go to the doctor 18 times, half of those visits with your primary care doctor, spend one day in intensive care and stand a 13% chance of dying in an ICU. You'll likely die at home, with the support of a hospice program. Total tab: slightly more than $14,000."
http://www.usatoday.com/money/industries/health/2006-10-18-end-of-life-costs_x.htm
While there are no doubt many reasons for that variation, the article notes that "experts on the end-of-life care say one main reason for the vast difference between the two cities may be that in Oregon, doctors, or staff at hospitals and hospices, encourage patients with life-threatening illnesses to talk about the end of life, what kind of medical care they want and where they want to die."
Ironically, it may be that by receiving fewer medical interventions, patients actually end up with better care, in the sense that the care they do receive is more in line with their wishes, rather than being swept along with "the doctor knows best" kind of thinking.
It is sad that people think the medical system should prolong life no matter what the cost. That death is something evil to be fought off with every ounce of energy. Sometimes death is the expected out come, death is part of life.
I used to see this in hospital with brain trauma patients, they would be brain dead, but the family would not let go, they would keep the person on ventilators for months waiting for their loved one to wake up. Whenever the doctors would discuss the brain death, the family would get angry at the doctors for not "doing more".
Another instance is end stage dementia, the poor patient has no interaction with anyone, bedridden and is still a FULL CODE. When that poor persons heart begins to fail, the family wants aggressive treatments and surgeries to bring mom or dad back to normal. If they do survive surgery, the family is angry because the dementia is still there.
Americans are more concerned about quantity than quality. Everyone wants to live to be 100, but expects the medical profession to make that possible through expensive interventions.
Everyone wants a quick fix like on those TV shows, no one wants to do the hard work of healthy lifestyle choices.
Everybody wants something for nothing.
This, of course, is just one of the reasons that she (and you) should stay out of my family's lives. We don't belong to you. We don't belong to the government. You have it backwards. The government works for US.
I'd love to see a gradual backing off of Medicare, to remove the control from people like the compassionate doctor/accountant (and you).
BTW neither of you have addressed the questions I raised about quality of life among the elderly and just how much of those dollars are spent on that, Sen. Kennedy's choices, the question put to the-Senator Obama (I have it in my posts), the actual breakdown of the graph the doctor has submitted, etc.
Also neither of you ask this: "Are the doctors in America supplying the elderly with something entirely useless? Wouldn't people figure that out? Is there something the doctors in Oregon know that those in Florida don't? Is it the AIR in Florida that makes the patients and the doctors such apparent morons? (Why would insurance companies PAY for useless treatment?) OR, are people simply choosing to do what they want at various stages of life and are those choices none of your business?"
I know they're none of mine.
I also know that in the real world, most of us can figure out for ourselves when we need to think about "end-of-life" without the doctors prompting us.
The patronizing of people evident in the whole idea of "holy" doctors "talking" to us about "end-of-life" would be hilarious if it were not so arrogantly infuriating. The new priests.
You people really make me laugh.
If you review the information in the sources I cited you'll note that 40 percent of Medicare costs occur in the last YEAR of life, and 25 percent of that in the last MONTH. So forget years. We're spending a huge amount of money just to give people a few more days or weeks of life -- days or weeks during which they may not even be conscious, or may be in physical and psychological distress, subject to invasive procedures and surrounded by machines and tubes. Given a world of scarce public resources, that makes no sense to me.
If you and your family want to have no-holds-barred, pull-out-all-the-stops, spare-no-expense medical care in order to last as long as possible, then you guys should purchase private insurance policies that will give you that. Because there is no country on the face of the earth that can afford to provide that kind of care for everyone.
Barbara: " . . . are people simply choosing to do what they want at various stages of life and are those choices none of your business?"
When that care is paid for out of public funds, then those choices are my business. That said, what you do with your money is your business, and if you want to pay some thousands of dollars a month for a private policy that will allow you to have virtually unlimited care based only on your own desires, then you should do that, and I won't have a problem with that.
Barbara: "The patronizing of people evident in the whole idea of "holy" doctors "talking" to us about "end-of-life" would be hilarious if it were not so arrogantly infuriating."
It's a free country, and you don't have to talk to anyone about anything. So when you're 89 years old, have a stroke and can no longer communicate your wishes, and your doctor has absolutely no idea what kind of care you might want during the last few weeks of your life, what happens then? Does he guess? Flip a coin? If you don't talk to your physician about what you want in the way of end of life care, how will he or she know?
Well, think again. We'll pull out. At least I will.
BTW, I might not decide to spend millions on a last month of life, but what I'm saying is that it is MY choice, not yours. And, what YOU are saying, is what I've been saying for years: To wit, if the Left is allowed to get into place a public-financed system, they will never stop in their efforts to control other people's choices.
How do you feel about people smoking, eating "wrong", using "bad" foods, having sex that can lead to AIDS or STD's? Do you want to control those actions via government because "you are paying".
You actually make the case for keeping government out of health care.
BTW, I am pointing out that the doctor who wrote this article doesn't appear to favour that extra care for my dad that extends his life from 80 to 90.
I wasn't speaking to a last month of wasted effort, although, if I was, I AM THE ONE who decides it is wasted, not you. Not some arrogant person who doesn't even know my dad.
BTW, do you think the disabled should be perhaps encouraged to choose death if they "cost" too much? Do you praise Kevorkian? Do you think women pregnant with special-needs children have a talk with doctors to perhaps be encouraged to abort?
And, you have still not answered the questions about Kennedy, the question put to Obama, the question about the homeless, and such.
I'll grant that at some point, some people, and I never said otherwise, need to decide how much treatment they want to have. It is simply that that should be THEIR decision. (And, although I hope Medicare someday fails totally and that we move away from ALL such government programs - and partly because it allows busybodies into my life and also because the Left is too in love with death - until we do, I hope we "err on the side of caution", as they say, and allow patients and/or their families as much choice as possible, rather than become a country where bureaucrats decide what happens to those, like some of the people I love who, I assure you, are better than most of them.
Also, how exactly is Misima going to determine the last month? Who decides just what "foresight" is acceptable and to be valued and what isn't? Will it be you? The doctor? A government committee? Or should it be up to the families of those involved?
Do you really want strangers to have the power to make those decisions?
Do you really want GOVERNMENT to have the power?
And, as I've said before, the "left" wow, they do crack me up. It's all about money for them. It really is.
I really think the Left doesn't love freedom much. They want a safe, good, illiberal, fascist-light state.
And they really, really, really care about money.
As a social conservative I find it odd to be categorized as a "liberal." And to be frank, I find the radical individualism that you appear to advocate to be very liberal. Your idea seems to be that when it comes to health care, you have an absolute claim to the public treasury to get whatever you want. And that's none of our business, even though we're expected to pay for it. That's about as liberal as it gets.
Barbara: "BTW, I might not decide to spend millions on a last month of life, but what I'm saying is that it is MY choice, not yours."
I don't have a problem with that, as long as it's with YOUR money, if you decide to spend millions.
Barbara: "How do you feel about people smoking, eating "wrong", using "bad" foods, having sex that can lead to AIDS or STD's? Do you want to control those actions via government because "you are paying".
No, I don't want to control anyone's life, though I think it makes sense for the government to provide information to help people make healthier choices. But the choice is ultimately theirs.
Barbara: "BTW, do you think the disabled should be perhaps encouraged to choose death if they "cost" too much? Do you praise Kevorkian? Do you think women pregnant with special-needs children have a talk with doctors to perhaps be encouraged to abort?"
No, no, and no.
Barbara: "And, you have still not answered the questions about Kennedy, the question put to Obama, the question about the homeless, and such."
I can't begin to comment on Kennedy without knowing the details of his illness, the treatment options, his preferences, and so on. I don't know anything about the question put to Obama. Concerning homeless people, there are certain treatments that are not offered to them, because they are unable to participate in their own care, show up for appointments, take medications on time, and so on. Beyond that I think they should be able to get the same care as anyone else.
Barbara: "I'll grant that at some point, some people, and I never said otherwise, need to decide how much treatment they want to have."
Yes, but it's important to make that decision while one is still conscious, otherwise other people have to make that decision. For patients that are hospitalized that often happens in the venue of a medical ethics consult.
Barbara: " . . . I hope Medicare someday fails totally and that we move away from ALL such government programs . . . "
So how does that work? You're not going to withhold care from homeless people. But they can't pay for their own treatment, and the government isn't going to pay for it. So who pays?
Yes, we spend WAY too much on life-prolonging treatments- my father was "cured" of many infections in the last year of his life that he did NOT want treated (but was unconscious and I was not there)-fortunately, I was there for this one- getting him into hospice (1/10 the price of his ICU bed, maybe less) was hell for me.
So my point is that there ARE people who, either because they lack a living will or because their condition isn't covered, are getting treatment they do NOT want, simply because their life CAN be prolonged (at a point when there is little to no quality of life left).
Yes, my father might still be alive today, 10 months later, had he had his gall bladder removed. Sure, he would have been hospitalized on and off for a bunch of other things, all the while being in constant physical pain, but his body would still be here.
Sorry to ramble but I guess my point is for each person to make his wishes known to family members, give those family members power to act on those decisions, and, hospitals, please respect those wishes and engage in palliative care when "treatment" is not wanted (and without a guilt trip, thank you very much). Between my father's assisted living expenses and hospitalizations, I would guess close to $1 million was spent on medical care for him from age 65-80 (when he passed).
I don't want to pay into ANY of this, but I object to, once I do pay in, it being YOUR money, but not, MINE and certainly not the money of the person who SHOULD BE ABLE to make his own decisions with his family and doctor.
My point is that none of this is THIS woman's business, or yours for that matter.
I repeat, why does your desire to save money trump my desire to spend? We're both paying in.
BTW, as said, I don't want to pay in and believe in individuals not be coerced into government schemes, but the liberals who wanted this stuff certainly can't then cut off people. Some of them, by the way, will have been paying in for longer.
I am a classical liberal. I want the government and this doctor OUT of my life. But if I have to pay into this system, I have as much say over how the money gets spent as she, or you, do.
Have a good day and all of you please stay out of my medical decisions.
Some of us do believe in leaving these decisions to individuals. If that is "radical individualism" to you all then, wow, that is so sad.
It's all, money. And it usually is with the "compassionate" left.
By the way, why is it HER money or MISHIMA'S money, but, suddenly, for those who may have paid in longer or don't agree with the doctor or her fans, no longer THEIR money? Oh, right, we are only part of the great "we" when we go along with the arrogant assumptions on the Left. Got it.
Now leave me alone.
And notice, I ain't trying to tell YOU how to make YOUR medical decisions.
It's all so illiberal.
Don't you see where this could go? If you withhold it for them, why won't others decide to withhold it for others for whom they deem care to be a waste? That is where this doctor's point of view could lead.
And, for the last time, why is it your, or the good doctor's, call?
Don't want those old folks using too much water and all.
By the way, I don't think the world is in danger of running out of resources, and I'm not letting fear on the Left determine who in my family gets or doesn't get care.
You don't want to be part of Medicare, help get rid of it.
You don't want to pay for me or have me pay for you? Fine. Agreed. Work to get Obamacare repealed. There ya go.