Solutions to Medical Malpractice Costs in America

The American approach to medical malpractice is odd at best. The general concept is that if a doctor makes a mistake, that doctor is then responsible for any harm that comes to the patient. The actual implementation of the general concept, though, is not so simple.

Let's suppose that Dr. Jane Love is a general surgeon and John Smith is referred to her after he is diagnosed with appendicitis. Mr. Smith agrees to undergo an appendectomy and understands that there are certain risks involved but he also understands the necessity of having his appendix removed. Mr. Smith undergoes the procedure and develops an infection at the site of the surgery. Following two weeks in the hospital, he recovers and then goes to talk to his attorney, Marc Nelson.

For arguments sake, let's say that there are some serious questions about whether or not Dr. Love did everything possible to prevent an infection. Dr. Love did a very good job with the procedure, but it is possible that she could have done something more. There is also evidence that the infection would have resulted no matter what she did. Nobody knows if Dr. Love could have prevented the infection but it is obvious that Mr. Smith suffered greatly, accrued extensive hospital bills and missed considerable amounts of work.

At this point the American malpractice system becomes very convoluted for a number of reasons. I'll just address a few of them:

1. Mr. Nelson and refuse to represent Mr. Smith and (assuming other lawyers do the same), he really can't sue Dr. Love. Whether or not malpractice was performed will not be decided unless a lawyer can be convinced to take up the case.
2. Since Dr. Roe followed procedure, she is not under threat of losing her license, she is only under the threat of monetary damages. In this case, "justice" is only about who pays what to whom and who covers the cost of the undesired result.
3. Dr. Roe doesn't believe she did anything wrong and followed hospital procedure. Regardless of her actions, she will be forced to hire an attorney if Mr. Nelson takes the case, even if it never even progresses to court. She is carrying the entire "risk" of the operation until Mr. Smith drops his claim (through a verdict, settlement or because he doubts he will win).

The major problems arise because it is very difficult to determine fault and causality in malpractice cases. There is rarely a clear-cut line where you can state that because person A did X, person B suffered Y (such has removing the wrong leg). Often, cases simply boil down to a situation where person A expected result X and ended up with result Y. When Y is a bad result, person A expects recompense. Is it justice to assign blame when no obvious blame exists? The American malpractice system operates on the basis that the answer is "yes".

Problems

The first problem with meting out justice in this fashion starts with the hurdles to have your day in court. Since malpractice attorneys generally operate under a contingency-fee basis (where they only get paid if they win - usually a percentage of the total award), they will only take cases that will pay enough to justify their time. Since litigation is expensive (court costs, depositions, travel, expert witnesses, staff, etc.), attorneys first make a business decision about a case before they consider the merits. Is it better to spend $20,000 litigating a case where you have a 25% chance at winning $1 million or to spend that same $20k on a case where you have a 95% chance of winning $30,000? Attorneys will only take cases that will make a return, and they don't really care who wins as long as they win enough to stay in business. An attorney can stay in business if they win one case a year and make $1million on it - losing another 12 wouldn't matter and each of those clients would get absolutely nothing. An individual, of course, could directly pay for litigation out of pocket, but few people have thousands of dollars available to take a case to court and there's no cheaper way to litigate. It would seem odd to have to pay a policeman a $3000 retainer (direct payment option) or else prove to him that you can tell him where the robber is (contingency-fee with a good chance of winning) before he investigates a robbery, but in malpractice law, that's the situation that exists. The entry to the case is based on the whims of the attorneys.


The next problem comes from the idea that justice is comparable to dollars. No matter what happens, Mr. Smith can't undo his time in the hospital, he can only be recompensed for his losses. Dollar values can recompense lost wages and hospital fees, but it is a bad way of compensating for pain and suffering since it doesn't recompense, it only replaces. The idea of monetary damages for suffering boils down to the idea that "because something bad happened to me, somebody should pay me" - it's an untenable position since bad things happen all the time. The idea that "my ex-girlfriend broke my heart and so now I'm going to sue her for all the emotional turmoil I went through" makes no more sense than trying to quantify how much pain is worth in dollar figures. If the ex-girlfriend kept the boyfriend’s car, getting it back is justified, but paying for emotions isn't. Only in the realm of medical malpractice do courts seriously try to repair a broken heart (or, for that matter, a broken leg) with a dollar bill.

The final problem I want to discuss is that once litigation has begun, it carries disparate risks on the opposing sides. In our example, once Mr. Nelson has taken the case, Mr. Smith has no reason not to continue with it since he has no risk of losing and only a risk of gain (Mr. Nelson is operating on a contingency fee basis and is paying all the litigation costs and will only get paid if Mr. Smith does). Dr. Love, though, is forced into a situation where she is only carrying risk. Once Mr. Nelson begins a suit, Dr. Love must hire an attorney to defend her. If the case goes nowhere, she is out the money she paid the attorney. If she loses, she pays her attorney and any damages awarded to Mr. Smith. Additionally, Dr. Love's lawyer has no incentive settle the case early since he will be paid as long as it goes on, often leading to increased litigation costs. Justice, then, cannot be had for Dr. Love, only for Mr. Smith - once he gets a lawyer to take his case (and has jumped the entry barrier) he cannot really lose, he can only gain. No matter what Dr. Love did, even if she was the best doctor ever and did the best job ever, she is going to lose - the only question is to what degree.


Solutions

There are some ways to get around these problems.

To start, we must identify the point of the civil courts - to make whole. If a physician is negligent or inflicts intentional harm, the physician should be punished by losing privileges or licensure from a professional committee or even being punished by the criminal justice system. This should be initiated and governed by the state or licensing committee and not depend on an injured party bringing suit and should not involve any benefit for the injured party. The state or professional committes can use expert panels who can decide whether a physicians actions were correct, honest mistakes or true mistakes that need to be punished. Conversely, the civil side of the law should not be involved in punishment but in restitution and making the injured party whole. Medical malpractice law currently attempts to both benefit the injured and punish the injurer and fails at adequately accomplishing either.


Next, we must continue with efforts to cap pain and suffering. There is no good way to quantify pain and suffering and money does not make up for it. Making someone whole by returning what they lost is appropriate, but paying a speculative amount serves no person other than to punish the offender.

Finally, we must remove the cost of litigation and inherent incentives and disincentives to pursue specific cases. The way to do this would be to eliminate the need to place all the risk on only one party. Why should physicians carry all the risk? While they certainly are involved with healthcare, they definitely aren't the only ones who benefit from their efforts. The risk pool should be shared more broadly and then recovering from that fund should be easier. By eliminating the litigation middle-man, millions of dollars can be saved and injured parties can be compensated much more quickly. I have two, competing suggestions on how to do that:

1. Create an additional insurance that patients can choose to buy (or have their insurance buy) before a specific operation or even just for life in general that is called "bad result insurance" where they will be automatically given money if something bad happens to them. If doctors can insure against future mistakes (medical malpractice insurance), why can’t patients simply elect to insurance against bad results? It would be very simple to pay an extra $100 for a wisdom tooth removal with the understanding that if dry socket resulted any future care would be covered plus you would get an automatic one-time payment of $1000 for pain and discomfort. The types of things that could be insured against are innumerable and the market would dictate who bought what coverage and how much it cost. In this case, risk sharing would be pool everyone who decided to buy insurance.
2. A state-funded entity comparable to workers compensation could be formed where, in the result of a bad result during a medical procedure, a patients losses would be automatically covered. Payments into the fund would automatically be charged for every procedure performed (with rates varying by the risk of complication) and as a general tax on healthcare expenditures. This would result in a risk sharing pool that includes everyone who uses healthcare.

Conclusion

Malpractice expenses can be curbed, but we need to recognize the problems and fix them from the base. Current efforts focus on limiting how much is paid out in damages, but the underlying problem isn’t the amount of the damages physicians have to pay, it’s the process by which those amounts are arrived at. We need to reevaluate our malpractice system and individually focus on the aspects of punishment and restitution. By dividing the two and taking the focus off the inefficient process of litigation we can truly lower the costs of medical malpractice while still making whole the injured and punishing the offender. When we leave all aspects of restitution and punishment in the hands of for-profit attorneys we arrive in the exact position we are in right now.

What The Democrats and Republicans are Missing About Healthcare

Let me briefly summarize the position of both parties relating to healthcare reform. I'm going to be somewhat simplistic, but the problems will soon be apparent.

Democrats:
Healthcare should be available to everyone. A government-run program that competes with the private entities is the best way to afford access to everyone.

Republicans:
Healthcare should be available for everyone to purchase. Private companies operating in true capitalistic fashion offer the best option where the market will determine the prices. A government-run insurance plan will lead to an unequal playing field and the private companies will be run out of business, resulting in only a government-run plan. This will result in government-sanctioned rationing and a limit in individuals' choices.

Both parties:
If the Democrats pass any major bill, they can lay their hats on it and benefit in the 2010 elections. Conversely, if the Republicans can stop any major bill from passing, they will benefit in 2010 by showing how ineffective the democrats are.

The problems with both sides:
The United States spends 17% of its GDP on healthcare. Yearly expenditures are also going up by at a rate of 6.9% a year - double the rate of inflation. NEITHER PARTY HAS ADEQUATELY ADDRESSED HOW TO LOWER THESE COSTS.

Both parties are simply debating who is going to be paying this same amount of money - neither has even discussed a feasible idea of how to lower the actual cost. (Rhetoric about electronic medical records saving us billions is ridiculous and won't be discussed in this blog post). At this point, I don't really care who is paying for healthcare - I want to know why we are paying so much.

Another glaring problem is that neither party actually will refer to "health insurance" as it really is - prepaid healthcare. If we want to discuss coverage, then let's do that, but let's be accurate and avoid the semantic fallacy that both parties are trying to pull. Let me reevaluate each party's postition

• Democrats: If everyone isn't insured they will not be adequately prepared for a health crisis.
• Democratic translation: If you haven't prepaid for your healthcare, then if you need a lot of help in an emergency you won't have already paid for how much you consume.
  

• Republicans: If everyone doesn't compete on a level playing field for insurance, prices will soar or government mandated rationing will result.
• Republican translation: If there's no competition among prepaid healthcare then the cost of prepaid healthcare will go up and/or what's offered on the prepaid menu will decrease.

Once you translate things, so what? I frankly don't care who wins this current argument. Neither side is actually working on making an improvement to the overall system, they're just arguing who gets credit for it. Risk-sharing, cost-cutting, changes in billing, reevaluating care and the overall goal of healthcare are simply being dusted under the mat as these two sides fight for a nearly worthless prize.



Solutions:

We need to actually lower the cost of our healthcare. There are countless ways to do that, but the most important is that we need to either implement true competition in healthcare or else implement some sort of cost-containment.

Here are a few ideas to cut costs.

Increase competition for procedures. Here's a very interesting post about the cost of CT scans in America compared to India. It turns out that for the exact same procedure with comparable equipment can cost 60 times less in India ($6500 compare to $115). It literally would be cheaper to fly to India to get a full-body CT scan (with contrast) and have it performed by a trained radiologist than it would be to get it in the states performed by radiological technician. As it is, there's a waiting list in America to get these procedures done. Why lower the price if there's a line outside your door? If there's only one choice for food in an area, the restaurant can charge whatever they want and people will pay it - ever been to a football game, ski resort or movie theater? Many procedures simply can be performed for less and will be if there is any competition. We need to encourage individual clinics to open up and specialize in offering select services for less and then let the market go to work.

We also need to increase the number of doctors. The US has 2.4 doctors per thousand people, which compares very poorly to Switzerland's 3.8 or Belgium's 4.0. Doctors currently don't have to compete for patients since there's a wait. Why should this one profession be competition free? It definitely isn't going to lead to better care, shorter waits and reduced cost. We need to increase the number of doctors who are trained in the US and make it easier to become a primary care physician. There's no shortage of people who want to practice medicine, just a shortage of programs who will train them.

Also, to cut costs, we must encourage people to live healthier lives. The fact of being unhealthy obviously isn't enough to dissuade many from leading unhealthy lifestyles, so we need to dissuade them in another way. I recommend we tax unhealthy behaviors. Cigarettes, alcohol, potato chips, most fast food and carbonated beverages could all be taxed and the money used to fund medicaid and fund anti-obesity campaigns. We wouldn't be taxing obesity, just the behaviors that are proven to cause it. People need to be spurred into action and since their health isn't enough encouragement, maybe their pocketbook will be.

Finally, to really spend less on healthcare, we actually need to reevaluate how it's provided. The 20th century has had a huge increase in the use of hospitals and hospitals are very expensive to run (thank you, JCAHO). Whenever care can be provided outside of a hospital, it should be. Smaller clinics, home-based care and services provided by non-doctor healthcare providers (nurses, PAs, etc.) should all be used. There's no reason that you need an MD to tell you that you are overweight and should stop smoking - a nurse is more than adequate to provide that important service.


Conclusion:

Health reform is an interesting and necessary topic that needs to be addressed. But, we actually need to address what matters - how to lower the cost we are paying. Right now, the major political parties are fighting for a prize that has no worth.

6 Things To Change in American Healthcare

President Obama recently began to attempt to fulfill his campaign promise to reform healthcare in America. He is being very pragmatic about this and recognizes that people will disagree about what needs to change in America.

I have spent many hours studying different proposals and I've come to the realization that the big issues aren't being discussed, let alone being considered. Both sides seem to be arguing more about minutia rather than what truly matters. To help the process out, here are 6 things that need to change in American healthcare. In conjunction with each point I will ask a probing question that really should be answered.



1. Healthcare should focus on helping patients, not avoiding lawsuits

Billions of dollars are spent every year by the healthcare industry in an attempt to prevent lawsuits. Whether it's striving for a better JCAHO review (a waste of time and money) or simply trying to cover your back by shoving piles of waivers down patient's throats, hospitals, doctors, HMOs and everyone in between often worry about what they have to do to protect themselves rather than to help their patients. Accidents and mistakes should be prevented, but worrying more about preventing a lawsuit rather than delivering quality care. Physicians might be more concerned with an individual patient, but the CEO cares a lot more about a possible tort claim than whether or not Mrs. Jones was pleased with her care.

Question 1: Are malpractice claims intended to help the injured or punish the offender?


2. Efficiency is necessary, even at a cost

The National Highway Safety Traffic Administration estimates that over 40,000 people are killed each year in traffic accidents. That's one out of every 7,500 people in America die every year just from traffic accidents. On top of that, roughly 2.5 million are injured by motor vehicles each year. That's one out every 120 people. How could we reduce these numbers? Simple - we just put a governor at 15 miles per hour on every vehicle in the country. Why won't that happen any time soon? That's also simple - the number of lives we save and injuries we prevent aren't worth the efficiency it costs.

Healthcare is in much the same boat except coming in the other direction. Rather than focusing on ways to make things more efficient and more cost effective, we focus on how to save that one more person. The American Cancer Society estimates that 565,650 people died from cancer in 2008. Of that number, 1/3 of the deaths are attributable to obesity/nutrition (188,500) and 170,000 can be attributable to smoking. Meanwhile, 49,960 deaths are attributable to colorectal cancer. They recommend, though, that after the age of 50 people get a flexible sigmoidoscopy every 5 years and a colonoscopy every 10 years. The average colonoscopy costs $3,081 while the average diagnosis of "obese" or "smoker" is free. Efficiency demands that we first focus on the bigger, more cost-effective diagnoses.

Don't get me wrong, I'm not against regular colonoscopies (there is, after all, a 5.4% chance that everyone will get colorectal cancer in their lifetime). What I'm using this example to illustrate is that we need to be efficient with our resources. Rather than using a new screening method that is 99.9% effective at detecting some rare disease, why not use the much cheaper 97% effective screening method? Will we miss some cases that we otherwise would have found? Yes. Will we save vast amounts of money? Yes. Healthcare shouldn't be confined to 15 mph - we need to make the changes that make us efficient, recognizing that there is a price that we will have to pay.

Question 2: How much risk are we willing to pool as a society?


3. Not all ailments can or should be treated

Americans love stories of underdogs who overcome long odds. While these tales make great stories, they make lousy justification for policy. When a patient spends the last days of their life in the ICU as opposed to at home with family, they may live a few days longer, but they also will pile up huge costs. A 2005 study (based on data gathered in from 2002) estimates the daily cost of a patient on ventilation in an ICU to be $10,794. That means that prolonging life by a few days costs huge amounts of money. I know I value my life, but if someone offered me $10,000 to give up next Tuesday, I'm pretty sure I would take them up on the offer - and that's not even an end of life sick day.

It may seem callous, but we cannot use insurance (cost/risk sharing) to try and work miracles. Hospice/palliative care must be viewed as a viable option. Medicine cannot simply be focused on delaying death but also maximizing life. Two weeks in the ICU compared to one week at home shouldn't be viewed as a tough choice to make by a care provider.

To accomplish this, there needs to be a standard set about what kind of care we are willing to risk share - the debate about what that is can then follow.. Is it that there must be a 50% chance of survival for two weeks and a 10% chance of survival at one year to warrant extraordinary care or is it lower than that? We cannot say that a 1% chance of survival beyond two weeks and a 0% chance survival at one year is worth $10,000 a day for the next week. People can still choose to pay for whatever care they want out of their own pockets, but risk sharing extraordinary care is untenable.

Question 3: What is the dollar value of a day of human life?


4. The federal government cannot make specific decisions about quality of care

Healthcare is a local concern. New Yorkers don't care about how rural doctors are able to get to remote communities any more than Alaskan Inuits care about whether or not a New Yorker has to go all the way from the Bronx to Brooklyn for an MRI (even after a 3 month wait!). The issues affecting each community need to be addressed by that community. Standards of care, expectations and willingness to pay all vary by location, culture and geography. These communities need to make their own decisions about what is expected and what can be afforded. Just as people make decisions about where to live, they also need to make decisions about what they want to pay for. New York offers everything from the arts to Wall Street and every service (including world-class medical care) in between. It also offers crowds, congestion, pollution and crime. Ashley, North Dakota might not have Broadway, but it can offer clean air, open spaces and much cheaper housing. Putting a New York standard of care on Ashley makes as much sense as putting an Ashley pollution requirement on New York.

Whether healthcare is administered via the government or through private insurers, the issue still remains what must be covered. If we have a federally mandated level of care, why should New Yorkers have any say in deciding how many MRI machines are enough for Ashley, ND? In New York, MRI machines per population might be the way to go. In North Dakota, distance might be the more important factor. Additionally, the administration needs to be local. A senator from New England who has never ventured west of the Mississippi has no more business telling North Dakota how to care for their sick than a North Dakota farmer has in telling New York what to do. They come from different backgrounds and are concerned with different things.

If the federal government wants to mandate that everyone is covered to some extent, that's fine, but it CANNOT try to oversee things. Primary care for the implementation of any standards has to be done on a more local level. Whether that is state-wide or smaller can be debated, but the federal government needs to keep its hands to itself.

Question 4: Who should make decision about which risks are shared?


5. People are responsible for their own choices

America is based on a system of rights and responsibilities. I have the right to vote, but I also have the responsibility to get myself to the polling station and make an informed decision. I have the right to choose to have children and I have the responsibility to provide and care for those children.

Healthcare is the same situation. It has been determined (I still wonder who made this decision) that people who need emergency healthcare cannot be turned away. This leads to the underinsured and uninsured flocking to emergency rooms for minor care. The cost of their care then goes to everyone else. Whether the solution is requiring everyone to be insured, creating a national healthcare plan (similar to our school systems where everyone can go) or if it's by somehow really holding people individually responsible for the price of the care they receive is up for debate. What shouldn't be debated, though, is that people need to be held responsible for the decisions they make.

Specifically, we know that certain choices (not genetic disorders) contribute to many diseases. Each year roughly 440,000 die from smoking. Their healthcare costs are a result of the decisions they made over the course of many years. Why should they only contribute the same amount to the risk pool when they are choosing to put themselves more at risk? Because of their choices, they should be contributing to healthcare more than those who aren't making those choices - let the penalty fit the crime. This can easily be implemented by raising taxes on products that are known to cause health problems: alcohol, tobacco, sugary drinks, many fast foods and most candy, just for starters, can be taxed (ideally at a state level) which an then go directly to the healthcare fund. An occasional Big-Mac probably isn't going to hurt you and neither will paying an occasional tax when you buy one. Eating them daily, though, will add up for your health and for your health plan.

Question 5: Should people pay for the benefits they receive?


6. A doctor at a hospital isn't always the best choice

When there is a health emergency, Americans instinctively think about going to the hospital to talk to a doctor. While in many cases this is a good idea, in other cases it really isn't necessary. Why does an MD need to sew up a cut finger or set a broken arm?

A doctor spends many years studying to learn to diagnose. Treatment, often, can be done by anybody with moderate training. While it might take a specialist to decide what drug cocktail is needed to treat a certain ailment, any nurse can administer the IV and any nurse's assistant can hand the patient the right pills. While it is true that certain procedures require specialized training, many (probably most) do not. You can get your eyes checked at Wal-Mart, why not get your stitches there, too? All we need to do is to change the definition of practicing medicine and then allow less-skilled diagnosticians to treat patients for less.

Question: Is a hospital an ideal setting to receive treatment?

I'll Give You 50 GMs for 1 Toyota

A market cap is what the market believes a publicly held company is worth at a particular time. You calculate it by multiplying the total number of shares of the company by the amount that shares are being sold for. As of today, November 12, 2008, GM's market cap is hovering around $2 Billion. Toyota, meanwhile, is right around $100 Billion. Yep, that's right, Toyota is worth 50 GMs to investors. While Chrysler and Ford are in a similar pickle, I will only focus on GM today.

According to Yahoo Finance Toyota employs about 325,000 people and has gross sales of around $260 billion. GM has 266,000 employees and sales of about $166 billion. So, while Toyota is definitely larger, it's not even twice the size, let alone 50 times the size. Why, then, is Toyota more valuable to investors?

The answer is that Toyota actually has a viable business plan. They build reliable cars and have dedicated employees. They do this by paying them with competitive salaries, 401(k) plans and healthcare benefits, not promises that they will pay for healthcare and pensions for the rest of their lives.

When GM was running the automobile world, it promised its employees pensions and retirement healthcare benefits. While that was great at the time with no need to pay into 401(k) plans, when hundreds of thousands of employees started retiring, the costs started adding up. Sure, GM had a pension plan whereby they invested money that could then be paid back to its employees, but the problem was that they weren't planning on all their workers living into their 80s. If you only put enough money into a pension plan to cover retirement benefits for 15 years post-retirement, you are going to be woefully surprised when you have to pay those same benefits for 30 or more years. One writer estimates that GM pays $78.21 an hour per employee to cover the salary of the worker (currently $26.65 for a new worker) and all the benefits they owe their current and retired employees. In contrast, Toyota only pays $48 for comparable benefits. That means that Toyota spends $1000 less for every car they make (and these are production costs, not sales costs). And you wonder why foreign cars, including those made in the United States, seem like a better deal - it's because you're getting $1000 more car for the exact same price.

Who do we have to thank for this mess? Culprit number one would be the executives running the company for the past 60 years. Sure, it was nice to save a little at the time, but you can't promise an inexact amount of benefits for a finite amount of service. If all GM employees died the year after retirement the company would be fine, but you can't base a company's future on that supposition.

The second culprit, and in my eyes the larger culprit, is the United Auto Workers. The UAW is an organized union that "represents" the autoworkers to management. I'm sure that most people are familiar with unions and the good they have done. Unfortunately, they have turned into a nearly insurmountable strain on our domestic manufacturing.

In our modern age people are able to relatively easily move to find new jobs (you're not stuck in the town where you're born) and are able to learn skills that make them desirable as an employee to an employer. A hundred years ago this wasn't always the case and unions put some parity in the bargaining process. Now, though, companies want reliable, low-maintenance employees who do their job and earn their pay. The cost of training a new employee is such that it makes more sense to keep an employee than to hire a new person. A hundred years ago, you could learn a factory position in a day - no need to understand anything more complex than a wrench. It is in a company's best interest to keep their employees since replacing them is an added expense both in time to find a qualified employee and in the cost of training the new employee. Unions don't help that process. Instead, they now simply fight to get more and more for the workers, eventually to the point of killing the company.

While I might think that the job I do is worth $50 an hour, if any high-school drop-out can do the same thing, $12 an hour might be too much. I, though, have the option of learning new skills and becoming indispensable to my employer. I have the right to leave at any time and my employer has the right to remove me at any time. If I'm doing my job, my employer has no reason to release me and instead has a great interest in keeping me. If, on the other hand, I have learned a skill that is worth more to someone else, I should have the right to go and work for someone else. Foreign company's understand this. No foreign auto-plant in the United States has yet to unionize since their employees understand this, too. If a Toyota plant someday unionizes, I hope Toyota closes down the factory and goes back to making their cars in Japan.

Sure, the threat of a strike is pretty tough on a business that is trying to make a profit. The answer, though, is that if all your workers really aren't worth more than they already make, it's time to let them all go. See what happened when when the flight controllers went on strike. Employees can go find another job anywhere in the world and companies have the right to bring in new employees. The unions, though, found that the auto companies weren't willing to let a temporary decrease in productivity stop them from making a new deal with the unions. The company executives weren't preparing for a future when there was more competition from abroad and the unions were sucking them for all their worth. Between these two groups (short-term thinking executives and blood-thirsty unions) we have an ineffective mess in Detroit. That's why Toyota is worth 50 General Motors.

Congress wants to bailout the American auto industry. Unfortunately, they don't need a bailout, they need an overhaul. Giving them money will keep them afloat for now, but it won't help their long-term prospectuses since the benefits they promised are sticking around for decades to come. We can protect American auto making only by blocking or heavily taxing all foreign manufacturers (an already-tried isolationist mentality) or by removing the unions and treating the manufacturing positions just like every other job in America. McDonald's, Best Buy and Dell have all done pretty well without Boss Tweed-type national unions. Maybe it's time for Detroit to try the same thing.