Very well made point Jonathan.

(You need to fix the headline of the post if you can - typo spelling reality) 

Excellent points.  To answer your question, I think those concerns are *somewhat* irrational, but not entirely.

The irrational part is the extent to which even middle-class people now face rationing -- or the potential for rationing -- only they don't know it.  Managed care run properly can be a great thing,  but the way it is frequently practiced in this country it makes life very difficult for people with serious medical issues, sometimes (though not always) to the detriment to their health.  And that's true even if you're relatively affluent.

Besides, if you can't get group insurance through a large employer, then you're basically screwed if you have any pre-existing medical conditions -- even ones that are not life-threatening.  (If you've been diagnosed with severe allergies, good luck getting coverage for your shots and/or antihistimanies in the individual market.)  Again, this is true even if you have a fair amount of money.

Universal coverage would basically solve these problems.  Even a regulated consumer-choice model -- like, say the old Clinton plan -- would theoretically set rules for how insurance companies could operate, so that they couldn't arbitrarily limit care for people with serious illness.

I also think many Americans have an unrealistic sense of their economic vulnerability.  Falling out of the middle class is a lot easier than it can seem.  Jacob Hacker has done some great work on this.  (And you can read more about when his new book comes out this fall.)

That said, the fear is rational in the sense that the line between the priveleged and non-priveleged would probably get drawn in a different place.  Yes, you could opt out -- and, personally, I think it's essential any universal system we have retain that option for people.  But in reality only the very, very wealthy are going to be able to do that.  If you're middle class, it's virtually certain you'll end up in the main, public system.

Of course, that's not such a bad thing.  Middle class people have the power to vote.  If the universal insurance program, whatever it looks like, serves them, chances are their political power will guarantee that it works pretty well.  The problem with these programs crops up when they only serve the poor.  See, for example, the difference between Medicare and Medicaid. 

Jonathan Cohn, the New Republic

J. McCutchen "JmacSF"

San Francisco. CA

A bit off topic but this the answer to Bush's latest "answer" from the Center for Budget and Policy Priorities.

WOW Jonathan Cohn's here..we are in high blogospheric  indeed!!!

A Big Fan I am

•  Admin Health  Care Relies on Misleading Use of Statistics (Shocker!)
• HSA Tax Breaks Larger - and More Problematic - Than Previously Understood

.

I think people also don't take into account the many ancillary problems universal coverage would solve.

There would be no need for a complicated, expensive system of workers' compensation that in the main, screws workers over and cripples our workforce.

There would be less litigation over small tort cases, because people's medical bills would be paid in a no-fault manner and they wouldn't need to sue each other to get money to stuff into the maw of hospital debt collectors.

There would be fewer personal bankruptcies, which would save middle-class people from being forced into the debt peonage system current bankruptcy law facilitates.

There would be less strained relations between management and unions. Unions wouldn't have to bargain away all their benefits plus wage increases just to hang on to health care coverage that costs more and covers less with every year, disappearing like water into sand.

Non-profit organizations would be able to employ more people to do the essential work of holding our society together, work the government doesn't want to do anymore.

Not to mention that large, struggling businesses (think GM, United Airlines, etc etc etc) would lose a tremendous financial burden.  Think how many jobs would no longer be at risk if Ford, GM, Chrysler, United, American, and Delta were all relieved of the need to pay for health care.

It isn't that we ration care (and I'm thinking of things like the donor match system for organs)... it's that we auction care. Frame it like that and everyone will understand.

Very well put.  I've always said that a good universal health care system requires adequate funding.  Otherwise, the floor -- as another commentor put it -- is way too low. 

I think that's the problem with Britain, which is at the low end of the per capita spending scale.   Again, in countries like France, Switzerland, and Japan -- where they spend more than the UK but still lless than the U.S. -- you don't have this problem as much, if at all.

Of course, there are values and cultural differences between the UK and the US that help explain these decisions. 

FYI, for more on this very issue see here.  Or you might want to check out that Henry Aaron book, which is about the UK and the US.  I haven't read it yet -- so maybe you can tell me what it says!

(edit: commentor?  commentator?  i clearly need some sleep...)

Jonathan Cohn, the New Republic

OK, last response, then I need to go back to work.

Some folks (like my friend and fellow blogger Ezra Klein) think HSAs/high deductible insurance hasten the arrival of universal care by marginalizing even more people, expanding the constituency for change.  I'm not so certain. 

I think it could simply create a bigger constituency for another patchwork answer. 

On the other hand, those patchworks seem increaisngly inadequate, too.  The right spends a lot of time talking up high-risk pools, which sound ok in theory but are absoultely lousy in practice.   We can keep expanding Medicaid, I guess, but it's getting awfully expensive -- and inefficient.

Jonathan Cohn, the New Republic

Until there's people in government that can (or will) think beyond patchwork solutions, patchwork is what we'll get, irrespective of the public demand.

*sigh*  It's sad, really - I can't remember when I got this cynical. 

Wonderful post - and your comment about the ill-conceived sense of financial security many Americans have was spot on.

My father was diagnosed with chronic myeloid leukemia in 1995. Shortly after he started treatment with interferon (the standard treatment for CML at the time), the company for whom he had been a loyal worker for more than 25 years relieved him of his position, citing the need to "downsize". Fortunately, my mother was also working full time and was able to cover him under her insurance, allowing his treatment to continue.

Several years later, my father's doctor (a wonderful man) was able to enlist him in a clinical trial of a new drug that had supposedly had an incredible success rate with his particular kind of cancer in earlier trials. The new drug was called Gleevec, and it saved my father's life.

My father had his blood tested just before Christmas last year. The doctors couldn't find so much as a trace - not even a single cell - of the cancer in his body. He is in remission now, and his doctors say that as long as he has access to the Gleevec he will essentially be cured and should be able to live to a ripe old age.

Right now, my father's life is costing upwards of $100,000 a year. I think it is worth every penny - but my family never could afforded to pay that kind of money out of pocket. Had my mother not had the insurance coverage she did, or had my dad not had my mom, he would have slipped through the cracks and would almost certainly not be alive today.

I wish more middle class Americans would realize just how easily the right combination of unfortunate occurances can change your life. More of us are one pink slip, one car accident, one death in the family away from poverty than we realize. That's just one reason why we should all be concerned at all times about just how low that "floor" is...

The Texas Health and Safety Code is a real example of overt rationing of medical care.  Please see:

Chapter 166 Advance Directives- Subchapter 166.050  "Mercy Killing not Condoned."

(Compare 166.050 to 166.052)

Chapter 166 Advanced Directives - Subchapter 166.052  "Disagreement About Medical Treatment:  Physician Recommends Against Life Sustaining Treament That You Wish to Continue.

Then consider:  Chapter 313 "Consent to Medical Treatment"

Subchapter 313.003 -"Exceptions and Application."

A reading of the Texas Health and Safety Code that governs medical care in that state is well worth reading.

If I recall correctly, HillaryCare would have made it a crime for a doctor to provide medical services privately for a fee, outside of the State system.  So it's a little hard to take seriously the claim that "in America, we obviously will never outlaw private care."

 The interesting question is why health care, unlike housing, clothing, entertainment, communication, food, transportation, etc. should be a government funded right.  This is not at all obvious as a matter of principle, although there may well be substantial public support for it. 

DBL says:
"If I recall correctly, HillaryCare would have made it a crime for a doctor to provide medical services privately for a fee, outside of the State system."

If I recall correctly, you're wrong about that.  There is a lot of misinformation out there about HillaryCare which was modelled on the German plan.  Canada is the only country that I know of where some -- but not all -- types of medical services can not legally be provided privately.

My parents are pretty well off and when my father retired in his late 50s, my parents needed private health insurance.  My mother was unable to get medical coverage without excluding her right leg.  She had had a fall (spectacular and not very good judgement, but not indicative of any sort of medical problem other than excessive enjoyment of competitive sports) and a fracture with complete recovery, however no insurance company would insure that leg for any reason whether or not it was related to the "pre-existing condition".  At 64 she had a freak pneumonia with sepsis, multi-organ failure, disseminated intravascular coagulopathy, need for multiple pressors, and 2 weeks in the ICU in a coma.  Although her prognosis for survival was less than 10%, she recovered completely (exercise is really, really important for health and a phase III drug trial didn't hurt) and lost her insurance a few months before becoming eligible for Medicare.  Although people like to believe that other people get sick because of poor judgement, the truth of the matter is that freak things just happen and people do get sick for no good reason.

I have learned that whenever one discusses what was in the Clinton Health Care Reform Bill it is useful to remember why it failed.  It failed not due to its monumental overhaul of health insurance.  It failed for two fundamental reasons, one political the other financial:

1.  In Bill Kristol's words, if this bill passes Democrats will be reassured of re-election for generations.  Republicans will remain a permanent minority.

2.  The financial services industry likes the cottage industry that is our medical care delivery system just the way it is.  This includes insurance, investment banking, durable medical equipment makers, Phrma, venture capitalists and IT. 

The Clinton reform bill would not have hastened the consolidation of either the health insurance industry nor the managed care industry beyond what has occurred to date.  It would  have opened drug and medical device manufacturers to greater price pressure as a result of unified purchasing power (monopsony) and much of what AmberJane discusses in her posts on single payer would have been in play. 

On the whole, the Clinton plan provided a public-private partnership in both the financing and the delivery of health care. It included longterm care coverage and reduced the number of uninsured. It did not exclude private insurance or medical care.  Lastly, there was plenty of opportunity for political maneuvering within the political heirarchy of the bureaurcracy that it established.  But that is hardly different from the corporate bureaucracy we endure today in the delivery and financing of health care in the U.S.

Just a small piece of pedantry: the fact that hospitals can't deny care based on the ability to pay doesn't mean -- thanks to our current patchwork system -- that you'll necessarily get the care you'll need. If definitive treatment (as opposed to palliative care) for your condition requires the services of a surgical team and a bunch of specialized therapists, consultants and diagnosticians, all of whom bill separately, and all of whom (depending on their contracts with the hospital) may be able to avoid or delay dealing with your case.

Hmn. Third attempt to send this. So instead of previewing I will post a no doubt illiterate and ungrammatical comment. Lindsay commented the increased NHS spending didn't improve care. Two responses 1.It was absorbed in the extra

staff required to shrink the outrageous waiting lists which Maggie

created , perhaps in attempt to disparage the NHS.2. My daughter who resides in the UK but frequently visits here sees

no need to "take advantage of the US medical system"-in fact the exact opposite is true. 

Excellent point about quality of care. One of my medical areas of interest is pain management. I'm constantly amazed how many clinicians don't understand the mechanisms of pain, and either how to treat moderately complex pain, or at least when to refer to a pain management team.

I emphasize "team", as it's not just in hospice care that a patient may need an interdisciplinary approach to return quality of life in chronic, nonterminal disease. Dramatic and even cost-effective interventions are possible. Perhaps the most striking case I ever encountered was a woman who, when I first met, seemed infinitely old, hesitant, and miserable. I guessed she was in her sixties. She had a complex case of sickle cell disease.

With interdisciplinary management, both of the blood disease itself and often should be regarded as the separate disease of chronic pain, some of the lines went out of her face. I didn't see her for several months, and then had to be reintroduced.

Given that the patient now was a vibrant woman in her early thirties, fully returned to demanding work as a chemical engineer, not content to be merely a soccer mom but playing league soccer, singing beautifully in her church choir, and doing an all-around impression of Superwoman, I think I have some excuse for recognizing her. One of the keys to her treatment was an implanted pump that delivered a huge -- but clinically justified -- constant dose of morphine into her spinal fluid. There were other pain management techniques involved, both in her rehabilitation, and continued support of quality of life. Given the professional level at which she functioned, the expense probably was quite justifiable.

There still needs to be a lot of education of medical personnel about quality of life, pain management being a part of it. Perhaps this is too much of a specialized reference, but it's amazed a great many people working with pain managment that Melzack and Wall, who discovered the fundamental mechanism ("gate control theory") about the way the explicit sensation of pain does, or does not, cause discomfort, have never been in consideration for the Nobel Prize in Medicine or Physiology. Their fundamental insights were at that level.

Melzack and Wall were the greatest theoreticians. While her work was hospice-oriented, there's still too little understanding of the clinical methods developed by Dame Cicely Saunders. While she is considered the founder of modern hospice, she pioneered dosing schedules, nursing interventions, and other techniques for improving quality of life, techniques that are often inexpensive and simple.