In yesterday's FT Brad DeLong walks step
by step through what he considers Obama's
brilliant health plan.

First , resuscitate corporate plans by play or pay. No plan :you pay a tax which the government
uses to finance its own health care intervention

Second , if you're not in a company with a plan you can sign on to the plan offered to government employees ( and Congressmen). Which presumably will be subsidized by the taxes
paid by those non-playing companies.

Third ,if you choose not to do that you are indeed forced to join an insurance plan but those will be regulated to prevent some of the current abuses.

That's my reading of DeLong but it's worth checking yesterday's FT to get it straight from
the horse's mouth.

There will be problems any way this goes. If the Democratic candidate presses for a gigantic reform, such as universal care from the outset, there is a good possibility it fails outright, and nothing happens for another generation.

On the other hand, if the change is too incremental, there is possibility for National Health to be sabotaged and left to die on the operating table. There will need to be considerable detailed legislation to make sure that for-profit insurers and opponents to National Health don't act in bad faith during the transition. For example, FP insurance could act in an anti-competitive manner to undercut National Health in the short-term to suppress enrollment.

Overall, I have more faith in the evolution of the National Healthcare debate developing healthily once things are rolling. Look at Medicare and SS. Those prove once people have buy-in to a program they pay attention and democracy works to optimize programs further. As the Hillary HC proposal of the 90's show, an over ambitious program meeting defeat maintains the status quo.

I'm convinced by Obama's argument against short-term mandated universal care, preferring instead to let "markets" determine the outcome by giving consumers a truly competitive and efficient choice i.e. Medicare. Actually, I've long wanted Medicare or a form of National Healthcare allowed to compete with for-profit health care, to as they say "let the market decide." When for-profit companies have to compete with not-for-profit Medicare, we'll see who is more competitive and efficient. And wouldn't letting markets choose the national system be the icing on the cake?

If public opinion shifts further towards universal, then of course he'd be free to revise his plan to be more forward, as he's always stated he believes that's the best long term goal.

Granted, there will be excuses by FP insurance in regards to the government's "unfair" advantages, such as efficiency of scale and lack of profit overhead. Boo-hoo. I'd rather hear those complaints, abstract ideological sour grapes, rather than the complaint that people were "forced" into health care.

Also, I believe Obama is correct that as people ease into a national system and see it's benefits, they'll be an outcry for taking National Healthcare to it's natural conclusions, which is to provide a fairly high ceiling of coverage for everyone resulting in tremendous efficiency gains, with supplementary for-profit insurance above that, as is the basic model in Japan and France for example.

Without mandates how will the plan keep the young and the healthy from opting out of the system and thereby increasing the cost? Insurance, even perhaps mainly social insurance, is challenged both by cherrypicking and self-selection. The Clintons' healthcare plan whatever its weaknesses recognized that everyone has to be included in the plan.

Daniel A. Greenbaum

You have to love these market-based solutions. Everything is so simple and elegant, not all messy and complicated like single-payer universal health care.

Does this tend to prove or disprove the old saying that liberals are in favor of anything as long as it is mandatory?

The sons of the prophet are noble and bold,
and quite unaccustomed to fear.
But the bravest by far in the ranks of the Shah
was Abdul Abulbul Amir

Health insurance gives profit to greedy bastards who distort the system to avoid real insurance.

Health insurance, in my eyes, is a jobs program which gives low skilled workers something to do.

i.e. The single-payer mandate would gut administration jobs and force workers into real health care jobs.

i.e. when Dennis Kucinich talked about single-payer, newspaper reporters and other politicians worried more about job loss than the implications of wasting health care dollars on useless work/employees.

To boldly go...

Different tack. So much of this debate hinges on the acquisition of health insurance for or by the individual, as well as the benefits of universal acceptance into the pool. What's missing in my estimation is how to address the insurance industry's business model. If, as I believe the current round of proposals from the candidates suggest, we keep a private insurer model (i.e. not a government program like medicare/caid), then we need to address the business models currently in place.

Insurance companies are financial funds with the key differences being that they output moneys to cover client medical claims, and their insured do not enjoy the proceeds of the portfolio performance, outside of claims. This is to say portfolio performance, less expenses, less claims equals profits which are distributed to shareholders.

Insurance companies are state regulated. There are some fed rules, but mostly it is the state’s responsibility to regulate the industry. Rather than just new industry regulations concerning universal acceptance, I'd like to see plans to move the regulatory authority to the federal level, and then adjustments to capital adequacy requirements (a.k.a. cap charge), liability, and reporting. Before the lefties sink their teeth too deep into my hide, let me say that of the aforementioned adjustments, none of them hurts consumers, and “reporting” is actually an additional cost the insurers

Capital adequacy or cap charge, dictates how much liquid assets need to be kept risk free in order to cover a predictable worst case scenario . State regulations provide formulas that evaluate the insured portfolio, risk management procedures, and financial portfolio risk. Think of it as a casino which is required to keep a certain amount of cash in the pit to cover the expected greatest jackpot. Today insurers dream of a young healthy/healthful clientele, rigid risk control processes, and a superstar trading operation; which represents the least possible claims, with the greatest possible amount of available capital, and the greatest possible return on investment on financial instruments (stocks, bonds and secure debt). In reality keeping the insured pool safe is a constant battle with regulators and competitors, risk procedures are not standardized, and cap charges are high due to the previous two realities.

A federal program that regulates the industry with one set of rules, sets best practices and procedures for risk, and mandates universal acceptance, which in turn spreads the risk in the pools, could prove a very attractive alternative the current model. There would still be competition between insurers, but the competition would be about fund performance and efficiency instead of getting the cream of the crop customers. Add to this reporting requirement to provide the regulators with the best transparency into the industry and you have an opportunity to allow the industry to continue to grow, get a good return on investment, remain an attractive investment, and provide better care to its clients.

Industry is not the enemy. It’s the solution. But like a medicine, it needs to be targeted and controlled, otherwise it’s just poison.

Ya but...even companies with average payrolls of over $200K have fully loaded costs (that is costs above and beyond payroll) that are stressed by insurance inflation. Mandates provide greater risk distribution which reduces risk and caps cost increases. If the employers didn't have such high health insurance costs they could afford to hire more employees.

You have to trim cost exposure out of the picture somewhere. Deductibles and copays do this, but risk distribution can do it as well, and there's no risk distribution without mandates.

I struggle with the idea that you can make health insurance more affordable without carving out cost exposure.

Except the federal program isn't expected to make a profit, whereas private insurance is.

mcs: "Without mandates, the market is forced to find affordable, cost effective solutions and individuals are forced to make smarter choices like keeping their weight under control and exercising." I see, so the market should already have worked then, and all the uninsured or obese Americans at present are just an illusion, and there's no point in discussing health care policy any further.

BTW, the Economix column in today's Times argues for giving more priority to reducing costs by monitoring payment for and delivery of unnecessary procedures. It says that this is not only more important than universal health care but could also make the debate unnecessary, as with costs reduced, we could all afford health care.

Call me unconvinced. First, on importance, I suspect that's judged by an economist's measure of efficiency rather than on usual policy grounds. If I lose my job, I lose health insurance, and I may die or go bankrupt on that account. If one state has more lumbar surgery than another, that affects me less obviously, and I can always refuse the procedure even if I live in the state.

Second, on affordability, I can't imagine that, even if we somehow could control all those procedures, that the average health policy would drop in costs by even 10%. I don't know many families in New York who'd be that much more likely to choose insurance if it were $5,000/year instead of $5,500. How many live such that that marginal difference matters? It's like saying rent stabilization would never have mattered if people would just stop renovating lobbies.

Last, even admitting it's a goal, it seems to me that uniform coverage is exactly the way to achieve it, as MM herself hinted at in her previous post. It's hard to imagine an activist federal government defining what procedures to have, short of going beyond health care to socialized medicine itself. It's easier to imagine that if insurers have to cover everyone, they'll be monitoring costs for everyone.

John

http://www.haberarts.com/

Mandating that people buy health care insurance is a great idea, but only if they are buying it from the government (i.e. paying taxes for it.) It can't possibly be constitutional for a government to force citizens to buy a commercial product from a private industry. The sole possible exception to that is utilities, such as power, water, sewer systems. Even then, people do have the right to do without electricity, do without water, etc.

We are making the health care coverage subject much more complicated than necessary by bending over backwards to keep private health care insurance companies in the mix. A much better way to do this is to split up the nation into regions, for example into 5 regions, and contract out operation of the health care insurance system to private insurers, but pay the cost through taxes similar to FICA. The only losers in this scheme are the high rolling insurance salesmen who take much of our health care money as sales commissions today. That can't be bad.

Hoppy in Sacramento

Why do we care if private insurance companies make a profit? We sure don't care if air transport companies make a profit, or if automobile manufacturers make a profit, etc.

Hoppy in Sacramento

It's a good thing, for Obama and all the rest of us, that the Congress of the 1960's had the courage to take on huge issues, like CIVIL RIGHTS, with huge solutions rather than this timid, incremental, let's-not-shake-things-up-all-at-once approach. If the legislators of today were to approach the Civil Rights issues of yesterday it would go something like this:

"First, let's allow the black males over age, say, 40 to vote; then in 10 years when everyone's adjusted to that, let's allow the black women over 40 to vote; then in anoher 10 years, when everyone's adjusted to that, we can lower the age elegibility, so in 30 years everyone will be able to vote. Aren't we wonderful, strong, LEADERS?"

And, while the right to vote is pretty damn important, I would say that the right to healthcare (ie. staying alive) is more so, yet today's "leaders" would rather let us die than do their job.

All the proposals to date from the current set of candidates leverage the existing healthcare economy. If the proposals looked to rip out all the plumbing and wiring and start anew, then the discussion could afford to disregard the existing private insurance industry. But that's not in the current slate of plans, so I guess we need to address how private insurers will adapt to a new paradigm.

I would take issue with your characterization of our lack of interest in transport and auto manufacturers. I think both the members of House and Senate, as well as their state level counterparts care very much that such industries remain employers in their respective states and districts. At least a cursory review of the voluminous tax codes would suggest this.

You did it again, Maggie! "We can't simply pass a law decreeing an end to the private insurance industry." Refer again to HR 676 and its 15 year roll out (still longer than I'd like as my post above reveals), which bill you say you support, but then in a forum such as this you make it sound as though there is no nuanced approach possible to eliminating the insurance industry. "Experts" making those statements do not advance the group-think in the right direction, rather they serve to cement in readers' minds a flawed argument against single payer.

With friends like that...!!!

Most of the inefficiency is the result of a lack of regulatory standards and a response to the even more screwed up healthcare system. Which brings up the point that you cannot reform insurance without reforming healthcare, but that's a few more long winded threads...

I don't agree with the second point because it does not take into account the profound changes in the health insurance industry that universal acceptance portends. I also reject that marketing, advertising and executive comp represent expense with no return.

I remember a story about Joseph Kennedy during his stock market days. He was an expert market manipulator. His comment to a friend was "we'd better hurry up and do as much of this as we can before they make it illegal."

Sadly we see this in the medical industry. Hospitals and doctors practices will invest large sums of money into the procedure of the month knowing that there is short window before the insurance industry clamps down on coverage. They are just gaming the system and when lumbar procedures stop being so damned profitable, they'll move onto the next procedure.

In an environment like this, is it any wonder 1/3 of procedures are worthless and unnecessary.

Again, we can talk about the health insurance industry til we're blue in the face, but there can be no health insurance reform without reforming the healthcare industry.

Thanks MM. Just for the record, I'm against federalizing health insurance. Not necessarily in theory, but in practice, as you ably explained.

One area that I would be very curious about is how mandated standards would play out in making health insurance more efficient. See my earlier, and long winded post about risk management.

jconorflynn wrote:
"Again, we can talk about the health insurance industry til we're blue in the face, but there can be no health insurance reform without reforming the healthcare industry."

This is absolutely true. There are three components to health care reform: access (providing insurance to everyone, through subsidies or Medicare for all), cost-containment (we can't afford universal access unless we rein in the waste) and quality (the whole point of
ensuring universal access is undermined if we're providing access to a broken system, bloated with waste and poor quality care.)

We need to work on all three--access, quality and cost control--simultaneously. Ideally, I think that means adderssing quality and cost control in Medicare now (insofar as its possible to accomplish anything while Bush is still in office). Assuming that Medicare is going to be the model for a public plan, Medicare reform will pave the way for heatlhcare reform.
.

By the way, for those who are especially interested in this topic and appreciate muckraking, you may want to visit this site:

Where the Money Goes

You are too skittish.  The "value" will return to somebody, particularly the 20% that is being skimmed by insurance companies as an unnecessary premium.  To the degree that that money is not spent on consumer goods, it is going to get into the stock market somehow.  When it is spent on consumer goods, it is going to compound through the economy and eventually get into the stock market at 2 or 3 times its original value.

Okay, you can compensate me for the 10 years I was a high ranked public employee.

I put your check in the mail. Hopefully the rank and file of the postal service will not misplace it.

Right, if they did not have narrow risk pools, they would be insurance companies rather than boutique accounting firms for specialized tax benefits, which is what they are now.  Perhaps we could just (1) eliminate ERISA style risk pooling and (2) permit an insurance company only ONE risk pool in the US.  I might actually believe such an insurance company was what it claimed to be in that case.

repeats above

Another one of those guyz who is gonna trust the blind hand of the market except when it doesn't help his argument. 

Maggie, it's considerate of you to get so involved in the debate. Regarding my question, I wonder how much of that cost saving can be realized in practice. No doubt some of it is procedures with insufficient probability that are hard for a patient or doctor to refuse when they're unwilling to give up certain hopes, and some of it is in all those copycat drugs to get around expiration of patent where one government agency is already allowing it (and allowing its promotion) while we're hoping another will restrict the cost. It'd take very strict regulation on treatment options indeed, I should think. In any case, I can't believe the best option for achieving it wouldn't be through what gets paid for, and thus depends on rather than must precede remaking the insurance system? 

John 

http://www.haberarts.com/

Not quite a Canadian (though when it comes to the personal impact of this particular issue I obviously wish I was!!) but I'm about 45 miles from Canada in northern Vermont, so I guess I picked up some Canadian linguistic tendencies!

I guess the closest analogy are state governments requiring people to buy auto insurance. But, as you say, people don't HAVE to own cars if they really don't want to.

What scares me about mandates though are that state governments have been great at mandating that people buy auto insurance but not so good at regulating the cost of a product for which they created demand, by law.

thosethingswesay.blogspot.com

Hardly.

My interest is in how reform can go forward on something that accounts for 16% of the US economy (over $1.6 trillion dollar per annum). The simplistic arguement that it doesn't work, so let's throw it out and start over again, presumes that such an enterprise can even happen. It cannot. The current slate of candidates know this, as do the think tanks who spend a great deal more time working on the issue than I do. The current system is entrenched, so solutions must be found to leverage what we got.

This is a discussion board, not you ideological litmus test. If you have a coherent counter or perspective bring it on, I welcome argument, exploration and debate. If you want to just label and shut down discussion, then I haven't time to waste.

"The easiest way would probably be to have people pay their annual insurance premium on their income tax. "

This sure seems like a long way to Tipperary. It also seems like a good way to shift more of the costs of care onto individuals and off of corporations. Why would that be good?

Corporations pay taxes for everything else -- why let them off the hook when it comes to health care?

The so called insurance industry (boutique tax accounting industry) is doing very little useful in our economy.  The defense that it is entrenched and the markets will rattle if take away their privileged intervention between patient and medical care practitioner would not sound so wise if offered in behalf of other dead weight members of the economy such as the gun industry or the cigarette industry. 

The loss I suffer by having my retirement portfolio shake a little is nothing compared to the gain I experience by having a 20% premium removed from the cost of my health care (actually more since the insurance industry has warped motivations related to prices).  I am willing to risk it and I am nearing retirement age.  I worked in health care finance for a long time, so I am not confused about what I am saying.

Mandating that everyone buy health insurance is a tax. Pure and simple.

The business of providing healthcare is another issue. Any private company that wants to stay in business will have to limit the services it provides. The trick for private companies is to do that in a manner such that only a very few people get caught not getting needed services in unexpected ways. Advertise the positives, hide the negatives, and the problem of restricting care becomes an additional cost for private insurers in an overall system that mandates the purchase of the insurance by everyone.

There is a trick involved here, too. As long as the government is allowed to compete with the private companies the government will be able to provide the same services at a lower cost, or will be able to provide better services for the revenue they each get. Sensible people will then take the more transparent and better government healthcare for the price of the tax they are forced to pay anyway.

Watch any legislation that mandates everyone purchase healthcare. There will be a major effort to prevent the government from providing health services in competition with the private companies, because the private companies cannot fairly compete on cost or service.

It really is that simple.

repeat

But we can't simply pass a law decreeing an end to the private insurance industry. For one, if we did that, what happens to the shareholders

Last I heard the stock market was for those willing to assume the risk of businesses they buy into.

You might as well ask what compensation we should provide for Halliburton stockholders what with the things not going so well for them.

Something that might be of interest here is an offer by Glaxo to cure your cancer or give your money back. Bet you think I'm kidding. I am not:

http://www.fool.com/investing/high-growth/2007/06/06/cure-your-cancer-or-your-money-back.aspx

Let it be known the proposed offer would only be good in England with its government-paid health insurance that excludes some high-priced drugs independent of efficacy.

Best, Terry

Thanks very much.

I think maybe some of this can be fixed by benchmarking the level of payments, either by an equivalency between the choices the employers make (the fund or private insurance) or by pegging the medicaid level to something which makes sense, given its economies of scale.  If there's some relational system, the benefits of cherry picking disappear, while the principle of choice is preserved (out goes the wind of that Harry and Louise insurance company scam).

aMike

Terry--
While many drugs are over-priced, when it comes to treating heart attack victims, drug therapy is considerably cheaper than angioplasty.

As for the effectiveness of angiolplasty, have you read the latest research? (New England Journal of Medicine, Dec 6, 2006)

(This is not about the argument over coated stents vs. bare metal stents; that is a separate issue. This is about the research showing that angioplasty has no benefit (in terms mortality or future heart attacks) for heart attack patients if they receive it more than 12 hours after the attack.

This is how an expert not involved in the research, Dr. Steven E. Nissen, chairman of cardiovascular medicine at the Cleveland Clinic and president of the American College of Cardiology, summed up the findings:

“Having an artery open ought to be good for you,” he said. “Why not open it late? Like a lot of things in medicine, however, when you actually test it in an organized way, in a randomized, controlled trial, you find out it doesn’t work.”
Dr. Nissen added, “It will change what I do.”

The notion that angioplasty is a "quick fix" is,I'm afraid, a myth.

Best, mm

"If there is no struggle there is no progress. Those who profess to favor freedom and yet depreciate agitation…want crops without plowing up the ground, they want rain without thunder and lightening. They want the ocean without the awful roar of its many waters…. Power concedes nothing without a demand. It never did and it never will."

Frederick Douglass, 1857

Can't say it any better than that.

Cheers

It struck me in the discussion of how the health insurance industry and all its jobs would be obliterated, or not, etc., etc. if single payer were effected without a transition, it is really talking unnecessary theoreticals IF you are talking about something like Medicare as the single payer policy.

Medicare is lousy bare bones coverage, folks! It really doesn't cover what most eldery people need in health care! There is big money in Medigap right now, just with over 65 market!

Look, for example, here's what you are responsible for paying the hospital if you are hospitalized if you only have Medicare in my parents' state:

You pay for each benefit period in 2007: Days 1 - 60: an initial deductible of $992 Days 61 - 90: $248 each day Days 91 - 150: $496 each day 150 days: All costs

If that's all you are going to be covering, insurance companies will still have plenty of products to sell, I guarantee it.

My retired parents last year paid nearly $10,000 to a non-profit HMO for their Medigap coverage for things that Medicare does not cover and that was within a large group of retirees from city civil service union.

Sure, the insurance companies would fight that transition, they would be in chaos for a while, but if all the government is going to offer right now is the equivalent of Medicare, they will still have plenty of products to sell. The total job loss would not be so great, if that's the case.

There's still plenty of private insurance in lots of countries with universal coverage, you know.

Once again, if all you are talking about is universal Medicare-style coverage, you are not talking devastation of the insurance industry. There's still a LOT of important health care needs that are not being covered by something like that.

As for the effectiveness of angiolplasty, have you read the latest research? (New England Journal of Medicine, Dec 6, 2006)

[For the record, I do not subscribe to any medical journals and typically only see abstracts unless I am particularly interested in a subject.]

I don't think the study results were particularly startling news. No doubt there is a reverence for NEJM that is surpassed only by The Lancet. Both can be very badly wrong as with all scientific studies. No particular reason not to accept this one but it does not seem to say what some think it does from reports I read.

[From a newspaper column:]

Local cardiologists say they already use medical therapy as a first line of defense.

"This particular study did not really change the way I practice," says Dr. Mallory Hatfield of Hyannis.

She has long recommended medicines — from aspirin to Plavix — to people with stable coronary heart disease, meaning those who experience shortness of breath and pain only upon exertion.

It's only after medical therapy fails that she has them consider an angioplasty and stenting device as relief.

http://www.capecodonline.com/apps/pbcs.dll/article?AID=/20070517/LIFE/705170301

Undoubtedly you can buy an awful lot of aspirin for the cost of an angioplasty but it hardly ends there.

The notion that angioplasty is a "quick fix" is,I'm afraid, a myth.

There are an awful lot of people walking around after angioplasties that would dispute that as well as their doctors.

The new study, published in The New England Journal of Medicine, suggests that patients with partially obstructed arteries can put off angioplasty or skip surgery altogether...

The study was conducted on patients with chronic stable angina. However, in Indian practice, interventional cardiologists claim that patients with this subset constitute only 10 per cent of the total number of interventions performed. Around 60 to 70 per cent patients have unstable angina and the rest present with acute myocardial infarction (MI).

http://www.expresshealthcaremgmt.com/200705/knowledge01.shtml

I take aspirin daily as just one of the drugs for diabetes. My wife years ago was hospitalized on an emergency basis from severe internal bleeding because of normal use of aspirin apparently. (The doctor said all they could see in the x-rays was a small remnant of what seemed to have been a bleeding ulcer.)

In one case the aspirin may be life-saving, in the other nearly lethal. People and conditions differ. One size fits all can be very bad medicine.

Best, Terry

BTW a longtime friend did not heed my advice not to get brain cancer. Too bad for him.

I have a theory that costs of drug R&D that Frost & Sullivan once estimated to be $1.8B for introduction of a new drug should be less. Some would prefer they were more. Seems to me drug costs are already too high. Others disagree. Way it goes.

Lots of research on brain cancer. Kind of a toughie brain cancer is. I particularly like the idea of a therapeutic vaccine. One company with a most promising one is in desperate financial health like most with truly innovative research. Could give one brain fever, that seemed awful common long ago, trying to figure out this stuff. Probably a good idea not to think too much on it.

Best, Terry

There are different ways to get from the mess
that is taken for health coverage to universal
coverage. And universal coverage can mean many
things.

Canadian has universal coverage, but management of the system is done by the provinces. So there
is no reason that states can't decide what the poverty level is in their neck of the woods and how to subsidize health care coverage.

Also to be noted, private the insurance business (for health related expenses) is alive and well in Canada, just not in the business of providing basic
coverage. They provide for things like dental care, drug coverage, out-of-country coverage, medical equipment, private room coverage, etc.
If you are employed you will likely have one of these plans.

As for mandated coverage, some places in Canada have that too. Quebec for example has mandated
drug coverage. This means the young and healthy can't opt out of at least basic drug coverage.
And if you can't find private insurance to pay then you are required to buy into the provincial plan. Sounds expensive, but the alternative is for the interested party (the province) to pay for the consequences of not treating chronic illnes (insulin or amputation).

Meanwhile the bickering over why the U.S. can
never fix what they have continues. Sad.

I suspect there will be a lot more innovation in pricing with the U.S. threatening to stop subsidizing medicines in developed countries on the backs of America's sick and dying.

the guy at the pharmacy told me the other day that quinine, for example, went from being $3.50 a bottle to $120.00 a bottle.

if you buy Claritin branded Loratadine it's like a dollar a pill whereas the generic ones can be less than 10 cents a pill.

I recently read that the pharmaceticals are trying to design drugs which can't be made generically. i.e. the new biodrugs.

while I like capitolism, I don't like capitolism gone mad and examples like this one show how some corporations seek nothing but power.

it's sobering to think that if I pay 10% of the cost of quinine, that price is still 4 times more than when it was OTC!

To boldly go...

Rick B.,

I respect your thoughts, and yes, it's a tax, period. However, it is really not that simple. A couple of things:

 1. Where in the Constitution does Government have the right to mandate people have health insurance? Where's the right to tax for it?

2. I don't agree that private business can't compete with Government. Yes, based on pure economic theory government wins, but we know in reality, government services always fall behind private services, atleast from a consumers point of view (if not from the point of view of the employees).

I'm concerned about our country's inexorable march toward socialism and then all that's left is communism, and we know that doesn't work for humanity.  I truly believe a socialized medical system in the USA will lead to the inevitable deteroriation of medical innovation and, thus, medical advancement for the whole world.  The long-term effects of that will be catastrophic for the world.

Better that people fend for themselves in a capitalist society, with all its ups, downs, inequalities, etc.  I don't see another viable way.

Respectfully.

Government services do not "always fall behind private services" from any point of view except the rhetoric of the right wing.  Next time you flush your toilet, remember that typhoid was a major killer in this country in 1900.  Government services (not private services) is why your life expectancy is around 80, not around 40.  I doubt you would really want private services providing the streets you drive on or the public safety that would undoubtedly only go to the very well to do.  

Socialism/Communisim talk is another right wing scare tactic to avoid reasonable taxes for public goods.  When you get over your rhetorical gambits you find that you really have nothing to say except the usual right wing claim  "I got mine."

Health care is a public good because effective production requires a type of cooperation that the private markets have demonstrated through failure that they cannot perform. Forty million Americans have extraordinarily limited access to health care services while millions more have poor access.  Yet the very wealthy have boutique health care services that contribute nothing to the well being of the society.

Health care is a public good because nearly all the medical advances of the last century and a half have come at public expense.  If the public made this industry, it deserves the benefit of it.

Health care is a public good because denying health care services that have such profound effect on individual lives for pecuniary reasons is profane.

So, would you get over your right wing rhetoric and behave like an adult? 

Good point, MCS. I expect that if we are just addressing the "payer" part of the problem, a head-to-head matchup that pitted a Medicare-like national program against the Humanas and Blue Crosses of the world would be over pretty quickly, provided subsidies were removed from the table. Medicare is efficient and effective, and operates at much lower cost.

But a solution to our health care mess involves politics and I really don't believe that Obama's program, if enacted, would result in a level playing field. Some have argued that it is a good start that will only get better as Congress tweaks it in years to come. Unfortunately, congressional tweaking can and often does go the other way (witness Medicare, Part D). Count on big money and big lobbying efforts directed toward handicapping the public sector and favoring the private sector if this plan goes forward.

Go about this incrementally with multiple workarounds and clumsy half-measures may wind up dissapointing everyone, leading to a retrenchment of the program in future years. That's why I favor going straight to single-payer now.

It is interesting to have your figures to compare, amike, thanks. By the way, mine are from Wisconsin, right next door.

While it doesn't have a lot to do with the thread topic, I have been trying to figure out the game with all of this, so it's helpful. Your Mom's gap insurance @ $200 per month came to $2,400 a year, for two people that would be $4,800. So my parents were paying twice that. I seem to recall my father complaining it went up a lot recently. Rather than having something to do with what state you are in, it could be that my mother had a lot of serious problems the last decade and required a lot of extensive expensive care. I suspect with Medigap, it might be exactly the same as with coverage for younger people, that if you make a lot of claims, they raise your rates, and you are then stuck with them because you have pre-existing? (So much for free market, buyer/seller unencumbered with conditions, and the consumer being able to shop around.)

Regardless of those issues, it was a learning experience for me helping my father figure out coverage when she was in the I.C.U. for months. I think a lot of younger people are expecting Medicare to be adequate for most needs and they are in for a rude surprise. On Medicare alone, if you go into the hospital, you have to come up with that big deductible payment from day one--I just looked at hospital inpatient coverage for Minnesota on the website and it's a $992 deductible for day 1 to 60.

(Not to mention the byzantine rules about hospitalization for long lengths of time if you have a chronic condition and its related--your hospitalizations better be 60 days apart or you might be out of luck. I found out it is not as simple as it sounds on that website and it is quite easy to use up those 150 days and become uncovered.)

Another thing I learned is how sloppy some HMO's have gotten with Medigap customers, not just my parents' company, but I read of others on the web. They don't pay any attention to the case until Medicare stops paying, then all of a sudden they are micro-managing with "not in plan" and similar. Made me suspect that, for example, they don't pay the same initial hospital deductible that an individual with just Medicare coverage would have to. I did know for a fact that the hospital's billing went directly to Medicare, not to them, until Medicare went off full payment. Remember when HMO's advertised management of all your health care needs as a feature, not a bug? Some don't bother with that when Medicare is paying. The patient is the one responsible to pay attention that when Medicare goes off, that whatever has been going on is "in plan." Or, you'll have to move the patient or get new docs. What a mess...

I come out of it a believer that if everyone had Medicare-style coverage, it would level the playing field, everyone would get interested in what the rules and coverage are, and you'd actually have a healthier private market of "gap" coverage. If I had my druthers, I'd want a fuller Canadian style system. But as a transition, it would shake up the insurance companies a lot, many would fall by the wayside, but's it is not going to obliterate the insurance business to have Medicare extended to all, what it would do is make a fairer market situation with a lot more informed consumers, the kind GOP types like to brag about. It just needs to be advertised as "bare bones" from the getgo, so that people don't get the idea that that's all the government can accomplish. It would be like giving the private health insurance business one last chance to show people what they can do to make it better. (I'm betting they can't and the public will then demand that the government cover more.)

Daniel --
The problem is that we can't make healthcare
more accessible unless we make it more affordable. We can't even continue to offer
Medicare to people over 65 unless we rein in costs. In just 11 years, the Medicare fund will be able to pay only about 70% of Medicare's
expenses. We could raise Medicare payroll taxes, but they are already pretty high.

The good news is that health care spending does not need to continue spiraling at the current rate. (6-7% a year). We've made some
superb techological advances in the past 25 years, but in the past 5-10 years we have hit a
point of diminishing returns. For example, although spending on heart attack victims continues to spiral, since 1998 the percentage of heart attack victims who survive has barely budged. (We made great progress from 1984 to 1998, but now the extra spending on coated stents and unncessary angioplasties isn't paying off.)

Finally, health care inflation in the U.S.
has a lot to do with the fact that we pay twice as much for many goods and servcices as patients in any other developed country. And we are talking about the very same goods and servcies.
This is because, in the U.S., we let the seller's set the price--with very little negotiating. In other countries the govt' negotiates discounts or sets a global budget.

But the in the U.S. the health care industry's
lobbyists have made certain that the sellers have nearly unfettered pricing power. (In other countries the lobbyists are not nearly as powerful--which brings us back to the need for
campaign finance reform.)

I don't claim to know a fraction about this debate as you obviously do, but, maybe, the ideas floated here, particularly by JConorFlynn could lead in another direction all together. The elimination of Medicare all together!

If we have an efficient, effective private sector solution to providing health-insurance then why can't we eliminate Medicare? We could establish health savings accounts people pay into during their working lives and then they draw on that in their retirement years. Obviously, there'd have to a mandate provision to insure people are have adequate protection when their elderly, but the tax savings to the American people could be enormous.

I think you are partially mistaken. There is no doubt that some costs, the extra paperwork, the lack of computers, and yes the profit of health insurance companies.
I do wonder if the U.S. tried to limit drug prices as the do in other nations whether the believe that there is so much profit in each drug that it will not matter or if advances in drugs will slow. I do not know the answer to that question.

However, you are mistaken that the key is reducing the cost of healthcare, or rather it better not be. With each advance costs go up. Would people rather not have the AIDS cocktails the new cancer drugs, MRIs? The U.S. is the richest country in the world. Why can't it just decide to spend a greater portion of its GNP on healthcare.

There is no reason to waste money for no reason. However, the advocats of cheaper healthcare will end up disappointed. Remember HMO's were brought about because employers did not want to pay so much for employee health insurance. First it was about better preventive care. then it became shorter stays and less healthcare because preventive care did not save enough money.

Daniel A. Greenbaum

artappraisor and amike,

Yes, the cost of Medigap does vary by state and in some states, insurers can charge much more for Medigap if the patient has "pre-existing conditions."

What a Mike's mother pays is typical, art-appraisor; your parents are (for whatever reason), paying far more than the average Medicare patient.

As to Medicare being "bare bones" coverage--
that really isn't true.

What sounds frightening in your description is the charges for hospitals stays after the first 60 days (which could really add up). But these days, patients rarely spend more than 2 months as inpatients at a hospital. And those 2 months are covered by the $962 co-pay (which is cheaper than a Holiday Inn). Hospitals are aware of the 60 day limit and so even if you are not well enough to go home, they almost always transfer you to a skilled nursing facility where you get another 20 days, with no charge, and another 80 days at a little over $100 a day. Alternative, they send you home where medicare will cover home care (100 visits) at no charge. IN the worst-case scenario, if you are dying, they send you to a hospice (again Medicare covers this, no charge.)

You really, really want to end up in a hospice (or at home) not in an ICU.

Medigap covers the 20% co-pay for physician's visits and most tests.

The other things that Medicare doesn't cover
are by and large fairly minor --acupuncture, eeyeglasses, hearing aids (though Medicare does cover implants in cases of extreme hearing loss) cosmetic surgery, care outside of the U.S. . .

(Eyeglasses and hearing aids are, of course, important, but if you really can't afford them, chances are you eligible for Medicaid.)

The two big items that Medicare doesn't cover are
drugs (unless you get Medicare through an HMO)
and long-term care insurance. I expect that under
any reform plan Medicare (or whatever national health care plan we have) will cover drugs--and
negotiate lower prices with drug-makers.

We still have to figure out what to do about long-term care insurance. You can buy this insurance separately, but, for most middle-class people it is pretty expensive. The problem is that we're just living too long . . .

Okay, you can compensate me for the 10 years I was a high ranked public employee.

to the next generation, you're going lower and lower until you're 6 feet under. The meek shall inherit the earth.

To boldly go...

Re: Next time you flush your toilet, remember that typhoid was a major killer in this country in 1900. Government services (not private services) is why your life expectancy is around 80, not around 40.

It's a mix of both. The immunizations and antibiotics that allow us to flip off most infectious diseases are supplied by market entities. Likewise the food we eat (albeit with major and often silly governmental subsidies). Sanitation services in cities is of course a government service. But household plumbing itself is not (and rural people also benefit from non-governmental sanitary systems).

Re: Health care is a public good because effective production requires a type of cooperation that the private markets have demonstrated through failure that they cannot perform.

Here I could not agree with you more (though I still see a role for the market in healthcare; I would not make doctors and nurses into government employees) And when rightwingers claim universal healthcare will mean the end of medical innovation I would point them to counter-exhibit A: our weapons systems. We have "socialized defense" in this country, and also the most advanced weapons known to humankind, for better or worse. If the rightwingers were correct we should be fighting with spears and swords because we don't have private armies.

 I'm convinced by Obama's argument against short-term mandated universal care, preferring instead to let "markets" determine the outcome by giving consumers a truly competitive and efficient choice i.e. Medicare.

I agree so does this expert:

Obama’s proposal is best understood as a new framework to provide automatic coverage for everyone who works (or lives in the family of a worker). In the Obama plan, if you work (or someone in your family works), you are entitled to good insurance, either from your employer or through a new public plan.

Notice what I said: a new public plan. Obama believes that a new Medicare-style public plan for those younger than 65 will deliver big savings and better coverage, and that this plan should be the default source of coverage for anyone whose employer doesn’t provide good insurance. Indeed, he takes a major step beyond Edwards by envisioning a national Medicare-like plan (Edwards would make a plan similar to Medicare available on a regional basis) and by clearly stating that this plan will have generous, guaranteed benefits

Remember HMO's were brought about because employers did not want to pay so much for employee health insurance. First it was about better preventive care. then it became shorter stays and less healthcare because preventive care did not save enough money.

HMO's were always about the least expensive care possible. Quality of care was not given equal weight. If a procedure or drug costs more it was not provided if there was another procedure or drug that manged the problem without the same high costs. Preventative care was not the cost in the system..quality care remains the economic issue. Doctors and HMO executives received bonuses for providing the least expensive care independent of whether the patients health improved, or the patient achieved the best clinical outcome based on therapy available. 

Any procedure or test carries a risk as well as a benefit--and if there is no benefit for a particular patient then he/she is just exposed to the risk.

This is an overly broad assertion. Perhaps you want to say Many vs. Any here or qualify it as invasive tests or procedures. There is no risk for a urineanalysis or pap smear being performed

this score,the Mayo Clinic does particuarly well. It
doesn't do nearly as many redundant tests or unncessary procedures, and as a result, it costs Medicare about half as much if a patient gets most of his treatment at the Mayo Clnic during the final two years of life as it would if the same patient were treated at a less efficient hospital.
The outcomes at Mayo (in Rochester, Minn.) are superior and both patient and doctor satisfaction are higher than at the average hospital . ..

Mayo Clinic is known by informed health consumers and providers to offer excellent testing and diagnostic procedures along with preventative health plans. They do not necessarily have a reputation for the best therapy nor clinical outcomes. Patient satisfaction is not necessarily indicative of the best care given how uninformed consumers typically are. Doctor satisfaction is typically based on compensation.

There is no risk for a urine analysis or pap smear being performed

*equal opportunity offense to both extremes*

"Those who cannot remember the past are condemned to repeat it" [George Santayana]

Not long ago, I received an e-mail from an oncologist who is on the national board of cliical oncologists saying "From where I sit, I see a lot of oncologists are making a stack of money giving chemo to patients who won't be helped by it. And they are not helping their patients recognize the implications of their decisions when they decide to have chemo."

While this is a valid criticism, the flip side is that when the oncologists ays that the chemo has only a 20-30% success rate. Few patients consider that they will be among the 70-80% of patients who chem fails and they die.  What then is the clinicians options after providing these stark stats and the patient still wants to give the chemo a chance?

And are the stats that stark? Rarely, it's a simple choice between life and death. It may be a choice among a low probability of a major remission, a delay in the disease but with decent quality of life, a delay in the disease but with poor quality, and no life extension but with misery from side effects.

Again speaking anecdotally, when my mother had metastatic breast cancer, at one point, we tried a therapy that had a low but not nonexistent possibility of remission, and a greater probability of a side effect that would mean a gentle death. Sadly, she chose to fight the side effect, take an even lower-probability treatment, and have a horrible death. One of the roughest things I have ever done is give her a realistic set of alternatives, things that her doctors were unwilling to do. Admittedly, this was 1975, and there wasn't much experience w