Sicko and the Health Care System: It’s Not About Values
Progressives must love to lose. Why else would they always adopt the right’s rhetoric in framing political debates?
This suicidal pattern is being highlighted in the debate sparked by Michael Moore’s new movie. The response of all reasonable people is to decry the fact that the United States, alone among rich countries, does not guarantee health care to its people. And we still pay more than twice as much per person for our health care system as do the people in countries with universal health care insurance.
The right notes these incontestable facts and then quickly runs to values – the issue is how much government involvement the public wants in its health care. They then tell us that the public doesn’t want the government telling it what health care it should or should not get. This leads us to a silly debate about what the public does or does not want in terms of government involvement.
The debate is silly, because the level of government involvement is not the issue. The real issue is the extent to which the health care industry – the insurance companies, the drug companies, and the medical equipment companies – will be allowed to rip off the public.
The government does not have to dictate anything. It can just give people a choice that they don’t currently have: specifically the option for every individual and employer to buy into a government-run Medicare type plan. Such a plan would likely offer care at a considerably lower cost than private insurers since it won’t have to pay high CEO salaries, marketing expenses, and dividends to shareholders. That is why the traditional Medicare program always wipes the floor when it competes on a level playing field with private insurers. (This is also the reason the private insurers insist on large subsidies from Medicare – they can’t compete.)
This sort of system is essential to providing universal coverage because it provides a mechanism for containing costs. Without such a mechanism, there is no way that the country can afford universal coverage. Rising costs will quickly make covering the uninsured exorbitantly expensive.
But, note that we don’t have to raise any questions of values. If those rugged individualist types don’t want the government messing with their health care, they have a real simple option – don’t buy into the government system. Get it – it’s real simple: you don’t like it, you don’t buy it. No one has to force these rugged individualists to do anything. We just need to give people a choice they don’t currently have. What’s the problem with giving people a choice?
The right’s ability to turn things on their head was best demonstrated in the debate over reforming the Medicare prescription drug benefit. While everyone recognizes that Medicare can reduce the price it pays for drugs by 30-40 percent by negotiating directly with the pharmaceutical industry, like the Veteran’s Administration, the right raised the scary proposition of a government-run formulary of preferred drugs. This sent the Democrats running for cover.
While we cower over the prospect that the government might have the same sort of formulary of preferred drugs as private insurers, let’s get a little perspective on the issue.
The Medicare drug benefit is 100 percent voluntary – it is a subsidy that the government provides to help beneficiaries pay for their drugs. Those rugged individualists who don’t want the government to determine which drugs they can buy have a simple option – don’t take the benefit. Isn’t that simple enough for the rugged individualists out there?
But wait, there are other options. They will still have the option of signing up with a privately operated plan competing with Medicare. That way the private insurer will tell them which drugs they can and cannot use. Isn’t this enough to make the rugged individualists happy?
And, there is still a third option. Suppose our rugged individualist signs up for the Medicare benefit, and chooses the government run plan, and then finds that he is unable to get the drug he wants, which would be a rare occurrence if the VA system is the model. Our rugged individualist now has a real simple option – he can shell out the money himself, which is exactly the same option that he would have in the absence of the Medicare drug benefit.
In short, creating a Medicare-run plan that negotiates directly with the drug companies is about giving people a choice they don’t currently have – a low cost simple drug plan. It is not restricting anyone’s choice. The only values at issue are the profits of the insurance and pharmaceutical industry – at the expense of beneficiaries and taxpayers. The same story applies to the larger debate over health care. It’s about ripping off the public to benefit special interests. Progressives should not allow the debate to be clouded with irrelevant discussions of values.
You make some good points, but I don't think we have to fear a debate about how much we want government involved in our health care. People do want government involved in their health care, as it is in MediCare, which is a popular program. You are right that people would have the choice of opting out. I think it's a win-win debate.
Personally, I have a MediCare Advantage program, in which my HMO (a very good one) contracts with MediCare to provide my health care. It's an excellent option.
MediCare does have problems, i.e. nightmarish arcane regulations which drive costs up, and inadequate payments to providers but it's the best alternative and it can be improved.
I also think we also have to avoid the simplistic viewpoint that all health care companies are all bad. There is no need to demonize them. We just need a better system than what most Americans have now. MediCare is a good model.
July 3, 2007 5:42 AM | Reply | Permalink
There are certain kinds of services that should not be governed by the race to the lowest common denominator. Food safety is one of them. Health care is one of them. Public transportation is another. Drinking water is another, as is sewerage treatment. Why do people have such an easy time accepting government when it comes to regulating water and sewerage and transportation, and air traffic control--but balk when it comes to providing clinics for people who can't buy commercial insurance?
Why is no one organizing non-profit health care co-operatives? The co-op concept is an excellent way to provide goods and services in a situation where the capitalist motivated race to the bottom in terms of cost in order to maximize profit compromises quality. Even the wealthiest among us are unhappy with the status quo. Look at what Steve Case is doing...
"If you talk about it, even the simplest thing becomes complex and incomprehensible." -Herman Hesse
July 3, 2007 6:01 AM | Reply | Permalink
What would a healthcare co-op look like?
July 3, 2007 6:05 AM | Reply | Permalink
Your HMO is hugely subsidized by the government, much more than regular medicare. Don't forget that in the bill for Medicare Part D was a huge give-away to the insurance companies in the form of subsidies for HMO's to provide what people can have for less through regular medicare.
Naturally if we give enough money to the insurance companies, people like you will rave about the care. But indeed, the whole point of managed care was supposed to be that the private sector would provide better care for less money. That's not what you're getting. You're getting better care for more money! And it is the poor and middle class who are paying for it!
July 3, 2007 6:13 AM | Reply | Permalink
If the "rugged individualists" opt out of the system and decide to buy private health insurance, or no insurance at all, doesn't that make the public system more costly and less efficient. I thought the argument for public healthcare had nothing to do with values and everything to do with the fact that having the largest possible pool brings down costs for everyone by spreading risk. I thought it was a practical argument that 300 million could buy a service more cheaply than 100 million.
thosethingswesay.blogspot.com
July 3, 2007 6:17 AM | Reply | Permalink
The argument about the government deciding what health care should be would end pretty quickly with a few commercials such as:
A couple of guys in a bar arguing the issue and finally one blurts out "I just don't want the government deciding my heathcare! I want THIS guy to decide what health care I get!"
Then pan to, oh say, an accountant punching an adding machine, some obviously well placed insurance exec getting into his mercedes, ... lots of choices.
Turn the argument around. If not the government, then WHO really is making the decisions. It is not the consumer.
dc
July 3, 2007 7:56 AM | Reply | Permalink
I'm wondering whether a dual system, where private and public sectors exist side by side, wouldn't lead the top practitioners to go to the private sector for higher salaries while poorly trained staff would stay in the public sector. Public health care would then be cheaper but also involve lower quality of service. How can a dual system avoid this negative side effect?
Marcos Ancelovici
http://mancelovici.wordpress.com/
July 3, 2007 8:19 AM | Reply | Permalink
Man Who is Refused Treatment: This is outrageous. I'm writing my congressman!
His wife: Uh, your congressman can't help. You have to right the CEO of HealthSouth.
Man: I sure will.
Wife: I'm sure he'll read every word.
Man: That's right, he needs me in order to... wait, why does he need me?
Wife: He doesn't.
thosethingswesay.blogspot.com
July 3, 2007 8:25 AM | Reply | Permalink
And don't forget to include the lawyers redlining your treatment out of the insurance policy.
July 3, 2007 8:32 AM | Reply | Permalink
It would look like an HMO combined with all the principles of a co-op. Instead of the top executives answering to a CEO who reported to a board of directors--there would be a member council consisting of members of the co-op that would help to guide policy based on the interests of the co-op. There would be an advisory council made up of hired members of the health care policy research community. The professionals would provide guidance to the members council to explain the consequences of different policy decisions pertaining to management and treatment. At the end of the day, any profit would be given back to the co-op members in the form of a dividend. This would actually resemble the French system in many respects, without the involvement of the government. Simple. It could be a parliamentary system where the election of the advisory council could be re-instigated whenever a majority of members loses confidence in the council. Part of the responsibility of members is to learn more about prevention--and part of the responsibility of health care providers is to help educate the members. There is no magic bullet solution--but there are sane, 'right-sized' approaches.
"If you talk about it, even the simplest thing becomes complex and incomprehensible." -Herman Hesse
July 3, 2007 9:14 AM | Reply | Permalink
Seems to me you are not involved in health care. You have no idea how many rules and regulations any organization is already required to follow!
It's a nice theory. But honestly, take some time to work in healthcare. And then rebuild this.
Medicare is a much easier system! The patient goes for treatment. No questions asked. The provider bills for the treatment. No questions asked.
Simple. Direct. Works!
July 3, 2007 9:22 AM | Reply | Permalink
I for one would take the public health care system any day! No intrusion in services from insurers! And no worry about being reimbursed. Yes, you get less - but also for less hassle - and with more privacy for the patient!
I would love to see everyone covered. I would love not to have to give so much free service. I'd rather be paid what Medicare pays - and know that everyone has a right to be seen. With no questions asked.
July 3, 2007 9:25 AM | Reply | Permalink
Especially mental health!
You'd have to be nuts to want that, right?
July 3, 2007 9:26 AM | Reply | Permalink
One more thought. And this may surprise you. Medicare has very high standards for who they allow to be in their system - when it comes to mental health.
The V.A. also has extremely high standards for the psychologists they will hire. You need top credentials to work at a V.A.
Your concern can be handled by government requirements. And many providers, myself included, would appreciate the security of that system.
July 3, 2007 9:28 AM | Reply | Permalink
Or a criminal and if you are nuts, you have to be a criminal to get treatment.
July 3, 2007 9:43 AM | Reply | Permalink
Marcos:
First of all, a dual system probably would not work, and mostly for the reasons you have put forth. Why would private insurance pay doctors better? Their duty is to their share holders to maximize their profit. Public run is more economical. And where the savings go is up to those that create the system. I may provide some relief to doctors, who actually may not need it because of their reduced costs for claim appeals caused by arbitrary denials, processing multiple company forms, etc.
How would private insurance compete if a single public system simply provided the same service?
July 3, 2007 9:57 AM | Reply | Permalink
I would love true universal health insurance coverage, but in the meantime, why cant we try something that we already know works, and tweak it a bit to make it even better?
My husband is a middle income (70K/ yr) federal employee in New Mexico, and we have six in our family who live on his income, so in some ways we are very blessed--out of many different traditional and HMO-type plans, we chose a local HMO/PPO plan that has pretty decent coverage, and since it is a small world out here, almost all our local providers are on the plan. The monthly premiums are around $225, which comes off the top of his bi-weekly paycheck pre-tax. We also just purchased (for the first time) separate dental and vision coverage (around $80 total for both) hat is also taken pre-tax. Our co-pays for office visits are 15pcp/25 specialists, and the prescription coverage is 7/15/35 depending on tier. Because our state and the FEHB demands certain services must be covered by all plans, we don't have to worry about not being covered for things like mammograms, birth control, cancer treatment, etc. My only complaint is that the Federal government doesn't have to cover my college student who turned 22 this year--even though our state mandates all other insurance providers to cover dependents through age 24. I am terrified that my son will have an accident or come down with a serious illness before we can afford to get him coverage that goes outside his college health center/insurance plan (which is not in effect during the summer, for example).
So, here's my question: Short of government funded universal coverage, at the very least, why can't the entire nation have a similar set of plans we have offered to them? With these plans, there is the "choice" element all the rich Republicans want--you pay more if you want total choice, pay less if your'e wiling to use a local HMO. If your'e really rich you can choose to forgo any coverage at all. Forget medicaid/medicare and all the rest-- If we combine government oversight/administration, mandated minimum coverages, with the inevitable expansion of the pool of insured, I am willing to bet that that alone would make coverage affordable for almost everyone. For those who are needy, we should pick up some or all of the tab for the premiums and co-pays. And it all should be portable, so if we go on vacation to another state, we are not sacked with a gigantic, uncovered bill in case we seek health care. Everybody is covered, at the same minimum levels, the government negotiates and enforces the contracts. Simple.
Dennis Kucinich is right--anyone with a brain who has to balance their own checkbook and pays their own bills knows that. Instead of the patchwork quilt of coverage levels and the incredible amount of waste caused by overhead and administration that gets repeated in every plan, we could take the savings and shove them right back into getting the best health care system in the world.
July 3, 2007 10:06 AM | Reply | Permalink
I see the primary advantage in expanding Medicare to be that this is an existing program, well accepted by the public, with the bureaucracy already in place. No hard sell is involved at all. Just gradually increase the number of people covered until it includes everyone. Then, start work on expanding the benefits until they actually equal the medical expenses and no supplemental insurance is needed.
Hoppy in Sacramento
July 3, 2007 10:10 AM | Reply | Permalink
As a practical matter, I am sure that the vast majority of people car much more about getting good health care at an affordable price. The number of people who thinks its real clever to screw themselves so that they can have as little as possible to do with the government is fairly small (that;s why almost everyone goes with the traditional Medicare program), but I wouldn't want to take away their option to waste their money.
July 3, 2007 10:12 AM | Reply | Permalink
You know, it is so sad that the very people who have the least wherewithal to jump all the hurdles needed to get treatment (i.e. those with mental health problems) should be left with the most hurdles and often the worst providers.
Believe me, the better ones opt out of the provider lists. You would never believe the paperwork they want from providers. over and over and over and over and over and over and over.....
Single payer is so much easier. Or out of pocket.
And yes, you nearly need to be a criminal to wring treatment out of the HMO's.
July 3, 2007 10:15 AM | Reply | Permalink
Thank you, Hoppy!
Just get right on, would you?
My elderly parents and my husband are happy with Medicare.
I can't wait.
July 3, 2007 10:18 AM | Reply | Permalink
It is a bit odd to talk about falling into the Republican trap by talking about values when it comes to healthcare and then talk about Insurance companies, pharmaceutical companies and other providers "ripping people off." How many Americans work in those industries? Do you know that they are ripping people off ,or only that if to make a profit they need to charge more than you want to pay and others can afford to pay?
The issue of healthcare is a bit like the Post Office. If the Post Office was truly private they would not deliver mail everywhere because it is not economic. However, we want the Nation to be tied together by mail and so we allow for certain inefficiencies in exchange for universal coverage.
In the medical area we too want universal coverage. There may be ways to wring out expenses but the true goal is to make sure that all Americans receive a minimum amount of both preventive care and treatment if they are ill. If order to accomplish this goal it is hard to see how people can be allowed to opt out without the cost being prohibitive but it is not a matter of values or rip-offs it is getting a more efficient universal system.
One aside. It will be important to monitor progress in pharmaceuticals. I have no faith that those who comment on drug invention and distribution have any idea what they are talking about. It is unlikely given the failure rates that the profit margins are all that large. Americans tend to overestimate profit margins in general. Since the greatest strides in medicine outside of some surgical techniques has been in the introduction of drugs we would not want to lose that in the name of an ideologically driven healthcare reform.
Daniel A. Greenbaum
July 3, 2007 11:29 AM | Reply | Permalink
I used to work for the Agency for Health Care Policy Research. I have worked for NIH, and currently work for a consumer health care portal. Sure Medicare is great--but there are political problems with trying to use it to replace the existing system--I just don't see that ever happening.
"If you talk about it, even the simplest thing becomes complex and incomprehensible." -Herman Hesse
July 3, 2007 11:47 AM | Reply | Permalink
I agree about the political problems. But that doesn't change my view of the current insurance system!
July 3, 2007 12:11 PM | Reply | Permalink
You can't compare the post office and insurance companies. Because the post office does deliver mail. But insurance companies do not deliver care!!! They are a "middleman." They want to profit. To have an accurate comparison you'd have to posit an insurance industry that occupied a middle ground between the post office and the people. Think about that for a while! And you will realize how insane that would be!!! And is!
July 3, 2007 12:14 PM | Reply | Permalink
Overhead for insurance runs around 30% or so. Medicare overhead is around 7%. These are guesses but pretty close. Do the math.
Also insurance wants to deny care. To make more money. They have a decided conflict of interest in being "for profit."
In order to deny care or lower costs they, in effect, force doctor's offices (and particularly hospitals) to employ extra people to comb through the chart and charge for every possible code they can. This happens on both sides, with insurance people also combing every chart to try and limit the cost. Again, do the math.
On top of it the insurers want to profit. More math.
Medicare doesn't have all that level of nonsense.
July 3, 2007 12:23 PM | Reply | Permalink
Dolgre: "I would love true universal health insurance coverage, but in the meantime, why cant we try something that we already know works, and tweak it a bit to make it even better?" It's not as easy as you think to preserve what for you, since not everyone gets anywhere near that deal in many communities and when the employer is not contributing. Say, when I was on COBRA, the payment was more than twice yours, and of course it wasn't out of pretax earnings. When COBRA expired, dealing directly with the HMO would have raised it to much higher levels still, and I dropped coverage. (I'm now employed again, although I took a bad job largely for this reason, another one of those "unintended consequences" of good ol' conservative values.) Thus, if we mandate the HMOs to offer your deal to everyone, they'll give up, and we'll be with a single-payer after all. So there's every reason to think that's what we're really mandating and hoping to mandate.
There's also the concern of how to make coverage affordable by sufficient pooling. If we allow HMOs to cover people sufficiently chosen, the cost to government for those falling to government could be very high.
And indeed that's a dilemma. Maggie Mahar has argued that it'll be had to enact single payer, because it puts too many people and firms out of business. Conversely, not enacting single payer could doom universal health care by "proving" it can't work and costs so much more than the present, even if European experience proves the opposite. Beating that political challenge is a big deal for the future, but it doesn't help just to assume we've already got it made based on your example.
John
http://www.haberarts.com/
July 3, 2007 1:20 PM | Reply | Permalink
The problem is how the insurance industry and pharmaceutical industry are structured -- not whether they are good or bad people. Insurance companies make money by not insuring people that get sick -- that's the basic economics. You have a huge skewing of costs so that 10 percent of patients account for more than 50 percent of costs. An insurance company that wants to make a profit (find me the one that doesn't) will find ways to reduce their share of this high cost 10 percent.
In the case of the drug industry, goevrnment patent monopolies give companies incentives to spend tens of billions to market their drugs even if they may not be the most effective treatment. They also give the industry an incentive to bribe doctors to prescribe their drugs, to conceal unfavorable research findings and even to lie about the safety of their drug. Government patent monopolies are an incredibly inefficient way to finance research. We can't afford it.
July 3, 2007 1:36 PM | Reply | Permalink
Why is no one organizing non-profit health care co-operatives?
I think the answer to your question is that those cooperatives would get an abnormally high number of people flocking to them who have pre-existing conditions, family histories that preclude them from "typical" private coverage, or have ever had a serious medical problem. (Insurance companies don't make their policies affordable to those people)
The only way Universal Coverage can work is to make it UNIVERSAL. Unless the population includes old and young, sick and well, it will not be sustainable. I have recently seen ads suggesting that with Universal Health Insurance, healthy people have to "subsidize sick people" as though there is something wrong with that. Even republicans get sick; they have children with birth defects; do they all fantasize that they are so rich they will never have to depend on the common good? We pay taxes to keep our Firemen available so that those who don't have burning houses subsidize those who do. If a person really doesn't want to have any give-take with their community they should probably not live in a community at all.
Currently the for-profits exclude, either by absolutely denying coverage, or making the premiums and deductibles so high as to be ridiculous for those at risk for needing health care. At the same time they include those who will pay in enough so that they reap profits for providing ABOSLUTELY NO SERVICE! They simply provide paperwork and hoops to jump through that restrict care. What a scam! Why not use those wasted profits to provide better health care, and stop with the scare tactics!
Oh, never mind. I know! Insurance and Big Pharma are fincancing our elections! How silly of me!
Jan
July 3, 2007 4:29 PM | Reply | Permalink
Thus, the "rugged individualist" does not want choice between public and private plans because doing so would reveal that his/her irrational fear of government not only has no basis in, but is in this case is diametrically opposed to the results of rational economic analysis.
This, of course, is not how the "rugged individualist" would explain his/her position. Instead, he/she would fall back on an ideological crutch. The competition between a government plan and private plans would not be true competition—it would be "unfair" competition in which the government is using its tax power to get a "leg-up" over the hard-working private sector. Of course, this argument only reveals further his/her intellectual bankruptcy, as it has no factual basis in a proposal like the one Dean makes above (which assumes that each new Medicare is paying the actual marginal cost of adding one more beneficiary to the public insurance system). Nonetheless, it is the thought process of the "rugged individualist:" government involvement in any project is so utterly corrupting that even otherwise sacrosanct concepts like "competition" and "choice" become polluted and can no longer be trusted. Such argumentation baldly relies upon the most hysterically irrational fears.
July 3, 2007 4:36 PM | Reply | Permalink
Re: If order to accomplish this goal it is hard to see how people can be allowed to opt out without the cost being prohibitive but it is not a matter of values or rip-offs it is getting a more efficient universal system.
Not a good analogy, because people can opt out of the post office system by using FedEx, DHL etc.
I would suggest a middle route: everyone should be required to contribute to the system, but those who want extra coverage should be allowed to buy it on the market. This is how education works, after all: everyone must pay taxes to support the public schools, but people are free to send their kids to private school as well.
July 3, 2007 5:17 PM | Reply | Permalink
Re: When COBRA expired, dealing directly with the HMO would have raised it to much higher levels still, and I dropped coverage.
Sometimes this works the other way: I paid COBRA for 18 months, only to discover when I got individual coverage afterwards (I was self-employed) it cost me half what the COBRA premiums had, for very similar benefits.
July 3, 2007 5:20 PM | Reply | Permalink
But Medicare is currently subsidized by privately insured and uninsured patients who pay higher fees for the same services. If everyone were enrolled in Medicare, there wouldn't be anyone left to subsidize Medicare's costs.
In that case wouldn't the elderly Medicare insureds who currently, pay modest fees (about $91/mo. for Part B) see very substantial fee increases?
July 3, 2007 5:27 PM | Reply | Permalink
I understand that you're paying $225/mo. to your local HMO/PPO as part of the cost of insuring your family.
Do you know how much the government is paying the plan in addition to insure your family?
July 3, 2007 5:40 PM | Reply | Permalink
One of the fallacies in trying to compare healthcare to other market activities is that medical "insurance" is not that comparable to, say, automobile liability insurance. It is a near certainty that a given medical consumer will need services fairly routinely, while a good driver might go decades without filing a claim.
There are several pieces here, only the last of which has a strong relationship to "insurance". I believe the middle one is the most complex.
Let me discuss #2 a bit farther. One of the mainstays of chronic disease management is drug therapy. Under my medical coverage, I pay $3 per month's supply of brand-name drugs ad $1 per month for generics.
Recently, there was a perhaps overstated safety concern over one oral diabetes drug, Avandia (rosglitazone). According to my assorted wholesale price guides, a month's supply was about $150. My physician and I had multiple discussions about changing to Actos (piaglitazone), with our both reading the actual research studies, thinking about risk reduction, and, eventually, changing to Actos for not just risk reduction, but that it also seems to have other beneficial effects. It happened that I went directly to the pharmacy to have it filled, so didn't check the wholesale price.
Frankly, I was amazed to look on the label where the pharmacy listed the retail price, and found that a 30 day supply, not at the maximum dose, was about $460.
Are these drugs very significantly reducing diabetic risk, as confirmed by laboratory measurements? Yes. Are they remotely affordable at list price? No.
I have no simple answers to the drug cost issue, which may indeed be the most difficult problem. There are cases, such as in this family of drugs (the TZDs), where there is a significant safety or efficacy difference between different members. In other families, the difference is harder to find and more "me-too". In yet other families, I cannot help but observe that pharmaceutical companies identify clinically superior variants, but deliberately delay introducing them until the older one is about to go generic.
--
Howard
*equal opportunity offense to both extremes*
"Those who cannot remember the past are condemned to repeat it" [George Santayana]
July 3, 2007 7:18 PM | Reply | Permalink
This is such a great thread, I had to come back and see what others were saying, and need to respond to a couple of comments:
To Ellen:
I think the government pays around $400/month, but we pay the total premiums for dental and vision. (We are on the least expensive HMO in NM, with the next costing about $100/ month more.) Here in NM, Federal Employees are actually not that big of a group, so in some ways we don't get as much of a break on our insurance package as say, our state education or university employees do.
Even so, we are extremely grateful we have good coverage. I know that this is not the deal most people have, and I think it is an outrage. In our 25 years of marriage, my husband was in the military for the first 4 years, and we used the military health care system for our needs. But when he got out, while we both looked for work and finished school, we had NO insurance for almost 3 years, and with our oldest a small child, it was a time of great anxiety and fear for us. Every medical cost was completely out of pocket, and we were barely bringing in around $700 a month, a $500 emergency room visit was a financial emergency. Back in those days, even though we were both working and making he equivalent of minimum wage, we didn't qualify for any public medical coverage at all, which today would not be the case--our son at least would be eligible for medicaid. It wasn't until my husband finally got into the civil service that we finally had insurance coverage we could afford and count on for our whole family.
To John:
The whole point of Universal Coverage is for the federal government to pool its multifaceted resources in order to cover everyone equally, and reduce these premiums and copays for the citizen. I have no problem with paying a reasonable amount of my income for health care. And believe me, I don't use my HMO any more than I have to, but when we need it, it's there and it's at an affordable price that doesn't present us with bankruptcy. I get so angry when I hear people talk about "personal responsibility" and "the power of market forces" when it comes to the life and death issue of health: so, if my son has torn cartilage his knee, I should just let it go and allow him to be physically disabled for the rest of his life because I can't afford the 10K surgery to repair it? Or if my daughter inherits a fatal liver disease and I can't afford the transplant costs, I need to run bake sales and fundraisers, crossing my fingers she doesn't die in the meantime? What do they think we have in terms of real choices in the health care market place?
In this day and age, health care should no longer be considered optional--any more than electric power generation, maintaining the public highways, clean water, public safety, k-12 education--where in the world did we decide that government should play no role in pooling and directing our resources for the common good?
July 4, 2007 9:44 AM | Reply | Permalink
Medicare itself is not subsidized, as you say, but hospitals and doctors are subsidized - not because Medicare pays less, but rather because the poor cannot pay at all. Insurance companies actually negotiate lower fees for doctors and hospitals. And it is the people who must pay out of pocket who are providing the biggest subsidies.
Once you have a true national healthcare system, don't forget that the many systems already in existence would also be folded in - freeing up a lot of money, institutions, and so on. Think of the Centers for Disease Control. Think of public health. Think military and VA systems. And medicaid (which is for the very poor). If instead of so many piecemeal agencies and types of care we have one central system, that would make more sense.
Beyond the basics, if some people want to pay for more, as is the case in many other countries, that's ok for them. But you could also have doctors and other health professionals on salary and so on.
Medicine should be a calling. It should not be a business. And if lower pay ends up as part of the mix, that is not problem in my view. If medical education became part of the whole system, then doctors would not be forced into huge loans they have to pay off. And they would not require such large salaries early on - to do that.
Paul Krugman has done a lot of columns on this during the past year. Many economists see that the savings of one system would more than pay for all to get care.
Medical care should be a civil right.
July 4, 2007 10:00 AM | Reply | Permalink
Our local news did a story apparently at the suggestion of the county jail about the huge burden mental health problems have placed on the local prison system. The mentally ill can't get meds and can't get inpatient treatment so they eventually wind up doing something that puts them in the prison system. So you have to be a criminal to wring treatment out of the social service system too.
July 4, 2007 10:43 AM | Reply | Permalink
Dean-- I agree with virtually everything you say--but . . . .
Isn't there a danger that young people would decide to go with private insurers rather than Medicare if private insurers offered them less coverage at a cheaper price? This is what insurers already are doing (See cut and paste from Blooomberg story below.) And don't we need those young people in a national pool--to help pay for those who are sicker and older?
My only answer to this is to outlaw private policies that provide less coverage than the national Medicare policy . . . . Though politically, this could be hard to sell. . .
June 14 (Bloomberg) -- Aetna Inc. and WellPoint Inc. are competing to sell no-frills health plans to a generation of so- called young immortals, Americans ages 18 to 34 who don't have medical insurance because they doubt they'll need it.
Aetna, WellPoint and about 160 other U.S. insurance providers see future sales growth in these 19 million young adults. The companies are offering policies with monthly premiums of $39 to $160, hundreds less than other plans. Insurers keep costs low by requiring customers to pay as much as $5,000 of their medical bills before coverage kicks in.
WellPoint, the top U.S. provider of individual health plans, may gain the most from the expanding market. Young adults are the fastest-growing segment of the 45 million Americans without medical coverage. If everyone in the group bought a policy, insurers would gain $25 billion in annual sales, said Sheryl Skolnick, an analyst with CRT Capital Group LLC. .. .
Health insurance providers are also ``trolling for new business'' to prepare for a time when the U.S. government or states may encourage or require that everyone have coverage, said analyst Rick Byrne. . . .
In California, WellPoint sells Tonik policies called Thrill- Seeker ($77 a month with a $5,000 deductible), Part-Time Daredevil ($87 with a $3,000 deductible) and Calculated Risk- Taker ($106 with a $1,500 deductible.) In addition to major medical coverage, Tonik provides dental, vision and generic drug benefits and several doctor's office visits a year. Maternity benefits are excluded.
July 4, 2007 11:44 AM | Reply | Permalink
Whether or not it's the 800 pound gorilla in the living room, there is a large creature that may very well impact the "immortals", and, even today, is an unfunded mandate for the healthcare system: EMTALA. As I'm sure Maggie knows, EMTALA is the Federal legislation that requires emergency rooms, ambulance services, etc., that receive any Federal money to examine and stabilize everyone who presents to them.
EMTALA addresses some very real needs but pays no attention to paying for them. Without EMTALA, Bill Gates might be in a car accident, be unconscious and have his wallet torn away, and not get treated because he can't establish his ability to pay. EMTALA also, however, is the legislation that makes emergency rooms the inefficient healthcare provider to the poor, because they can't turn anyone away until "stable".
While the 18-34 year olds may not think they are likely to get sick, what is the probability they will be in a car accident? Trauma care can be very, very expensive. One option, which still would not include the non-drivers, would be to add a medical coverage requirement to liability insurance for drivers. In some states, it is the drivers that must be insured, while in others, it is the vehicle owner.
--
Howard
*equal opportunity offense to both extremes*
"Those who cannot remember the past are condemned to repeat it" [George Santayana]
July 4, 2007 12:35 PM | Reply | Permalink
Re: And if lower pay ends up as part of the mix, that is not problem in my view.
It could be a problem if trhe result is that too many bright people turn away from medicine and go into, say, finance instead. Something like this has already happened with teaching. Do we want mediocre doctors and incompetent nurses?
Re: One option, which still would not include the non-drivers, would be to add a medical coverage requirement to liability insurance for drivers.
Some states already do this. Here in Florida the extreme rightwing (flush with insurance money) under Jeb Bush succeeded in blocking the renewal of our auto insurance law so this provision would sunset. The Neanderthals failed to realize that in doing so they also effectively canceled the general requirement that drivers carry any insurance at all. So we're going to have a special session of the legislature to restore the auto insurance law (and fortunately Bush's successor, Charlie Crist, is that rarest of species, a common sense Republican who supports renewing the insurance law, personal injury coverage included.)
July 4, 2007 1:32 PM | Reply | Permalink
And, just visible though the plate glass window, a hearse heading a funeral profession while the guy punching the adding machine stamps a claim "denied".
aMike
July 4, 2007 1:36 PM | Reply | Permalink
There are a lot of ways people get "paid" for work. One is money, but there is also a sense of mission, of doing good, as well as one's working conditions.
Right now the working conditions for doctors, because of managed care, lead to them having to see way more patients in an hour than they really want to. They feel their medical decisions are intruded on by insurance, which is true. They feel a loss of independence and an increase in stress.
Doctors used to work into old age - for a very long time, due to enjoying their work and a sense of fulfillment and being of service. Now they are leaving medicine in droves, as soon as they can. Stress has led to many of them needing disability, something which is unprecedented.
What kind of a doctor do you prefer? One who went into it for the money? Or one who does it for a sense of service, meaning, fulfillment? I'd prefer the latter kind of doctor, myself.
If medical education becomes part of the whole system, and costs very little, then talented people, inspired to be doctors, could afford to enter the profession.
Money isn't everything. Meaning matters. Work conditions matter. A sense of public service matters. Given better working conditions, without the worry of trying to practice in the present stressful environment, would likely lead more and more people to postpone retirement.
July 4, 2007 2:51 PM | Reply | Permalink
Maggie,
I think the key will be to make the Medicare-type plan sufficiently attractive that it gets the bulk of employers to join and sign up their workers. I think that can be done. There is the issue of getting young healthy people who might try to go with a cheap private plan -- I think there are some ways to deal with this (e.g. penalties for not signing up with Medicare plan when given the chance, requiring insurers to pay fees in excess of average for a substantial post-coverage period). I think there are screws that can be applied to insurers that attempt to game the system that would be something short of outright prohibition, but the bottom line is that we really don't want them there (gaming the system is not a useful purpose).
July 4, 2007 3:34 PM | Reply | Permalink
There is another factor which is worth considering. One could probably trace this back further to confirm things, but here are some readily obtainable statistics which people might find interesting.
So, in nearly 30 years, the population has grown 80,000,000.
There has been no corresponding increase in the number of doctors graduated from Medical Schools.
Why the drop in applicants between 1996 and 2006? Applicants to medical schools aren't stupid. They realize that with a static student body in medical schools and a growing student population generally, it makes more sense for them to choose allied professions and get into schools on their first try.
In other words, the declining number of applicants does not reflect a declining number of persons interested in becoming doctors. It is reality based...unless opportunities for medical education are increased to mirror population growth, fewer Americans are going to pursue medical education proportionately, and the number of American doctors relative to the American population is going to decrease. The brutal statistics indicate
The root problem is NOT the immigration of physicians and surgeons trained abroad. This is no anti-immigration screed. The problem is the failure of the American educational and medical establishments to grow institutions for training American doctors proportionate to the growth of the American population generally.
aMike
July 4, 2007 5:25 PM | Reply | Permalink
The answer to your question, Short of government funded universal coverage, at the very least, why can't the entire nation have a similar set of plans we have offered to them?
...is this:
Short of government-funded (which means private, and therefore, for-proft) those offering coverage must do everything they can to ensure that they don't get the diabetics, the chronic lung patients, those who have cancer, chronic back problems, obesity -- you get the picture.
HMO or not, medical care for chronic problems is very expensive, and only by excluding those who are known to have such conditions can costs be controlled. Insurers hate to pay for health care; that is why their terminology for such payments is "loss."
The patchwork quilt will remain unless risk can be shared across the spectrum of the population. The portability issue is significant, and should simply not exist. The only reason it does is to give insurance companies one more excuse to reduce their "loss" and to deny appropriate payments to people who go out of town and have the bad luck to get sick or injured. If Anthem exists in pretty much every state, why should they add fees on if you make a claim in another state?
This simply does not exist in other developed countries; insurance companies do one thing very well. They manage to scare everyone to death about "socialized medicine" so they can continue to skim big profits at the expense of the health and well-being of our citizens.
Jan
July 4, 2007 6:44 PM | Reply | Permalink
Medicare itself is not subsidized . . . .
I wish that assertion were true, but I'm afraid it's not.
Congress sets Medicare reimbursement funding which when divided up among Medicare patients and procedures results in fee schedules lower than what insurance companies negotiate and much lower than the fees paid by the few uninsured who actually pay for their services.
Thus, Medicare is SUBSIDIZED by all non-Medicare payers. And if everyone were enrolled in "Medicare," Medicare's fees would have to go up. If we're to look at the proposal realistically, we have to face that fact.
July 4, 2007 7:09 PM | Reply | Permalink
Treatment=Strapping the prisoner in a restraint chair until he recovers his sanity.
July 4, 2007 7:14 PM | Reply | Permalink
This is how you can compare insurance companies and mail delivery:
You (the letter-writer, or bill-payer) apply to various "mail brokers," and depending on how many letters they expect you to mail each month, they quote you a monthly fee, for which they will put their very own special stamp on each envelope. Note: They won't actually DELIVER THE LETTERS, but they will put a stamp on them (only these companies have the stamps of course) and then you can put them in a mail-box. If you don't have a broker you have to buy much more expensive stamps because the brokers have negotiated special fees with the Post Office, which you are not entitled to do.
Now, the only way these "brokers" can stay in business is to limit your mailings or charge you enough so they have money left over after paying for all your stamps. Oh, did I mention that your letters have to be "preauthorized?" How about the myriad forms you have to fill out to get a letter sent? If you start sending out more letters than usual your broker may either drop you or charge you more. If you have a "preexisting letter issue, you may not qualify for a broker, or you may have to pay a large deductible for your own stamps before they will start issuing their own stamps.
I won't keep this up; don't want to be too tiring, but I think the message is valid. The "brokers" don't offer a service; they are gatekeepers and money-skimmers. Because there are no other options now, the insurance companies do provide (although with increasing limitations) catastrophic coverage for health events. In a single-payer system, every penny could go to providing care; preventive, therapeutic, chronic, and catastrophic.
I also think the term should be "Universal Health Care," rather than "insurance." We buy insurance for events that we don't expect to happen, like fire insurance and automobile accident insurance. It is there in the unlikely event it is needed. Everyone needs health care. The catastrophic part falls closer to an insurance need IMHO.
Jan
July 4, 2007 7:29 PM | Reply | Permalink
And it can be expensive to train doctors outside the US especially when they require an Operation Urgent Fury to prevent them being taken hostage by Commies.
July 4, 2007 7:36 PM | Reply | Permalink
Re: those offering coverage must do everything they can to ensure that they don't get the diabetics, the chronic lung patients, those who have cancer, chronic back problems, obesity
And yet the current system doesn't really weed these people out of private coverage very effectively. Diabetics, people with back pain, etc. mostly still work and as such they still have employer-provided health insurance. Only at the extreme, where people are too sick to work (and so end up on Medicare, after a year's wait) does the private system avoid them. And even the chronically disabled may still end up on private coverage if they are some other worker's spouse or child. The people weeded out of private coverage are the self-employed (unless they are young and perfectly healthy) and people working for low wage employers who do not provide benefits (or price their benefits too high).
July 5, 2007 3:27 AM | Reply | Permalink
It seems lika lot of Republicans would be driven out of the heath care professions. Wouldn't that be a good thing?
July 5, 2007 4:12 AM | Reply | Permalink
Even though it's an unfunded mandate, if EMTALA required providing a simple walk-in clinic alongside ER services, the high cost of exploiting the ER would decrease, n'est-ce pas?
July 5, 2007 7:03 AM | Reply | Permalink
Still, there are disincentives in some of the private coverage. For example, the ideal in diabetes care would be an intelligent (i.e., sensing sugar levels) implanted insulin pump, that changes dosage in real time, just as my intelligent pacemaker does.
Short of that, the gold standard in using insulin, in both Type I and Type II patients, is to measure sugar about 5 times a day, try for 5 small meals, use a basal dose of long-acting insulin, and then, at each of the measurements, add the appropriate small amount of short-acting insulin. The problem here is that insurers are reluctant to cover the significant cost of the test strips for the glucose meters. They are rather like razor makers giving away the handle because they make their money on blades: my meter cost about $30, but my test strips are $0.50 each.
Spending $2.50-4.50 a day on precision insulin adjustment (test strips, lancets, additional insulin and syringes [although lancets and syringes can be, with reasonable care, reused a few times] avoids major complications, but the insurers, with a perhaps quarterly viewpoint, don't look at it this way.
--
Howard
*equal opportunity offense to both extremes*
"Those who cannot remember the past are condemned to repeat it" [George Santayana]
July 5, 2007 10:27 AM | Reply | Permalink
Alexandria Hospital, in suburban Washington DC, has done something just like this, but it gets into tricky areas of reimbursements and EMTALA implementation. The way this is set up is that some of the very expensive services, such as labs and X-ray, are shared.
The problem is that patients don't know, or in some cases care, that they can go, uninsured, to the clinic and still get seen without having to prove the ability to pay. IIRC, the auditors claimed that once a facility was not designated "emergency", the staff needed to demand to know patients could pay.
So, Tom, you are perfectly right that this would be workable. It addresses some of the less obvious reasons people use ERs: they are 24/7 (necessary for people without sick leave) and also tend to be on the best public transportation routes for the area.
This is just the sort of thing that can be cost-reducing in what I'll called "integrated" healthcare system not designed to maximize insurer profitability. In the particular example, the hospital I cited, which is part of a larger not-for-profit system, INOVA Healthcare, came up with this experiment on its own -- it's not "centrally-directed socialized healthcare". Several states are experimenting with approaches to universal access, such as Massachusetts and Hawaii (and to a lesser extent, Oregon and Tennessee). I don't think anyone seriously is proposing a rigid federal command, but the Harry and Louise play certainly exploits that fear.
Serious healthcare economists know that we don't necessarily have the total answer to economical delivery of services, and recognize some experiments will work and some won't. One controversial area, for example, is putting walk-in clinics into Wal-Mart, Walgreens, and other superstores, staffed by physicians' assistants and nurse practitioners. Certain insurers are incentivizing some of this, including waiving copayments if prescriptions are filled in that store -- something considered unethical if a physician prescribed. AMA comment on these clinics, which may not be neutral
Part of the concern about these mid-level clinics is continuity of care, which can be addressed with electronic health records. More difficult is avoiding conflict of interest.
Another non-obvious problem is that delays in getting seen in physician offices tend to screen out urgent and emergent situations (not the same thing). A question that no one can yet answer is whether clinics of this type will divert some people that really need to be seen in a full-service ER.
--
Howard
*equal opportunity offense to both extremes*
"Those who cannot remember the past are condemned to repeat it" [George Santayana]
July 5, 2007 10:58 AM | Reply | Permalink
The current system DOES weed out sick people UNLESS they work full-time at a place that provides health care (and is large enough that they get a break in pricing because of the shared risk). People who work part-time rarely get work-sponsored coverage. Many relatively large employers, such as department stores structure employee times so that only 5% of their work force gets any benefits.
Diabetics, people with back pain, etc. mostly still work and as such they still have employer-provided health insurance.
Really? Where did you get that? Although many do, who are the millions who are too wealthy to qualify for medicaid but too poor to pay for their own insurance? Is it only young, healthy people? I don't think so.
It is those working, and non-working people who have to get private insurance, and they all have to give detailed medical histories. Every previous illness or injury puts them at a higher premium, or a high deductible or both. The self-employed are in the same boat. How many people over 50 (and not old enough for medicare) have spotless health histories? And why should insurance companies get to shaft those who don't?
Jan
July 5, 2007 3:02 PM | Reply | Permalink
Only an issue if people are forced to go to the clinic first. I'd put a big sign at the entrance of each place with a list of easy choices concerning which facility to use. Kind of like a store directory.
"Bright red bleeding, won't stop?---ER."
"Kid says stomach hurts?---Clinic."
July 5, 2007 3:35 PM | Reply | Permalink
Were you thinking here of the store clinics, or the colocated urgent care facility with ER?
Might want to reconsider the second directory line, given one of the Laws of Emergency Medicine is "it is impossible to diagnose abdominal pain in a woman of childbearing years without at least two consultants."
I suppose it depends on how intense the stomach complaint may be. Severe abdominal pain needs an ER. The problem is deciding if it's "severe". It's relative; I did not need lights-and-siren ambulance, last fall, for mild bleeding at the nether end.
--
Howard
*equal opportunity offense to both extremes*
"Those who cannot remember the past are condemned to repeat it" [George Santayana]
July 5, 2007 4:24 PM | Reply | Permalink
It's not at all about values, but it is about VALUE.
http://medicynic.com/?p=143
July 6, 2007 9:20 AM | Reply | Permalink
Right-wing propaganda tells us that some people have adequate health care, and we have to do something about that! The wingnuts say that some people, with government "subsidies", are getting what they call gold-plated, extravagant care - a strawman of their own invention. What we need to do is extend adequate care to everyone.
The service delivery model, and what it costs, is a separate issue. A not-for-profit HMO offering comprehensive care is more cost-effective
than a Medicare beneficiary running all over town trying to find providers who will accept Medicare and trying to coordinate a CT scan, lab work, purchasing prescriptions, etc.
July 6, 2007 9:31 AM | Reply | Permalink
I believe I noted in my post that the people weeded out of private coverage are people working for low wage employers who do not provide benefits (and who of course cannot afford coverage on their own, even if they have spotless health histories). However is it correct to say that low-wage people = sick people in some sort of one to one correspondence? I am NOT disputing that this large coverage gap is a serious problem crying out for solution, but the notion that health plans have a perfect mechanism in place for avoiding people with chronic illnesses is not true. Most people with such illnesses, assuming they are healthy enough to work, or are married to someone who is, do in fact have health coverage under a group plan. I could cite examples of people I know you probably could too. So the current system doesn't even really serve the interests, such as they are, of the insurance companies: they still mostly end up covering sick people, because they have no real mechanism in place to avoid sick people under group coverage (which is what most people have). The best they can do is avoid self-employed and low-wage people, but that doesn't equate to avoding the sick.
July 9, 2007 2:35 PM | Reply | Permalink