You know one way around all this hassle woule be to change thway healtu insurance is priced. Instead of the premium being a flat dollar amount it would become like a flat rate tax: a percentage of the suscriber's income (with community rating so everyone buying a given policy would be charged the percentage rate). The insurance companies could set that rate at whatever they wanted, and different types of coverages could have different rates, but no one would be priced out of the market entirely.

The Bush administration is trying to force our state to stop covering children in the SCHIP program because they believe their parents make too much money.

What's to prevent the same thing from happening with this program? This program doesn't make universal CARE a right, it supposedly makes universal insurance an obligation.

But insurance is increasingly become a cruel joke as companies use every trick in the book legal or not to delay and deny coverage that people had every reason to believe they had covered in their policy.

Insurance companies are in business to make a profit and they do that by denying health care. They do not provide care. Requiring everyone to buy a policy absolutely does not require that they actually are provided care.

Yes -- if everyone is supposedly going to be covered why on earth do you need the insurance companies at all? What is the point of the middle man. Why not just have a single payer plan, cover everyone, tax for the benefit, and those too poor to pay taxes still get covered.

What do the insurance companies actually need to do? What do they do but find reasons to deny people care?

"But mandates won't work if premiums continue to spiral." Can we ensure that barring age discrimination will contain the cost of insurance? If pricing is cost-plus, then insurers have to raise their price to some customers to make up the lower fees to others, although it's possible that they'll have less incentive to offer lower fees to some once young people's purchase is mandated and thus requires less in the way of market incentives.

However, if pricing is just supply and demand, then even at a single set price, there's nothing keeping the companies from jacking up theirs. Maybe even more so once they know purchase is mandatory and supply is concentrated in the hands of a few insurers eager to make a buck. Of course, some proposals have a government insurer on top of private insurers, for those who can't otherwise afford a policy. But then that risks gathering in the poor, who are more likely to be high-risk cases, dooming the government's costs to rise and the system to fail.

John 

http://www.haberarts.com/

No, Maggie. No.

Mandates are worst than the current situation. Nothing about mandates suggests, let alone guarantees, that private insurers will reduce their premiums. The problem is not just the size of the pools, it's also that the pools are all captive markets. Oligopoly - buyer captivity - buyers have no influence on pricing. Mandates write that captivity into stone. It's exactly a cause of the current problems, and thus exactly a wrong thing to do. They certainly provide no reason for private insurers to reduce premiums - likely to the contrary; they just turn people who can't afford coverage, and still won't be able to afford coverage, into people who have to buy it anyway; i.e., into bankrupt criminals.

Terrible, terrible, terrible idea. Only an irrational capitalist could even consider such a disastrous idea. Think Mitt Romney, Republican presidential candidate.

You say yourself that if premiums continue to spiral, mandates won't work. But premiums are already way too high to be affordable, so unless premiums come way down, mandates are not going to work (it's not going to be a crisis; it is a crisis). Private insurers are not going to bring them down voluntarily - they don't have to - they each have a captive market, no matter the size of their pool - that's the nature of the situation. You're going to have to regulate premiums to bring them down, and that won't work either; you'll just end up spending that much more to regulate premiums, administratively, than to pay for actual care, than is already the case.

It. Will. Only. Make. Things. Worse.

If Hillary Clinton does this, there's no way under God's heaven I'll vote for her.

Or for anyone else who pushes this disaster of an idea. And until I read this, I was leaning her way.

I might just as well vote for Romney.

There's only one workable solution - public funding for universal coverage, with no individual direct payments at all, mandated or otherwise.

I'm really more tired than I can tell you of capitalists trying to spin a capitalist solution to this problem. Enough already. 30-plus years I've been waiting for the US as a country to get enough over its fear of socialism to do the right thing - the only thing that will work in cases like this:

Socialize. Socialize. Socialize.

"What do they do but find reasons to deny people care?"

They negotiate discount rates with providers.

"Why not just have a single payer plan"
Well, take a look at our educational system, how much progress in understanding how to teach and evaluate children has been achieved in the last 100 years.

Can you name any of sceintific breakthrough in education for the last 50 years?

What's the quality of education?

Do you want the same system for your healthcare?

Don't get me wrong, I agree that the current health care system is broken.

The VA health system negotiates discounts. Other governments negotiate discounts. No reason the US government can't negotiate if it has the will to do it.

Public education depends on the will and the resources of the local community. It can be excellent when the community has concerned parents with financial resources. We haven't figured out a way the federal government can replace the lack of community commitment when it comes to education.

There is a major difference between socialized healthcare financing and socialized medicine. The latter, as in the British system, controls the actual practice of medicine. There are some excellent British healthcare facilities and innovators, and some less so.

Germany and Japan manage to have effectively universal healthcare coverage, without a central control of either the practice of medicine, and, somewhat surprisingly, with multiple payors. Both systems tightly regulate their payors, which, at least in the case of Germany, are often not-for-profit. They also have a government safety net for those not covered by the other mechanisms.

Germany also manages to run with much lower overhead by not trying to micromanage every patient's care, and using nonmedical personnel to preapprove certain tests and treatment. Instead, the German system looks at costs by provider on a statistical basis (quarterly, IIRC), and audits the high-cost outliers. Perhaps Dr. Schmidt's patients lived in a city where there was an epidemic and that explained his costs. Perhaps the audit showed that he was inappropriately ordering CT scans on every patient, which is both unnecessary for many diagnoses, and subjects patients to a nontrivial amount of ionizing radiation.

I tend to lean toward a universal requirement to have coverage, with the only exceptions being First Amendment cases such as Christian Scientists who do not accept conventional medical care. There is a good working example of regulated multipayor coverage in this country, the Federal Employees Insurance Plans. That's not an exact match for the needed system, but it's certainly a decent starting point.

For the record, I've written device drivers, variously for communications protocols and for medical laboratory and intensive care equipment. I've also worked on expert systems to assist physician prescribers, and have myself worked in the biochemistry of antibiotic resistance.

Much of my education was self-delivered. Some of the public school education was useful, some (mostly science and math) was not.

--
Howard

*equal opportunity offense to both extremes*

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

Maggie, where ever you are, please come back! Someone wrote a nonsense piece using your name.

It is inherently wrong for any government to mandate that citizens must buy anything being sold by private businesses. The sole exception to this is when a utility, needed by everyone, is allowed the monopoly to provide that service, but is very rigidly regulated as to what they sell, how they provide it, and what they charge for it. Think sewer service, for example.

How about we make it the law that every single one of us must buy a haircut every two weeks? Each of us would have to pay the same price, so wouldn't that be fair? Of course, we would expect the barbers to make a good living, so that price would be whatever the barbers collectively decide to charge - say $400 per haircut, for example. Is that ok?

There is simply no answer to the health care problem that includes health care insurance companies, unless both the product they sell and the cost of that product are strictly regulated by an agency beholden only to the citizens, not to the health care industry.

I'm just totally astounded that Ms Clinton didn't propose such a system - dumbfounded, disillusioned, befuddled. Who'd a thought?

Hoppy in Sacramento

I have no objection to Maggie's (Hil's?) mandating plan just so long as young people's insurance rates are based on experience.*

I'm sure they can afford the $2-300 a year their insurance would cost.

That is what Maggie's arguing for, isn't it? :-)

* I wonder how your average 50 year old driver would like it if he or she was assigned to an automobile insurance all-ages pool.

"No reason the US government can't negotiate if it has the will to do it."
This would not be negitiations. You can't negotiate with monopoly.

"Instead, the German system looks at costs by provider on a statistical basis (quarterly, IIRC), and audits the high-cost outliers"

Why Medicare and insurance companies don't do this today?
Seems like easy hanging fruits.

No good universal health care plan can include insurance companies in the mix. Period. Now we know what Hillary's payback is to all those insurance companies who have lined her campaign coffers with gold. Not surprising at all.

That's $200/$300 a month, not per year! For an older person getting a $600 SS check or a young person with a part-time or low-paying job, $2400-$3400/yr is quite a bite out of income. And this still allows insurance companies to make profits? Here in NY private insurance for a couple costs $1800-$2100/month. Absolutely crazy.

Maggie,

Everything you say makes sense for any plan in which private insurers play a role. Everyone would have to share one risk pool at one price (it'd work against you when you're young but would be a bargain when you're old) and insurance companies would have to start selling their product as a pooled scheme as opposed to how they sell it now, which is a phony "savings account" model that winds up driving everyone nuts.

Thing is... once you standardize the pricing and make the risk pool universal... what exactly do we need insurance companies for? If we're all in one pool, isn't it better that we all have one provider?

thosethingswesay.blogspot.com

This is the Blunder we have been expecting from Hillary.

This is really stupid.

She should have kept listening to that song--"You say it best---when you say nothing at all."

"One woman was denied because she had not reported a previous YEAST INFECTION."
This is not going to be issue because, if everybody has insurance, there are no such things as pre-existent conditions.

I have run this up the flag pole before and I don't think a single person saluted, but that doesn't mean I give it up.

There is a way to have single payer health care and still not cost all of those insurance companies their business. That is for the federal government to set up health care districts throughout the country, say a dozen total districts. Then let the health care insurance companies bid to do the paperwork, office work, filing, etc. that goes with such a business. Each district would have the low bidder insurance company as the operating entity, but the financial part would all be by the federal government. Now, all of those clerks who would otherwise lose their jobs will still be employed, but the stock holders would be totally bummed out over the drop in value of their stock. Boo hoo.

Hillary's plan is "DOA".

Hoppy in Sacramento

davai,
You're wrong.

Why?

Exactly.

Keeping insurance companies as the primary dispensers of both money and (even if indirectly) services, while making them unregulated de facto monopolies, or at best, oligopolies who also set the rates for those services is a prescription for disaster. Add to that a public mandated to buy their product and government subsidies to afford it and disaster does not completely encompass the resulting situation.

The insurance industry is not part of the solution. It is the problem.

The insurance industry is, however, enormously politically powerful. Witness the sums of money they are not only willing, but eager, to spend on politicians and campaigns. It will be very difficult to arrive at a workable, reasonable, functional system as long as they can buy it off. They understand that because of the outrageous costs, profits and inefficiencies inherent in their system, an efficient, fair and effective one will be inimical and antagonistic to their entire current business model.

The political will to counter to the insurance industry, or any other large, entrenched economic, corporate interests for that matter, will only develop with publicly funded clean money elections.

Given our unprincipled system of legalized bribery and influence peddling, accomplishing substantive change in something like our health care industry will be likely impossible unless we fix that corruption first.

We need to get insurance companies-- who profit from denying care to people when they are down-- out of the picture.

We spend more on healthcare and die sooner than Europeans, our k-12 education is third rate, and we have no border security. But hey, our Congress did manage to get something done in the last couple of decades: they looted our tax dollars in the treasury for earmarks, unecessary wars, no-bid contracts, tax cuts, oil subsidies, etc.

Congress is NEVER going to spend our tax money on real,high-quality universal healthcare (like other democratic countries do) unless we Stop Voting for Candidates who Accept Campaign Donations.

Our seats in Congress have essentially all been bought by special interests like insurance companies. Until we voters change our tactics, Congress will give only scraps and excuses to passify the voters.

Anyone know if Hillary's plan includes a provision to make companies pay when they sell products that degrade public health?

How about companies that pollute air and trigger record asthma rates in children? What should they pay? How about those that put toxic landfills in poor neighborhoods?

And what about the government? What is their responsibility for health problems when they check less than 1 percent of food and toy imports?

It is my guess that if our government stopped all of the wasteful spending, they would find they're already getting enough in taxes to cover health care.

The federal budget has waste in it that I am confident easily exceeds half a trillion dollars per year. They pay too much for everything and then we see lavish spending by government departments like the recently revealed DOJ spending on staff get togethers and conferences. And then we have earmarks that are nothing but payback for political campaign support that fund an awful lot of things that are simply unnecessary. Congress is spending our money in wasteful ways that are too numerous to mention. Everything they do is measured in billions and there is little or no internal audit control for most expenditures within agencies. Legislatively, costs for everything are inflated like crazy. Another thing that has cost us dearly in late years is the contracting out of a lot of things that government once did in house. I don't believe for a second this represents a cost saving or is even a wash. I am sure it has actually cost us money. Look at all the weapons procured for use in Iraq that nobody knows where they went.

We all need to do is just not pay our taxes for a couple of quarters to send these clowns a message. We are letting this happens because we won't act to stop it. We can and we have the legal right to do so. Gov't could never win a suit by taxpayers that challenged the waste and fraud.

Maggie

Are you more concerned about universal health insurance e or universal healthcare? Which is your prority better healthcare or less expensive healthcare? If the health insurance system won't be acturarily sound as new drugs, machines, and procedures both allow people to live longer and by themselves drive up the price of care who or how will allocation of care be determined?

Daniel A. Greenbaum

Corvid

Sounds like a plan to "insure" profits for the morally reprehensible private insurers and that Americans will continue to pay more than anyone else in the world for second-rate health care. It's kind of like our lovely student loan program, which is mainly about subsidizing politically powerful banks at public expense, students be damned.
.
Think about it for a moment: Here we have private insurers who have made it a profit point for decades to willfully and even joyously deny needed health coverage to people with pre-existing conditions and others who need it--literally getting away with murder--and Hillary proposes to reward these people with comfy, government-guaranteed immortality.
.
Why do we need to preserve these immensely wasteful and ethically repugnant private entities? They are the worst kind of parasites. I understand those who say that the industry (such as it is; it doesn't actually produce anything other than amplified human misery) is politically powerful and we can't get any kind of health care without their approval.
.
But to just concede that point without a fight is to utterly give up on our democracy, isn't it? How disgusting.

Thanks for all of the comments. I' m going to reply to four or five at a time, beginning with the earliest comments:

Robert Brown--I agree, if we're going to finance health care reform with taxes, I'd favor a progressive tax,probably as part of the income tax. But for the healthcare fund, I'd tax earned income and capital gains at the same rate, and probably tax all income up to $1 milion--making the health care tax more progresive than the regular income tax.

Rick-- You and I (and Hillary and Edwards) are in complete agreement on this one. If we want to have a universal sustainable healthcare system, we Must rein in spending. I recently wrote about this on my blog (www.healthbeatblog.org) in a post titled "Do We Really Have to Cut Back On How Much We Spend On Health Care?"

Bluebell--You are right, a mandate alone does not make universal coverage a right; it makes universal insurance an obligation. (And that's a very good way to put it.) That's why I think that a plan with a mandate must also include price regulation, limiting how much insurers can raise premiums, and regulation of what they must cover. They shouldn't be able to sell "Swiss Cheese" policies (filled with holes) or bare-bones plans. If we're going to have a mandate, the product must be comprehensive-- something roughly equal to what Medicare offers, plus the benefits that younger people need (maternity, etc.)  I'd also like the law to cap profits-- perhaps by saying that insurers must spend at least 85% of the money they take in  on medical care, leaving 15% for administration, advertising and profits.

 ammasdarling -- I, too, would greatly prefer Medicare for All. But Clinton (among others) says that we just don't have the votes in Congress to pass it. We might, of course, after 2008. But if we don't, I'd like to see a universal plan that lets Medicare compete with the for-profit insurers (for all customers, young and old) on a level playing field. I suspect many people would choose Medicare, and the for profit insurance industry would begin to fade away.

I thought that single payer was supposed to bring dramatic improvements in efficiency by eliminating duplication of effort in insurance companies. Seems to me that that implies getting rid of a lot of duplicate employees.

Isn't your idea very close to the 1993 Hillary health care plan? That had government-controlled regional alliances with a controlling national health board, HMO's under government supervision administering at the regional level. One of the problems there is that it requires tons of varying rules, regulations and interpretations to let non-government employess basically do government work if it is to work well, which brings up the "bureaucracy" complaint. You're putting it in an place which is the flip side of the process of partially privatizing vital services. If not done right, people complain from both sides, about too much government control or too little government control. This is what doomed the 93 plan: dislike from both the right and the left--when the right and the insurance business attacked, the left did not want to stand up for it, as they didn't like it either.

Thanks to the handy comments feature here, let me ask about the interactivity of Health Beat. I see that some other voices have comments in the form of full entries. Are they people who've emailed? (There's no blog-like comments feature, which is fine with me.)

John 

http://www.haberarts.com/

I can think of one reason:  the same people with enormous incomes who pay little or no taxes would presumably get the same exemptions and pay nothing for their health care plans.

I'm for the flat payment with subsidies for those who can't afford it.

Jan

Just look at the rest of the world!  We can cherry-pick what we like and leave out what we don't!  We have hundreds of examples to choose from and it is silly to say it would cost too much.  We pay more now, with a lower standard of health than several countries. 

The right answer is staring us in the face, but the insurance, & drug lobbies keep saying, "boo!" and scaring everyone.  Also our Congresspeople have very little incentive to do this because their current health care plan is a gold-plated one.  They don't want to lose it.

Jan

Can I just add to your "of course" that what was labeled the "baby boom" is fast coming upon a certain age? And also that they are known to be a generation that yells if they don't get what they think they need? A much more fearsome version of the AARP ever, that's what's coming. (Knee MRI's on demand, cause I read I need one on teh internets!) :-) This is being experienced by all western countries. The point: health care is expensive and is going to get more so. Savings switching to another system are going to be temporary, at best we might see static costs by changing. It's going to be a hard row to hoe for quite some time. It occurs to me thinking on this that with any change to governmental coverage, it's really important to keep the health care expenditures separate. Right now people getting insurance from their employer without deduction from the paycheck should be getting a statement on its value, as if it was part of their salary, even though it isn't taxed.

Hoppy, it's still a waste of money.  Would you like to grocery shop, chosing everything that you want, and then have it all shipped over to a middle-man (to whom you have already paid a pre-set amount to cover your groceries)?  Then Mr Middleman would decide what things you actually really needed, deny the rest, (which you could pay for out of pocket, of course).

Why not just leave out the creep in the middle, and all the infernal ridiculous paper work, and spend your money on services?  What a concept!

Hoppy.  Just out of curiosity, what service do you think insurance companies actually provide?  What do they actually DO to earn their money?

Jan

Except in the marketing departments and the executive suites there are few if any "duplicate" employees.

adding figures to Logico's statement of owning congress...
The Finance/Insurance/Real Estate lobby (s)
gave to Hillary 12 million so far...far ahead of any other donor.
Key donors have been insurance and Citicorp, other financials, which is often the same kind of co.
Source : http://www.opensecrets.org/politicians/sector.asp?CID=N00000019&cycle=2006
I no longer for Dems.Repubs, they are same thing.
We desperately need a viable 3rd party.

I think five percent of federal income tax payers pay about fifty percent of all federal income tax and fifty percent pay something like five percent. I that the way your see the burden of health care costs being shared?

Bluebell, jhaber, DAniel and JohnOneOne

First, let me ask you all to go back to the homepage and read the update on Hillary' s plan that I posted this afternoon after I saw the whole plan.

Two very important points: First, while she is not putting an explicit cap on how much insurers can charge, she is guaranteeing that the premiums will not be allowed to cost more than a certain percentage of family income. She doesn't specifiy the percentage, but she makes it clear that she understands that if you mandate insurance, it must be affordable. (Something Romney didn't understand). So it appears that she plans to regulate insurance pricing) . MOreover, by letting a Medicare-like non-profit public sector insurer compete with for-profit insurers on a level playing field she is putting great pressure on private insurers. Many of them won't be able to compete with Medicare, and will just drop out of the game.

Secondly, she requires that all insurers offer coverage equal to what federal employees get--i.e. comprehensive coverage.

Finally, I agree with Daniel--we cannot turn health care insurance into a welfare entitlement or we will wind up with something like Medicaid for all.

John--

    To comment on my blog (www.heatlhbeatblog.org) you have to scroll down on the left and click on "contact". You can then send your comment in the form of an e-mail, and I will post it on the blog.  The Century Foundation wants to do it that way because they are wary of crazy or extremely partisan comments (they are a non-profit bipartisan think tank and could get into trouble with the IRS).

But I haven't had to censor or edit any comments. The people commenting on the blog seem to be extremely intelligent and rational--much like the readers I get here on tpm.

artappraisor--

   These are good questions. Based on my reading of her plan (see my post updating her plan after reading the whole thing) this is not a small step--it's a very big step.

   I remember that NYT Magazine cover article. I find it very boring. She just didn't say anything. This plan--and some  of her recent speeches are much bolder.

   I don't see this as a step back from what the Clinton's wanted in 1993. It's less complicated (or she has figured out how to describe it in a more succinct fashion.) The only significant difference is that in the new plan she isn't trying to put an explicit cap on insurance premiums. But as I've said below I think the Medicare-like option will drive insurers who offer poor value for the dollar right out of the market.

   Bottom line, her new plan is much like Edwards plan--which is much more radical than Obama's plan.

hoppycalif2, Hward and Koshema--

  First, Hoppy, let me try to restore your faith. Under Hillary's plan the product that insuers sell will be strictly regulated and premiums (or premiums plus tax credits) will not cost more than a certain percentage of a family's income. (See my update that I posted on tpmcafe this afternoon  after reading her whole plan.)

I was pretty sure that she would be regulating insurers when I wrote this post yesterday (before her plan came out) because I have been following her speeches. Also, the rumor was that she would be tough  on insurers. If they have to offer comprehensive coverage (no less than what Congressmen have ) and compete on a level playing field with a Medicare like option (which will be available to everyone)many will simply disappear.

So as I see it, her plan is mandating health insurace as a necessity--much like heat and light--and regulating it, in part by making Medicare a competivie benchmark that for-profit insurers will have to try to live up to.

Like many of you, I would prefer to go directly to Medicare for All, but you have to realize that people on this thread probably don't represent the mainstream of American opinion. Then there is the fact that many of our Congressmen seem spineless. Finally, while Hillary is a tough lady, I don't think she can wave a wand and make the insurance industry go away--not all at once. But she can turn up the heat so that much of the industry withers away on its own.

Finally, insurers are not the main problem with our system--just one piece of it. Drugmaker and device-makers, some hospitals and some healthcare providers are all part of the problem. To put it very simply, we waste about 1/3 of our health care dollars by paying too much for everything--from drugs to some specialists--and by being over-treated. More care is not better care. More expensive care is not better care. The newest treatment is not necessarily the best treatment. Hillary understands all of this.

I've written about how we waste one out of three healthcare dollars in this piece on Jack Wennberg's work at Dartmouth that you will find here. http://dartmed.dartmouth.edu/spring07/html/atlas.php. He is one of the most honest, courageous and deeply intelligent healthcare reformers that I have ever met. I've been writing about his work for about four years. He knows Hillary quite well. She respects him and he respects her--which I take as a good sign. I also like Edwards' healthcare plan (which also mandates insurance) but she probably understands healthcare in more depth and detail.

Howard--Let's face it, people in New Jersey are just weird. They're obsessed with rules--and yet they can't drive!

Koshema-- great line about if a private company ran our fighting forces they'd realize that war is just too expensive.

“Welfare entitlement” and “socialized medicine“ are labels that some will stick to any plan for universal health care administered by government. So, to avoid those labels, should a plan be designed to not be universal? Unless no one can avoid qualifying, many medical needs will still go uncovered. If unmet health needs and resulting unnecessarily early deaths aren't important enough, the medical costs of treating the uninsured will still run up the medical costs and the cost of medical insurance for everyone.

Medicaid is a net with gaping holes. Many fewer patients would be forced into that net (possibly to fall through) if there were something like universal Medicare. Even then, there would be the issue of unaffordable co-payments or deductibles for some persons needing medical care.

I wonder if any candidate will dare to come up with a viable plan that is truly comprehensive. There would be political risk in doing so, sadly.

OOOpps again. Perhaps growing up in New Jersey provides enough environmental toxins to leave tremor?
--
Howard

*equal opportunity offense to both extremes*

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

MM, thanks as always for the careful commenting. You addressed my concerns. Like Hoppy and others, I'm concerned that the middleman adds too little and slants results against success, but your points are well taken, and I'm hopeful.

About the NYT mag article, it was boring in the sense that it wasn't specific, but in another sense it was less restrained than her usual. It's often principle she avoids, and this one's basic claim that universal health care is going back on the table was rather good for her nd useful in itself for everyone. She also had a paragraph I liked a lot, about how all the hints about what the original Clinton proposal would bring have come true, only they go the cause wrong.

John 

http://www.haberarts.com/

OK, I am so happy that you, Hoppy, realize that insurance companies offer absolutely no service and that you support single-payer.  I guess I missed that in your other posts.

Thanks, Hoppy!  I knew we had to be on the same page!  The nuts and bolts can be disputed, but as long as there is a for-profit-gate-keeper, there is no way to make it work.  Glad you agree!  jAN

Jan

Art Appraiser--

    But $503.50 a month is the cost of providing heatlhcare for people over 65. Keep in mind that a huge chunk of our nation's health care spending comes during the last six month of life!

   The cost of providing coverage for people under 65 is much much lower, so the premiums will be much lower.

   Keep in mind that Hillary's plan doesn't say that people under 65 will have the option of going on Medicare; rather they will have the option of picking a plan that is like Medicare--public sector, offering comprehensive coverage, etc.But it won't cost as much as Medicare to cover them.

  Destor 23 and Robert Brown:

Exactly.

  And I don't think it will take people long to figure out that we don't need private insurers as middlemen. Once you standardize pricing and make the risk pool universal, the Medicare-like option is bound to offer more coverage at a lower price.

So more and more people will choose that option. But right now, if you tell people that they all have to go into that pool, they will flip out. People who have good insurance way to be able to keep it.

Until they see the Medicare-type insurance (which, like Medicare itself) will be as comprehensive as really good insurance that you get from a generous employer. Except it will cost less (lower administrative costs, no need to turn a profit, advertise, etc.)

This is a very, very clever way to eliminate the private insurance industry-- by giving Americans a choice between private for-profit insurance and what is essentially single-payer (the Medicare-llike option) and let them CHOOSE Single Payer.

When can the other side say if individual citizens decide to take their business away from for-profit insurers?

It will be so much easier to pass Hillary's bill because it is based on individual Americans making a CHOICE.

The insurance industry knows this and they are NOT happy about Hillary's bill. Right now, they're trying to figure out what to say--What can they say? "We don't want to compete with a public sector plan because we know we'll be wiped out?"

(I'm going to repeat your comment adn my reply at the end of this thread so that people who joined us later will see it.)

Davai--

That's absolutely right. Thank goodness, you actually read the plan.

Could I ask everyone on this thread to PLEASE scroll up and read the detailed description of Hillary's plan that I've posted under the headline "Update"??

Because many of you haven't read it--or the plan itself--there is a lot of misinformation in these comments--which is distressing. Usually our thread on this site is so good. But in this case, people are making assumptions without looking at the plan.

For example, it's true that Hillary has taken a lot of money from insurers. And, boy, are some of them feeling burned now. From what I can see, by forcing them to compete, on a level playing field (no cherry-picking, no charging more or refusing to cover if a patient has a pre-existing condition) , and by regulating what they must cover, she is going to regulate them out of existence.

No, sadly "healthbeat.org" was already taken, so my handlers here (at The Century Foundation, a progressive think tank that is sponsoring the blog chose www.healthbeatblog.org. (Even I find it hard to say, but changing at this point would be too complicated. )

Corvid--

    Hiillary's plan express bars insurers from denying coverage to people with existing conditions. And it caps how much they can charge by forcing them to compete, on a level playing field, with a Medicare-like public sector plan.

    Please read my newest post (from yesterdaY) on this blog headlined "Update: Hillary's Plan" before jumping to conclusions.

repeats above

Art Appraiser--

    But $503.50 a month is the cost of providing heatlhcare for people over 65. Keep in mind that a huge chunk of our nation's health care spending comes during the last six month of life!

   The cost of providing coverage for people under 65 is much much lower, so the premiums will be much lower.

   Keep in mind that Hillary's plan doesn't say that people under 65 will have the option of going on Medicare; rather they will have the option of picking a plan that is like Medicare--public sector, offering comprehensive coverage, etc.But it won't cost as much as Medicare to cover them.

Don Bacon--

    I'm afraid you are wrong.

    Clearly you haven't read Hillary's plan (or my 2nd post about the plan) and as a result you're spreading misinformation on this thread.

    Hillary's plan specifically bars insurers from denying medical claims (or charging more) because of pre-existing conditions.

repeats above

On my trauma and critical care mailing list, many of the more respected physicians speak of VOMIT: Victim Of Medical Imaging Technology. There are several dimensions of this. Don't get me wrong -- a knee MRI may be totally appropriate for you.

There is increasingly widespread concern about overuse of what can be lifesaving medical imaging. At the silly end, virtually anyone going into an ER with an injured ankle will be sent for an X-ray. Unfortunately, X-ray information is likely to change treatment only if there is an actual break. There is a widely accepted set of physical examination criteria, called the Ottawa Ankle Rules, that quickly gives a clinician a quite reliable way of knowing if an ankle is broken or not.

I've been in a couple of situations where I was in so much pain that I couldn't insist on what I knew was the correct approach. In the case of one ankle injury, I knew it was broken within a couple of minutes of catching my breath (kudos to my late and beloved cat, Clifford, who protected me from a well-intentioned helper that thought massaging my leg was a good idea). In this case, I went from primary care provider to ER to orthopedist. Had I been in less pain and thinking more clearly, I would have called my orthopedist and gotten an emergency visit.

I'm by no means expert on knee injuries, although I suspect I'm getting some arthritis there. In some cases, I suspect, the MRI may not give information that really would affect treatment: a good orthopedist may be able to make the call, on physical examination, whether to use conservative treatment and physical therapy, or if you are going to need arthroscopy (which is diagnostic as well as potentially curative). [please excuse me, but I cannot resist one of my favorite lines: the orthopedist doing an arthroscopy on the knee of an especially lovely and graceful gymnast, who said, sadly, "what's a joint like you doing in a nice girl like this?"

Yes, healthcare is expensive. Sometimes, and remember I build technical medical systems, there's too much dependence on expensive technology. After a fall on my knee, my lower leg became hot, swollen, painful and red. Coupled with some other clinical information, that was 99.999% likely to be cellulitis, a soft tissue infection. Theoretically, there was a risk it was a potentially lethal condition called deep vein thrombosis (DVT), but I considered that a risk that, uninsured, I was willing to take. My orthopedist saw it first but was unwilling to risk it being DVT. My primary physician, a cardiologist, wouldn't do an office ultrasound to rule out DVT. In the ER, the physician asked what I thought I needed, and I told him the appropriate antibiotic and pain meds, but he said he felt he had to have the ultrasound. Bluntly, everyone was practicing defensive medicine, and I didn't need an $800 ultrasound.

The other aspects of VOMIT including treating a patient because the radiologist sees something suggestive on a scan, but there's no other evidence to support that diagnosis -- watchful waiting may be more appropriate. Yet another aspect is that not all imaging is benign. CT is absolutely essential and lifesaving at times, but it gives enough radiation that the population of patients that have had CT are at higher risk for cancer. MRI itself is pretty safe, but the gadolinium contrast agent often used, thought safe, has now been demonstrated to present risk to the kidneys.

All of medicine is balancing risk and benefit, and some of the risk being balanced is defensive testing to protect in a future malpractice suit. Do any of these plans address malpractice reform, taking on the trial lawyers as well as the insurance companies?

--
Howard

*equal opportunity offense to both extremes*

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

Howard--

    A few weeks ago, in a speech that she gave at Dartmouth, Hillary came out strongly in favor of "shared-decisionmaking"-- a process which lets the patient participate very actively (with much info on risks and benefits) when deciding whether to have a test or elective surgery.

  What's interesting is that the state of Washington recently passed a law which says that if a doctor participates in "shared decisoin-making" (using accredited video, pamphlet, etc.) his exposure to a malpractice suit is greatly limited.

    I have an article coming out about shared decision-making and will be writing about it on my blog.

That is the real attraction of single payer isn’t it? The ability to shift the cost of health care for the vast majority of people onto someone else. Cost savings and better quality care are just talking points.

But Maggie, my pereption is that people in the top 1% hardly pay any taxes at all.  My concern is that the burden will fall on the middle class.  Look at Social Security:  the cut-off for contributions is absurdly low.  A person making $55,000 annually contributes the same to Social Security as someone making $1,000,000 plus! 

I have no faith that the "progressive" health care contribution would actually be progressive, especially if it is linked to taxes.

***The only year I ever had to pay the Alternative Minimum Tax was when I had a mastectomy for breast cancer and had thousands of out-of-pocket medical expenses.  Somehow, I knew that the Bush's didn't have the same problems.  My income was nowhere near the upper 5%, but I felt like I had to bear a greater burden than was reasonable. 

By the way, unless I am mistaken, Robert Brown didn't say that the top 5% are paying 50% of the taxes; he just said that 5% are paying it.  I may be wrong in my reading of his points, but if it is TRUE that the richest are paying a higher percent, I am fine with that.  I just don't believe it.

Is it true?  Not according to what I have heard.

Jan

Yes of course I am sure there is cost shifting going on in our current system, but I think that shift is rather broad based. Mahar would like to pay for health care with a tax that is more progressive than our current federal income tax, I don’t think the system we have could ever be that progressive.

Real-world example from a few years back: if I had paid "list" (i.e., self-pay) hospital charges for my pacemaker, the bill would have been $24,000. I was under an ERISA program administered by Aetna/US Healthcare. The total hospital reimbursements, including my copayment, was $1,800.

Sound broad based or fair?

It's very easy for a victim of a drive-by shooting in a bad part of town, possibly someone malnourished or with drug problems, to run well into the hundreds of thousands before they are stable. Under EMTALA, the hospital has to eat that. Where will some excellent big-city hospitals, medical school affiliated, find the funds other than cost-shifting to people that are accessible as revenue sources only because they need to pay hospital bills? Those other patients are no more guilty than the rest of society for the victim getting shot. A police officer shot under the same conditions would get line-of-duty reimbursement. Some jurisdictions have victim assistance for the emotional aspect of being a crime victim, but I don't know of many that will help pay the cost, to someone totally uninvolved with the crime, of expenses shifted to them.

--
Howard

*equal opportunity offense to both extremes*

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

Am I correct in reading that you believe that the unmet costs has to be passed on as part of the premiums of all insured, rather than the present practice of marking up the bills of those who happen to be receiving services? Now, if it is passed on to all, as a result to a mandate without specific funding, why should that cost be tied to the insurance system at all, rather than national health costs?

Indeed, should other health costs, such as medical and public education, which might actually reduce costs, come out of the premiums? How should research be funded, especially if it leads to commercialization?

--
Howard

*equal opportunity offense to both extremes*

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

It's not passed on only to those who have insurance. It's passed on to those people being billed by the hospital, except that the self-pay/uninsured have no economic leverage to get discounts, so their bills contain a proportionately greater fraction of the shifted cost. Medical charges to uninsured people with income or assets, I understand, is one of the major causes of bankruptcy. That isn't helping the overall economy.

Never forget that insurers, and I do include Medicare, do not necessarily pay the true cost of services. I'm absolutely in agreement that some prices of services are greatly inflated (although discounted to the largest insurers), and that some high-price services should not be used.

Medicare recently declared that they would not pay for the treatment of hospital-acquired (i.e., nosocomial) infections. Even with the best infection control, these are going to happen on occasion. It may not be any failure in technique or equipment, but that the patient already has the organism acquired (really community-acquired) in their systems, and the disease that puts them in the hospital drops their existing defenses.

Policies like this are adversarial, and Medicare does other things along that line, expecting that hospitals and providers will respond with greater efficiency. Medicare doesn't compensate for actual materials and services, but a fixed payment for a disease in a "Diagnostic Related Group" (DRG). In the real world, that may cause a slight surplus for people who have very mild cases, breakeven for moderate, and moneylosing for severe.

In one hospital with which I work, the most common DRG is congestive heart failure (CHF). We've indeed come up with some efficiencies, but CHF often reflects several simultaneous disorders and can be very expensive to treat. In end-stage CHF, although some patients might get heart transplants or artificial hearts, we are rapidly getting into how aggressive the care of a terminal disease should be. I mean aggressive in the sense of disease-modifying (curative) rather than aggressive comfort care (an ethical imperative).

--
Howard

*equal opportunity offense to both extremes*

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

Howard-

   I tend to think that Medicare should refuse to pay for hospital-acquired infections AT HOSPITALS THAT ARE OUTLIERS AND HAVE EXTREMELY HIGH INFECTION RATES. I'm guessing that, in many cases, these are hospitals that need to be closed. (In some cities, we have too many hospitals--and a fair number of very poor hospitals. For political reasons, it's hard to close a hospital, but if Medicare started penalizing poor hospitals for high infection rates, medication mix-ups, etc., they might just naturally go under . ..

Jan--

   I entirely agree that the cut-off on income taxed for social secuirty is absurdly low.

   When it comes to regular income tax, however, I'm pretty sure that Robert is right: the top 5% pay 50% of the taxes.

   But that doesn't mean that they pay an equitable share when compared to the middle-class. Rates for the top 1% and teh top 1/2 % are too low (compared to rates for people earnign $75,000). And if you are very, very wealhty, there are still some great tax loopholes.

   When it comes to loopholes, there are way too many ways to avoid estate taxes, which leads to the concentration of wealth in a relatively small number of families.

.

My variant, especially when I am in a teaching hospital, is to run off 20 copies or so of a two-page (couldn't get it to fit on 1 any more) medical history, with every tweak of a good EMR that I can think up. Conditions in prior medical history are color-coded with the matching drugs, and so forth. When a particularly innocent med student wakes me up for a history, I hand them a copy and tell them that's their report and I'm going back to sleep.

The writeup, however, also gets repeated questions from some of the staff, as to which doctor wrote it. I tell them I wrote it, and then deflect any clear statement as to my being, or not being, a physician.

While it again requires a conscious patient, also in teaching hospitals, there are dominance rituals that can be worked out to one's benefit. When I was in Georgetown for my first angioplasty, unfortunately in the first week of July (when the new academic year starts), I put up with the first three or so residents. An especially pompous cardiology fellow then trooped in, followed by an entourage of students, residents, and camp followers.

"And how are we today, Mr. Berkowitz?"

"Well, I can tell you about myself, but as far as you, why don't you strip and let me examine you, and I can give you an informed opinion?"

*cough* *harrumph* (many grins starting among the procession) "That won't be necessary. What brings you to the hospital today?"

I responded, in a monotone more or less appropriate for a Grand Rounds briefing, with a well-organized presentation, in the third person, about my history, symptoms, test results, and differential diagnosis. Bigger grins.

He was starting to move back, perhaps hoping to grab the crucifix off the wall and sprinkle me with holy saline. "Umm..you certainly seem to know a lot about your disease."

"Yes, that's true." Switching now into my best pompous tenured professor voice, "And now, doctor, you will, of course, have noticed some inconsistencies about my potassium metabolism. Would you enlighten the group about the differential in that case, and your opinion on whether or not we might be dealing with an atypical Conn's Syndrome?"

He turned and jogged out without another word, and the giggles were now audible.

--
Howard

*equal opportunity offense to both extremes*

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

Logico--

     You make a very good point. If we reformed campaign contributions  we would have a much better shot at true health care reform. The lobbyists (and the big contributors behind them) represnt the real barrier to health care reform.

     But in this country, money has so much power that I am very discouraged about the possibility of campaign reform.

     This is why I am inclined to go directly to heatlh reform. This, at least, is something that most Americans understand: our health care system is broken. I don't think that the majority would be as quick to accept the propositon that our elections are rigged in the sense that whoever gets the biggest contributions usually wins..