"I’m afraid what will end up happening is, all businesses will drop their health insurance plans telling their employees to look elsewhere." Sounds like they're being required to "begin or continue to offer coverage." If employees choose another option, it does get them off the hook, but that'd be a sign of the plan's success, no? 

Like Maggie, I'm heartened by the resemblance to Edwards's plan.  If we're building some kind of consensus like this leading up to the election, it'll be that harder to stop once a Democrat is in office.

John 

http://www.haberarts.com/

  Coonsey,

     The plan doesnt let employers off the hook. The plan says:

l"Large employers will be expected to provide health insurance or contribute to the cost of coverage: small businesses will receive a tax credit to continue or begin to offer coverage."

If large employers don't continue to offer coverage they will  have to Pay INTO A FUND THAT WILL FINANCE ALL OF THE OPTIONS INCLUDING THE  Medicare-like option.  

As for small employers, while the tax credit will help them they will have to offer comprehensive insurance (equal to what Congressmen get) or pay into the fund. Today, many small employers don't offer any insurance--or if they do, they can only afford inexpensive bare-bones insurance. The tax credit will help them buy better insurance, but probably will still wind up spending as much as they do now (if they offer coverage) or more (if they don't now offer coverage.)

 Howard--

    A wonderful ditty. And yes, I think we do need more unbiased reserach establishing the efficacy of varoius surgical methods. Though I would add that what works best for one surgeon may not work as well for another. By and large, you want a surgeon using the method that is most comfortable with--and has used many many times before.

   But when it comes to new procedures, I think we need to look at electronic medical recoreds and check outcomes to see if new methods seem to be working at least as well if not better than older methods.

Well, for me, you have apparently inadvertently figured out the little shove towards single payer inherent in the plan.

BTW, your health insurance is part of your salary, that's the way we self-employed have always seen it, now you get to see it that way too. They buy it and deduct it or you buy it and deduct it, what is the difference there? Up until now, the difference has been that they can buy and bargain for a group and you cannot. The only problemo is getting them to give you in money the money they spent on health insurance. And Maggie's reply below says with Hillary's plan that if they don't want to buy it for you they have to put a certain amount of money into a fund for you.

P.S. Do you like the idea of being stuck at a job you don't like because you have a pre-existing condition and cannot change health insurance cos.?

Maggie,

It still seems like the employee loses - employer will likely opt to pay into system - saves on paper/computer work keeping up to date with insurance forms/plans - less ITS work to do.

Coonsey's View

HTTP://WWW.FREEWEBS.COM/COONSEY/

fyi: Here is a quickie analysis of Hillary's plan from Don McCanne's at Physicians for a National Health Program:

http://pnhp.org/news/quote_of_the_day.php

Hillary Clinton’s proposal “preserves existing health insurance,” and includes the responsibility of individuals “to get and keep insurance” through the current private insurance market, or through a “Health Choices Menu” of private FEHBP-type plans, or through a Medicare-type public program.

Thus her proposal is an individual mandate to purchase private insurance that is no longer affordable for average-income individuals, or to purchase a public plan that will be even more expensive because of adverse selection.

To make the plans affordable for individuals, she would use a combination of refundable tax credits and a cap on premiums at a percentage of income. Assuming that the plans would provide adequate benefits and adequate protection against financial hardship, the increased spending through the tax system would be exponentially more than the estimates in her plan. And most of the proposed savings to pay for these increases are largely nebulous, and some of those measures would actually increase costs.

Further, the administrative complexities of refundable tax credits and means-tested premium caps would still leave many without coverage. Coverage will never be universal unless it is truly automatic for everyone.

If we are going to use the tax system to pay for health care anyway then why should we waste funds on the profoundly inefficient system of segregated private health plans? A universal risk pool that is equitably funded through the tax system is the most efficient and least expensive method of ensuring comprehensive coverage for everyone.

Many will try to contrast the differences in the Clinton, Obama and Edwards proposals, but they are all basically the same. In spite of their rhetoric, they have each made the protection and enhancement of the private insurance plans a higher priority than patients."

I would only disagree with Don insofar as saying that Obama's plan is significantly even less than this, and Edwards a bit less bad. A pleasant surprise that Hillary's is offering something this "bold" and not a surprise that it is more subsidy and support for the private for profit insurers that have given so much to her campaign.

Once again, time to point out that Medicare overhead of 3-4% versus the private for profits overhead of 15-20% is $350 billion not going to health care, but going to an unneeded middleman. Plus further savings by not having the paperwork involved in determining and rejecting eligibility if everyone is eligible, and all the many other reasons single payer is the way to go to provide Universality & Comprhensive coverage & Cost-control.

I'm a bit of a novice when it comes to health care issues (relatively healthy, and I've always been covered by employer health insurance), so I'm approaching this subject at a disadvantage.

A quick glance at the major candidates proposal comes down to HRC/Edwards requiring insurance and offering tax credits to "working" families and Obama having no mandate and working to keep costs down through other measures. So essentially, all the same plan with two requiring coverage by all (sucks for the youth and healthy) and tax credits.

I've always been leary of "tax credits" to offset the costs of a particular item, since a person always incurs the "cost" of the service long before they can claim the credit. So, if I understand it, a person has $10,000 in medical bills in 2007. He or she can claim some credit on his or her 2007 tax bill (in 2008). How does this help the person in 2007 when the monies are due? What if there income is too low in 2007 to qualify for the credit? Wouldn't it be better if the system lowered the premium for those individuals (the rich and upper middle class subsidize the cost)? Or if the Medicare/public piece is supposed to be an equivalent to private insurance, why not automatically enroll them so it is transparent to them (same difference, subsidize the cost)? Is there something I'm missing here?

DrSteveA

While it probably won't happen I am for single payer "Medicare for all" but I would modify HR 676 to include much more individual AND institutional prevention

I wrote to my Congressman Pa Murphy (DEM -PA-8th) on my blog

Be Well,

Dr. Rick Lippin
Southampton,Pa
http://medicalcrises.blogspot.com

Howard and Maggie

GOOD FOR YOU!

Surgeons and surgery has definitely gotten a free ride for far too long.

So many surgical procedures are unnecessary and many are downright dangerous. Need I just mention hysterectomy and back surgery as models of abuse?

It's about time we make them accountable!

Dr. Rick Lippin
http://medicalcrises.blogspot.com

I agree. Tax credits are a gimic for people who make enough money to need a tax shelter. People who don't pay for professional tax assistance often miss out on the credits entirely not understanding when they do or do not qualify for them. Another pay off to the tax preparation lobby?

While it was in reference to drugs, I'm reminded of Sir William Osler's comment, IIRC, that the best time to use a drug was while it was still believed to work. Admittedly, there's much more chance a new drug will actually do something today, but the side effects tend to meet his criterion -- not fully understood until Phase IV surveillance. In fairness, some side effects won't show up in any statistically significant way until you deal with the populations after market approval.

While there are a lot of surgical procedures that can get into question, I'm thinking of some of the gyrations about the internal mammary artery. At one point, before CABG was common, someone had the seemingly bright idea that ligating the internal mammary arteries would somehow force blood into the coronary circulation. Didn't work.

When I had my CABG, after reocclusion after two PTCAs (pre-stent, but let's not go there), the grafts were all from the left saphenous vein. I had a very experienced surgeon, who I still respect greatly. Given the usual attitude of cardiothoracic surgeons ("what's the difference between God and a cardiothoracic surgeon? God doesn't think he is one..."), when he learned I was interested in the details and understood them, he spent an hour and a half on the phone with me one preoperative evening, promised to get back after he checked some references, and did.

Anyway, he explained that he was planning to do all the grafts from the saphenous vein, because I was still pretty young, and he expected to get 10 years out of the vein grafts. He wanted to save the left internal mammary artery for the reoperation he expected to do later.

Well, two of the four venous grafts reoccluded in six months. We now know that if the mammary artery is used to start, it rarely occludes, and reoperation probably would not be needed. (certain details skipped).

I can't really say that anyone could have predicted that until there was a large data base for retrospective studies. Still...

--
Howard

*equal opportunity offense to both extremes*

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

IIRC, you are a little older than I am. Still, I remember house calls and direct payment.

As I was growing up, there were more and more diagnostics and treatments that really did something. Yet, in the sixties, my father was a cardiac cripple and dead at 42. Given similar genetics and early onset of cardiac disease, by the time I had the problems, there were real therapies. I had a birthday a couple of years ago, and I've made it at least 17 years more than my father. I don't think it was only that I'm a nonsmoker.

Developing these techniques, and I fully understand the roles of federal & academic research, overmarketing by pharma, and the like, isn't cheap. In my medical library, I cherish a 1934 book, privately printed, called Modern Office and General Practice. I cherish it because, IIRC, every treatment suggested was, by present standards, either useless or actively dangerous.

The costs are greater now, but the benefits are greater. As Rick Lippin will confirm, the insurance industry also is not incentivized to do cost-effective preventive and chronic disease management. They don't do the former because they see the benefits as devolving to the next insurer, and, with a few exceptions, they tend to avoid the latter under preexisting conditions.

It's for-profit, largely unregulated insurance that is the core of the economic problem. Germany and Japan manage to make multi-payor work with tight regulation of insurers, many of which are nonprofit, and a government safety net. There are more ways to run a social good than by totally centralized federal control.

--
Howard

*equal opportunity offense to both extremes*

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

"P.S. Do you like the idea of being stuck at a job you don't like because you have a pre-existing condition and cannot change health insurance cos.?"

What state you live in?
I don't think this is the case for most states
where you can switch job and take all your -pre-existing conditions with you to a new insurance.

It's obvious that the only rational way to achieve a workable, affordable system is to get private insurers out of the picture or, as in countries like Germany, regulate them so heavily in the people they must insure, the coverage they must offer and the rates they can charge that they become de facto quasi public entities like utilities.

The bright spot in Hillary's plan, as in Edwards', is the "public plan option similar to Medicare." Ms. Mahar is right in that private insurers will have a difficult time competing in that atmosphere and very likely will gravitate to insuring only those who want and can afford options beyond the basic but adequate coverage offered by the public plan. That's fine with me. You want a private room with a gold plated bedpan and can afford it, great. Most everyone else will end up being covered by the medicare-like plan, which will be the rough equivalent of single payer.

Given the political power of the insurance industry this may well be the only road we have to get to an essentially single payer (with some other options) solution but it's a start. It will take some time for the private insurers to realize they can't compete and whither away or change their business models but in this environment we seem to have no choice.

As noted by others, the publicly financed medicare like plan option is the essential ingredient in this plan. Without it, it's just a full employment scheme for insurers.

I'm sitting here now with a tooth that needs to be crowned. I'm deferring the crown because I've already spent my FSA money for the year. Darn, but it's hard to guess how much health care you are going to need in advance! This is not wise. The tooth may not be worth saving by January.

If you are faced with making the mortgage payment or buying the health insurance, a future tax credit doesn't do you any good. The goal should be to have everyone covered every day.

My complaint with so many of these proposals and so much of the discussion is that we always lose sight of the goal -- health CARE. Instead, we inevitably fall into arguments over financial instruments - insurance, tax credits, tax savings accounts, employer taxes, employer paid fringe....

Some have posted on concerns about preventive care. I agree and I think we'd get further down that road if we could focus people on HEALTH.

Instead, we'll be off selling tax credits and insurance. And I won't get my tooth crowned because I've been sold the idea that I can get a tax break if I wait till January.

I assume that insurers would still have deductibles and co-pays of some sort, plus a monthly premium. My question is if the plan is to subsidize part of the cost (premium and or co-pays), then why not subsidize them on the front-end? A tax credit requires the insured to bear the cost of the insurance up front, which would create a barrier to entry.

you are correct -- group plans have NO PRE-EX. Individual plans DO have pre-ex and are impossible to get for about 25% of applicants. So, Hillary will have to force someone to offer individual plans to diabetics and heart patients. Unless you've got the bottomless bank account of a Medicare plan behind you, I'm not sure which private insurer is going to take on this risk.

I certainly agree Hoppy and would add one thing which is that in states where some minimum auto insurance is required (which I think is now most if not all states)the poor routinely are either uninsured or underinsured. In other words they either drive illegally or drive with the cheapest available policy (often liability alone)thus not really achieving the goal of the law.

Thus, once again, those who are most in need of the assistance insurance can provide are the people least likely to be fully covered. Whether the lack of insurance is because someone made a poor/unwise choice to be uninsured or they just flat out didn't have the cash it is a costly situation not just for them but for everyone. So even that system doesn't work in a universal manner. Unless and until there is universal healthcare provided to the citizenry we will all continue to suffer with a burdensome system that costs too much and doesn't meet the medical needs of the population just as the needs of the driving population are not met with mandatory auto insurance laws.

Not sure how that would be done, but an excellent question.

hoppy, you wrote: "If I am going to participate in such a level payment plan, lumping my health care costs with everyone else, one thing I absolutely don't want to do is pay a business a big chunk of those payments just for the privilege of being in the group. This must be a not-for-profit operation except for the actual health care providers, and as long as "insurance" companies are skimming the cream off the top we are being scammed!"

Yes, exactly. Which leaves me a little confused about your proposal in Maggie's earlier thread to allow private insurance companies to bid on doing the administration and other paperwork that would be wholly regulated by the government(which I may have misunderstood earlier). There, you wrote:

"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." (end quote)

Competing for the contract should serve to keep that cost down. But if it's a private company, doesn't that be definition it means it is for profit, and therefore, if it is a company of large size, under pressure to provide dividends to shareholders or otherwise divert costs from what is required solely to do the administration they are hired to do?

This is why the folks administering single payer plans should be employees of the federal government (or perhaps of some nonprofit organization, but wouldn't the potential lack of stability in such an arrangement be a fatal drawback?) Same argument holds, it seems to me, for why airport security folks should be government instead of private-sector employees. I thought artappraiser was getting at this same point in Maggie's other thread as well.

My political observation is that seeing Clinton try to co-opt the health care issue he wanted to make his explains Edwards' lashing out at her yesterday while also noting that imitation is the highest form of flattery. One of the reasons I wanted him to push a straight out single-payer proposal. I didn't think there was any chance Hillary would do that.

He and his supporters can point to all the campaign contributions Hillary gets from insurers and other health care interests. But, for all that, the burden now shifts to him to show what his greater independence on health care interest group contributions might get the public if he wins.

The Clintons' theory of campaign finance clearly seems to me to be twofold:

i) getting public financing done requires a great deal of political capital, with no certainty of it leading to better policy results that improve peoples' lives. (true, in my view, which is why it's a bad issue to focus on as a new Administration's first priority, I think)

ii) if you take campaign contributions from everyone you have just as much freedom to do what you want as if you take it from no one (incorrect, because many of the people affected by policy decisions do not have powerful lobbies able to contribute big money to campaigns and have representatives at the table when the decisions are made and the deals get cut. But a very convenient practice for improving one's chances of winning when most unorganized voters are not participating and have no faith any of the candidates will really speak for them in the closed rooms where the decisions get made.)

Edwards has been pushing Hillary and Obama on Iraq. Obama's people surely want him out early with the hope that if he can pick up most of Edwards' support he'd have a chance against, presumably, Hillary. It will be interesting to see if Edwards has a response on this latest development on the health care issue. Obama, too, as Hillary now has positioned herself to Obama's "left" on health care during Dem primary season.

This is just great. As a self-employed American, I already can't afford health insurance, and now some clueless, filthy-rich bimbo with NO CONCEPT of what it's like to struggle to make the rent wants to FORCE me to come up with money I already don't have? Just fucking great.

Screw her. If this is her plan, I'll oppose it (and her) with everything I've got. I'll vote Republican before I'll support this.

If she wants to fix health care, she should fix it. Making it MY problem by forcing me to pay for something I already cannot afford is not fixing anything. Let's watch her poll numbers. I suspect this plan is going to be enormously unpopular.

This is why I find myself asking why we don't have younger people in an "insurance" plan that is really a savings plan, whose purpose is to pack away the "insurance" money for a rainy day.

When I was young, my employers and I paid into pay-as-you-go plans, and the essentially zero requirements I had for health services were completely covered.

Later on, with a few (thankfully very minor) difficulties of age, I actually need health services, and now that I am no longer easily employed, I pay much higher fees for insurance out of a far far smaller income.

For the second time in my life, I wish I could go back to my own history and make a suggestion to that younger guy: "start saving NOW. Once you get to 50 or so, the deal will change, all the money that was poured into the system due to your economic activity will be totally gone and you'll be on your own.

That change in plans is what really gets my goat: It was all great paying into the system when I didn't need it, but now it's way more expensive exactly when my ability to pay into it is compromised.

So I haven't heard about the idea of "enforced" packing it away by young people, so they have something to rely on when they are no longer young.

This addresses the arguments I've seen from people who do not want to pay into "the system" because they are healthy and don't want to pay for others' bad choices. Health insurance could be much like a competently managed social security system: Contribute to the pool, and have a cushion for a time when it's needed either due to premature need (disability) or to natural progression of time (retirement).

Moreover, the plan guarantees that working families will receive a refundable tax credit designed to prevent premiums from exceeding a percentage of family income.

What part of this don't folks like Hillary and Edwards understand? If the poor could afford to buy health insurance, they wouldn't need these plans! For heavens sake, I can't afford to insure my kids on the WalMart plan now. Does a "tax credit" in April every year somehow help me pay it next week?

Tax credits are an absolute joke!!!!!!!!!!! They don't help me insure my children. Not now. Not ever.

If I could pay for the insurance, I wouldn't need a tax credit.

http://ajliebling.blogspot.com/2007/09/harry-and-louises-golden-years.html

Those who talk about private insurance companies competing with a government run system, talk about “comprehensive coverage” and “a level playing field”. By that I think that they mean that a minimum level of coverage would be required of all policies, thus making it illegal for private companies to offer low cost, catastrophic only coverage. If the level of comprehensive coverage is set high enough, it would make it difficult for private companies to differentiate themselves by product offerings but would need to compete only on the efficiency of delivering a commodity product defined by the government.

You are pointing out the problem with having health insurance paid by employers. If people could buy a long term policy when they are young, they would be effectively paying for the statistical probability of needing expensive health care all through their life. Unfortunately, now they effectively loose everything they have contributed when they change employers.

I'm guessing that he does know that but would put forward three objections:

1) That the threshold for subsidies or assistance would be too low.

2) That even if the government paid say, half his costs, paying the other half would be too much.

3) He doesn't want the government telling him what he has to buy.

Obviously, I'm speaking for him and he might agree with none of that, but those are probably three legitimate concerns.

thosethingswesay.blogspot.com

Here's the part you just don't seem to get:

I can't afford to pay insurance premiums. Not at any price. Every penny is used to pay for necessities - you know, like rent, food, heat.

A once a year "tax credit" still won't let me pay for that insurance which Hillary is suggesting should be mandatory!

We currently pay $80.00/month for employer sponsored health care for my husband - just to pay for the medications he needs to keep him alive.

That $80.00/month will pay 2 natural gas bills I have sitting on my desk right now.

Do you have to make those kinds of choices on a daily basis?

repeats above

Ammasdarling and Coonsey--

First, I agree with you Ammadarling, Hillary's vote on Iraq makes me very  uneasy. But she wasn't the only one. So many supposedly intelligent progressive Congressmen voted for the war. Bush had done such a good job of convincing the American people that they were in imminent danger of being attacked by terrorists, and that Iraq was somehow tied to the 9/11 bombing.  (Everytime I go through an airport and am forced to take my shoes off, I feel I'm being subjected to Bush's brainwashing. He wants us to feel that we are in constant danger.)

Bottom-line I don't give Hillary a pass on Iraq. And when I compare her to Edwards, I really don't have a favorite. His health care plan is similiar to hers, and I very much like his emphasis on poverty.

Coonsey--

Employees don't lose if employers save on paperwork. The fact that someone else saves money doesn't mean that they have taken something away from you.

And I'd just as soon see most employers get out of the healthcare business. Most don't know enough about heatlhcare to pick good plans. (I don't blame them--this isn't their business.) And most are more interested in finding a plan that will give them a good discount than in finding a plan that will ensure high quality care.

Hillary's plan insists that all insurance policies must provide coverage that is at least as could as what Congressmen now receive.

Ammasdarling and Coonsey--

First, I agree with you Ammadarling, Hillary's vote on Iraq makes me very  uneasy. But she wasn't the only one. So many supposedly intelligent progressive Congressmen voted for the war. Bush had done such a good job of convincing the American people that they were in imminent danger of being attacked by terrorists, and that Iraq was somehow tied to the 9/11 bombing.  (Everytime I go through an airport and am forced to take my shoes off, I feel I'm being subjected to Bush's brainwashing. He wants us to feel that we are in constant danger.)

Bottom-line I don't give Hillary a pass on Iraq. And when I compare her to Edwards, I really don't have a favorite. His health care plan is similiar to hers, and I very much like his emphasis on poverty.

Coonsey--

Employees don't lose if employers save on paperwork. The fact that someone else saves money doesn't mean that they have taken something away from you.

And I'd just as soon see most employers get out of the healthcare business. Most don't know enough about heatlhcare to pick good plans. (I don't blame them--this isn't their business.) And most are more interested in finding a plan that will give them a good discount than in finding a plan that will ensure high quality care.

Hillary's plan insists that all insurance policies must provide coverage that is at least as could as what Congressmen now receive.

Agreed. Tax credits are about the suckiest way to pay for anything, especially a necessity.

DrSTeveA--

   I'm afraid that the PNHP analysis is terribly misleading. I know so many doctors who have dropped out of their organization because they are such ideologues--with only one idea, their plan.

    I, too, am in favor of single-payer. But the fact is that there are not enough Congressmen in favor of it and there are not enough American citizens in favor of it.  Americans are very way of government involvement in anything. (And given what has been going on for the last 7 years, how can you blame them.) I like single-payer. You like single-payer. But we can't shove it down the American public's throat. And if we try, we might lose health care reform altogether. We could even wind up with another TV star in the White House.

But-- HILLARY"S PLAN OFFERS A VERY INTELLIGENT BACK DOOR TO SINGLE PAYER AND IT PUTS FOR-PROFIT INSURERS IN AN IMPOSSIBLE POSITION.

Don of PNHP suggests that the public sector plan will be very expensive because of adverse selection (with all of the old and sick people who have high medical bills choossing that plan) while the private sector plan takes all of the young and healthy people.

Did he not read Hillary's plan? Or is he deliberately lying? (I hope it's the former)

Her plan very explicitly says that for-profit insurers will not be able to turn down sick people or charge them higher premiums because they are sick or are expected to become sick. Moreover, her plan says that all insurers will have to offer the same comprehensive insurance that Congresmen have. If I were sick, that is the coverage that I would want.

Right now, for-profit insuers are allowed to "cherry-pick" health customers, turning down people with pre-existing conditions --or charging them exorbitant premiums--in all but five states. This is how the majority of insurers make their money. They also make money by selling essentially worthless Swiss cheese policies filled with holes.

Hillary's plan won't let them do either of these things. How then will they stay in business?

Under her plan is no way that private insurers will wind up with the healthy young people while the public sector Medicare- like plan is filled with the sick people. I don't know how many different ways I can say this: her plan outlaws cherry-picking by private insurers.

Both the for-profit private sector insurance plans and the public-sector Medicare-llike plan will have to offer insurance to all comers, without penalizing those who are sick, and they will have to offer the same comprehensive insurance to everyone.. What then will be the difference between the for-profit plans and the public sector Medicare-like plan?  

The Medicare-like plan will probably cost less because Medicare doesn't have the high administrative costs (advertising, the need to distribute profits to share-holders, 7-figure executive salaries, etc.)

So both health people and sick people are likely to choose the Medicare-like plan. Meanwhile, many for-profit insurers will simply drop out of the competition. If they can't "cherry-pick" healthy patients, they won't be able to compete.

What does this leave us with? After a few years probably the vast majority of Americans will be in the public-sector Medicare like plan BY THERE OWN CHOICE. Inother words, they will be in a single-payer system where the payer is the government (funded by employers, wealthier tax payers and middle-class taxpayers who will pay no more than a certain percentage of their income toward healthcare premiums.) .

Hillary is also counting on the savings generated by  an independent Comparative Effectiveness Institute which will weed out over-priced ineffective treatments, drugs and devices. These savings are not "nebulous" --as anyone who has read the Dartmouth research knows.

For this you would no doubt be treated just the way you would be by a Democratic Congress & administration for your other taxes, at your income level. How are you able to "pay" your taxes now? They are deducted from most people's paychecks, which is adjusted for income level, and number of dependents. Some people end up getting more back than the small amount deducted.

If you are year after year getting a big refund check from taxes that you have actually paid, you need to check into changing what is being deducted.

It may be that you & your children may be covered for nothing from you at all if your income is low enough.

Your concerns may not be best served by fighting a plan such as this in principle, but in fighting for what you think are the correct income level cut-offs.

Also, do you think you are low income enough that if single payer was adopted, your taxes would not go up? If so, then then costs will probably not change much for you with this either.

Think about the alternative of leaving health insurance as it is, is that working out for you? Many employers are still offering insurance, but getting real itchy about it, raising the amounts employees have to pay, changing to plans with higher deductible, stuff like that.

What part of this don't you understand? There is no money left to pay for mandatory health insurance.

And, are you aware that any income disqualifies folks from medicare? Yeah, my husband was on medicare after he had his heart attack. And, thank to "welfare reform," at the end of 2 years, he no longer qualifies - not even for prescription assistance. 2 years and you should be dead, evidently. Because at the end of that 2 years you're gonna die anyway when they cut you off.

Have you ever taken a family member to these doctors who are a part of the "free" medical system? In a medical emergency, they couldn't see my husband for 3 months. They told us to go to the ER if he needed to see a doctor sooner than that. That medical emergency was a hospital acquired MRSA infection from open heart surgery.

I suspect an awful lot of people, including Hillary Clinton and John Edwards are unaware of what medical care means for the poor. When Bill Clinton had his heart attack and subsequent surgery, he didn't have the issues my husband is now enduring for the same illness. And Elizabeth got the best care available.

Tell me why my tax dollars are paying for them and not for my husband.

There's another problem. Insurance companies call it "churn" when their covered individuals change employers, or, as happens not infrequently, the employer changes insurers.

From an actuarial standpoint, given churn, the benefits of preventive medicine are apt to save money for a different insurer, so why pay for it? The industry doesn't look at the possibility that if most insurers did it, the savings would even out. They may have a rationale for doing this, if they consider people that lose coverage.

To a somewhat lesser extent, many, but not all, insurers are reluctant to use case management with patients. Case management with providers is something else. Most often, case management is by nurses, often by phone, sometimes in person. They help ensure compliance with chronic disease treatment, try to spot exacerbations early, and sometimes (I was amazed when Aetna/US Healthcare did this after I got a pacemaker) even act as a patient advocate to the rest of the system.

Especially when the patient has a complex medication routine, there have been successful experiments with community pharmacists in this role. In general, however, insurers are not set up to compensate for the time and cognitive effort of pharmacists.

While there are other issues in phone and especially email communications between physicians and patients, this potentially cost-saving (in a global sense) mechanism is rarely reimbursable, so a lot of physicians don't do it. My primary care provider is fine with emails for me, as I write in a focused way, and, when relevant, do journal scans and give him a timesaving literature review (e.g., with the recent concerns over safety of the diabetes drug, Avandia).

--
Howard

*equal opportunity offense to both extremes*

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

Destor 23 and American Dreamer.

    First, Destor 23 --you're right. And I think the bulk of the for-profit insurance industry will wither way (or drop out) in much less than 10 years. 

   American Dreamer--and you are right, as the industry sees the handwriting on the wall, it will fight this plan tooth and nail--probably just as hard as it would fight single-payer.

   But the difference is that the insurance industry will have a much harder time persuading the American people that Hillary's plan is a threat to us. Her plan is all about choice. You can choose to keep the insurance you have. Or you can choose another private sector plan. Or you can pick the Medicare-like single-payer plan.

That isn't very frightening. By contrast, the majority of Americans are very wary of single payer. Americans are wary of governmentn involvement  in their lives. Many people explode if you just utter the phrase. You have to show them that government sponsored health care can be better--by letting them choose it themselves.

Finally, what can the insurance industry say when fighting Hillary's plan: "We don't want to have to compete with the government because we know we'll lose?  We don't want to have to insure sick people.?It's just not fair?"

Have you ever been self-employed?

Destor 23 and American Dreamer.

    First, Destor 23 --you're right. And I think the buik of the for-profit insurance industry will wither way (or drop out) in much less than 10 years. 

   American Dreamer--and you are right, as the industry sees the handwriting on the wall, it will fight this plan tooth and nail--probably just as hard as they would fight single-payer.

   But the diffrence is that the insurance industry will have a much harder time persuading the American people that her plan is a threat to us. Her plan is all about choice. You can choose to keep the insurance you have. Or you can choose another pviate sector plan. Or you can pick the Medicare-like single-payer plan.

That isn't very frightening. By contrast, the majority of Americans are very wary of single payer. Many people explode if you just utter the phrase.

Finally, what can the insurance industry say when fighting Hillary's plan: "We don't want to have to compete with the government. We don't want to have to insure sick people. It's just not fair!!"

Yes. Self-employed and uninsured.

Maggie, you wrote: "By contrast, the majority of Americans are very wary of single payer. Many people explode if you just utter the phrase."

I don't know single payer financing supporters who are hung up on the wording. In your experience do people have similar wariness when the phrase "Medicare for all" is used? Or when an approach is described as offering the same choices in health care for all Americans as are available to members of Congress? Especially if it is made clear in the course of asking the question that this means health insurance for all, not tied to one's job?

Been filling my own Schedule C's for over 20 years. Afforded health insurance in NYC for the first 3 or 4, with the tax credits & deductions. Then the group I was in, based on a professional association, kept getting switched and went up and up and up in premiums. I have done out of pocket ever since. I bargain for services. I don't like it. I would love to be able to be covered for catastrophic and do health savings account. But no one offers catastrophic to groups of one in New York state, they are no one interested in selling such a product here.

C'mon, admit it, you're angry about this because you're healthy and have few health expenses, right? Because if you're paying for any small amount of health care, you're probably already paying close to what you'd pay in premiums, especially if your income is so low. A "simple" blood test can cost in the low 3 figures these days. Deductions and different lower charges for low income will make it up if you truly can't afford it like you say.

You would be against single payer, then, too, right? Because it would show in much higher taxes to you, probably, oh, like at least $2/300 per month to every mid-income Tom Dick & Harry.

If you are truly living on a few hundred bucks profit a month llike you imply in this comment upthread the plans would probably cost you nothing. If it is rather the situation that you have extremely erratic income, you know your experiment at self-employment is a big gamble overall, and that's your choice, isn't it? If you have income so erratic that you have trouble making those quarterly tax payments consistently and regularly, couldn't it be due to something like the unfairness of life or your own incompetence at getting work or a recession in your field? Is it possible you might have to go back to the employer/employee model? Others who judge thatthey cannot work for themselves and make enough income, they should subsidize you in doing so?

So what you are saying is that you'd like to be free to not use health care when you need it? Libertarian? You promise not to go to the emergency room under any circumstances, unless you have a large cash deposit upfront, maybe we can put a rider in the plans that you get no fine for not participating in health insurance.

If you are in such financial dire straits, I can't imagine any Democratic plan not providing your health care for free.

Yes, those who advocate competition between private and government health care are not interested in productive competition, they intend to set the rules to drive the private sector out of business.

    This is a good point. Hillary has always been concerned about poverty, heatlhcare and children.

    She is a complex person. When Clinton was in the White House, I thought they both moved too far to the right. But she is entirely sincere about "It takes a village." And I think her ambition revolves around a desire to change the world for the better (rathern than a desire for money or power for its own sake.)

Re: And, are you aware that any income disqualifies folks from medicare?

This is not true. Anyone older than 65 can go on Medicare regardless of income. There are income limitations for persons with disabilities who are on Medicare; they are the same limitations for collecting Social Security disability.

KJ 593, destor 23 and bluebell--

    It's true that you don't get the tax credit until the next year. And if you don't have a lot of cash lying around, this could be a problem.

   But if you know you are getting a tax credit, you can reduce the amount of taxes withheld from your paycheck, giving you the money you need to pay he insurance  premiums. For instance, if I know that I'm earning less this year--and have more expenses than I had in the past--I might claim 13 dependents on my withholding. This means the IRS  withholds less (as if I had a lot of chldren). I won't have to pay a penalty as long as it works out that I didn't underpay my taxes--i.e. that in April  didn't owe the government any more than I did last year.

   This may sound a little complicated for anyone who is not an accoutant. But under health care reform presumably many employers (and their human resrouce departments) woud explain to people how to reduce their withholding to get the benefit of the tax credit this year.

Maggie, any of the plans presented by the Dems will undergo significant changes before enacted into law.

The Iraq War is the first concern, followed by universal healthcare as the big domestic issue. I'm not very interested in the various plans since what is enacted is often very different from what is proposed. I want the can kicked further down the road and it doesn't seem that Hillary is willing to use the political capital in her first 100 days (if elected, which is a big IF right now) to start the process.

That's what I find most troubling about Hillary--not committing until the first year of her second term? That's fairly self-serving, IMHO.

But many people who cannot wait for thier rebate don't earn enough to pay any federal income taxes so adjusting their withholding won't help.

Wrong. See Medicare premiums and coinsurance rates for 2007.

You & spouse can only get Medicare Part A (hospitalization) free of charge if you have paid into the system for 40 or more quarters. If you have paid in only 30-39 quarters, you pay a $226 per month premium for Part A. If you did not reach that level, you pay a $410 premium for Part A.

I believe everyone has to pay $93.50 per month premium for Part B (covers the non-hospital stuff.) Some may not be aware they are paying this charge because it is being covered by a Medigap policy they are in.

Medicaid is all that we currently have to cover the gaps. Its execution varies by state. My disabled brother's Medicare Part B premium, for example, is covered by Medicaid in his state.

I'm suggesting if you don't want to be a part of insuring all, you are screaming that being self-employed, you don't want to be mandated to have health insurance, that yes, you should not be allowed access to what everyone else is going to be paying for.

Low income will not be contributing anything for their insurance, but people like you will be, by offering to be in the pool and contribute an insurance payment adjusted according to your means. You want out of the pool because you're healthy, then you are taking from those poor that need it. Here's your chance to practice what you are preaching. Single payer would be the same thing. At a certain minimal level of income, your taxes would increase nearly the same.

We already all pay for Social Security, we all pay for Medicare, on our income taxes. You pay for Medicare right now, every time you pay taxes, you want to stop doing that? You want to opt out of FICA too, you will take care of your own old age health care needs?

This is 1/7 of the economy we are talking about. If you one of those who think, just have "the rich" pay for it all, tell them we are going back to 90% top rate and you are going to pay for eveyone else's health care. Good luck selling that one. And would that even cover 1/7 of the economy? Why do you think Social Security is a "third rail," why it is so popular? You are talking just like the people who want to get rid of Social Security, they'd rather take care of their own retirement and no one else's.

Really, your arguments are ridiculous and hypocritical--you can't have socialism for "everyone but those who don't want to be a part of it, like me." Doesn't work that way.

Mjshep--

   Thanks for the help--I 've been trying to say this all day and am getting hoarse.

There is no getting around the fact that wealthy people can afford everything they want, and they will spend on health, youth and staying alive (as will people like heads of state who will fly to the specialist needed wherever he/she is.) Most universal health care in other countries does not prohibit someone like Keith Richards from going to get placenta injections to try to stay young or buying your own kidney dialysis machine for your home with attending nurse. If one is to be realistic, this is where private insurance might recoup some business, just like with "medigap" policies. Destor's point elsewhere on this thread that the eventual congressional fights over such plans could end up being about debasing the inherent value of the government plan is therefore very interesting.

Roxanne--

     You're absolutely right. It's not the cost of the insurance that is the problem, but the cost of the product--that is being delivered poorly. (See my replies to some of the comments above.)

Before judging Hillary for taking insurance company money, I'd have to see what she actually does with the industry if elected.

Do you see the fatal flaw in that reasoning? If not, let me tell you: we surely have learned by now that it is a very, very bad option to suspend our judgment and elect someone obviously not suited to the office of President just to see how she performs.

Hoppy in Sacramento

Robert Brown--

    This is a "refundable tax credit" and I am pretty sure that this means that even if you don't have any income to pay taxes on, the government sends you the credit to use to pay for your heatlh care.

    If there is an accountant or tax lawyer out there, pls. correct me if I'm wrong.

SCHIP is well within the scope of work that Hillary performed on healthcare issues first in arkansas, and then in the WH. If you want evidence, read a real biography. Her participation in these issues is a matter of long historical record.

Hoppy-- come on.

   Even people who really don't like HRC don't compare her to GWB.

   (And let me repeat: I'm not at all sure that HRC is my favorite candidate. I really like Edwards. )

destor 23--

    I think in this case the government telling you that you must have health insurance is like the government tellin gyou that you must have auto insurance in this sense:

    If I don't have auto insurance and am in an accident, other people have to pick up the slack and pay.

    If I don't have health insurance and get sick (which is a certainty unless I die in my sleep) other people will have to pick up the slack and pay. (The hospital probably won't leave me outside on the sidewalk. When I'm really, really sick they will treat me. And then they will have to shift the cost to other people, boosting how much they charge them.)

artappraiser--

    Hillary's plan says that she plans to "plug the holes" in both Medicaid and SCHIP. She doesn't say how. And I don't remember what Edwards plan says on this point.

   For my part, I think Medicaid should be folded in with Medicare. The worst thing about Medicaid is that it varies so much by state (it should be a federal program) and it pays doctors and hospitals much less than Medicare for exactly the same treatment (as if treating poor people is somehow easier?? If anything,  many poor people are harder to treat because their lives are so complicated.)

Hoppy, and Everyone--

 Thank you for all of your comments. I'll come back tomorrow to see if there other comments that need a response.

This has been a very interesting discussion. We don't all agree, but that's fine. (And I admit I may be overly optimistic in my hopes for what HCR would do. I just so much want health reform to work.)