I'm with atrios. Send everybody a membership card. Let them use it.

If you want to phase it in, then start with everybody under 18. Raise taxes to cover the additional costs. The tax increases will be offset by reductions in premiums to people with kids.

Then drop Medicare eligibility to 50 years old, require everyone to buy some kind of insurance and float a federal catastrophic insurance plan with 2000 and 5000 dollar deductibles. Allow everyone to participate in the federal employees plan through direct enrollment.

The only thing that makes this complicated is that the participation of the insurance companies IS the heart of the difficulty, but politicians see some need to(read "get contributions to") protect them.

That's bad public policy. The insurance companies are the problem.

If we give up on the best plans before we even start the negotiating process we are left with plans like that in MA. It's failure is more of a failure of educating folks to push for the best. Cause third or fourth best will still be hard to empliment and maintain and they will not give the cost savings and sense of we are all in this together that the best plans offer.

How long as it been since anyone bothered about the loss of manufacturing jobs? I can't count the number of times some blogger (and usually a "progressive" blogger) has told me all those union stiffs are a bunch of dinosaurs who better get over it and get on with it and stop whining.

Vincente Navarro has said for years, that the greatest barrier to health care reform are big employers - insurance benefits are a form of employee control. How many people take jobs or stay in jobs because of the health care benefits provided?

Destor 23, Jay Acroyd, Bluebell, Dale JHaber, Larry Greater,BevD--

It's good to hear your voices.

Destor 23 and JHaber, I too very much like the fact that Hillary's plan (and Edwards) would force for-profit insurers to compete with a public program--supposedly on a level playing field.

That's the catch. As JHaber says, insurers would have to be tightly regulated, offering the same price to everyone regardless of whether they're sick or old, offering only comprehensive insurance--no Swiss cheese plans or catastrophic plans--otherwise older, sicker people will all sign up for the public plan and it will go under.

But Blendon is pointing out that unless progressives manage an exceptional (read historic) sweep in Congress, they won't have the votes to get regulation of the for-profit insurance industry. And keep in mind that these days, many Democrats are not that progressive.

The New Democrats of the 1990s went after the upper-middle-class suburban vote. And that vote brought many moderates to Congress who know that their constituents are worried about losing any of what they have. Bob Blendon says its the middle-class that is worried about losing something; here I disagree with him. I'd say it's the upper-middle class.

I don't think that most truly middle-class people (as defined by median joint income of $52,000 per household) are feeling that happy or secure with what they have. But many upper-middle-class people (defined as families with joint income of, say $70,000 to $110,000) do have pretty good insurance (or at least think they do.)

They are afraid of real health care reform. They don't want to see the system cut waste so that we can afford to insure everyone. They don't want Medicare (or private insurers) to tell them that it they want  a second MRI , a "cutting edge" $10 million procedure that has never been proven to be effective , or a drug they saw advertised on TV, they'll have to pay for it themselves.

 (Drug-makers advertise on TV when they can't sell the product directly to doctors because there is not enough evidence that it works. Did you ever notice how when a film isn't doing well at the box office, you start seeing a lot of ads on TV? Same phenomena. The companies only spends the big bucks for TV ads because they have to.)

And these moderate Democrats are backed by the for-profit insruance industry. Think Connecticut and the initials J.L.

Blue-bell--I, too, am very frustrated with how risk-adverse our legislators seem. But I should say that  I borrowed the phrase "grand compromise" from Paul Wellstone, the late, very left and very honest Senator killed in a plane crash. I recently corresponded with a   woman who knew Wellstone very well and talked to him about healthcare  a few weeks before he died. He also thought that change should come at the state level. (Then again, he came from a progressive state.)

I'm sorry to say it, but yes, there was a lot of compromise involved in the New Deal. In particular, FDR compromised with Southern Governors and legislators who insisted that the New Deal be segregated. In the WPA white workers and black workers did not work side by side. FDR didn't want to lose Southern Democrats. For the same reason, FDR refused to support an anti-lynching bill.

Some thirty years later LBJ decided that he was willing to lose the Southern Democrats in order to support civil rights legilsation. But of course LBJ made many, many other compromises along the way. Blendon's point is that you have to decide which group you are willing to compromise with.

When it came to Medicare, LBJ decided to compromise with hosptials and doctors and essentially cut them a blank check. (I tell the story in my most  recent post on www.healthbeatblog.org about national health reform. )

BevD--I agree that, for certain wealthy corporations, health benefits represent "golden handcuffs." Though that is not as true as it once was. Even at the wealthiest corporations, health benefits are not what they once were. (Unless the company is unionized. )

Jay Ackroyd--  Your suggestions are interesting. I particualry like rolling Medicare back to age 50 and letting people buy Medicare (with help from their employers if the employer now helps them buy private insurance.) But conservatives realize that this would open the door to "single-payor" healthcare. Many moderates (including Democrats) are against single-payor because the people who voted them into office do not want to find themselves in the same boat as everyone else. They would prefer to be in a tiered system because they are wealthy enough to feel confident that they would be on the top tier.

Larry Greater--You are right--, Congress is not going to vote to eliminate the private insurance industry. One reason is jobs. Another is campaign contributions.

Finally Dale wrote: "If we give up on the best plans before we even start the negotiating process we are left with plans like that in MA. It's failure is more of a failure of educating folks to push for the best. "  Dale, that's what my heart says. And I've been saying that for a long time. But listening to Blendon, I realize that you also have to count the votes in Congress. AS I said in the post, I'm not giving up on major reform. And I'm holding out hope for a Progressive sweep in Congress.

But I now think that the new Democratic president should also have a fall-back plan. Paul Starr is right--if he/she tries for something major --and fails--he/she will lose much of his/her political capital  And Republicans will try to lay the trap.

One path to universal health care is always ignored. That is to make Medicare a universal program, covering everyone. Medicare does not cover 100% of the medical expenses, especially not in high cost of living states, so it leaves an opening for the insurance companies to make money with supplemental insurance. That is an advantage.

Once we get universal Medicare coverage, we can start increasing the value of that coverage until supplemental insurance is only needed for plastic surgery, weight reduction, and other elective procedures. But, that still leaves a corner for insurance companies to make some money.

I don't see why this is not a workable method to arrive at our goal.

Hoppy in Sacramento

Maggie,

Thank you for your response.

I agree with the distinction you make between the upper middle class interests and middle classs interests. Democrats need to do a better job of directing messages at both. In Minnesota, Republicans have lost ground in several upper middle class communities including Rochester home of Mayo Clinic. They've lost because of quality of life issues on health and education. Upper middle class voters are generally highly educated. You can appeal to them on the importance of a quality health infrastructure. I don't care how rich they are in Texas, when George Sr. wanted his hip replaced he came to Minnesota.

But I disagree with you on insurance. President Reagan and President Bush came to MN because of the Mayo Clinic. They didn't come because it's the home of United HealthCare and the obscene compensation given to their insurance CEO's. And if you are an upper middle class Minnesotan you know you're a short drive from the best and you also know that the only thing blocking the road is your insurance company making you go through hoops before you get it. When BCBS decides to do a "tiered" system on hospitals and conveniently places all the children's hospitals and Mayo in the tier they don't routinely provide, upper middle class folks can figure that game out too.

Democrats need to work harder and get more confident at making common sense arguments. When our bridge fell in the river (due to lack of attention to public instrastructure) at least the people who fell in were within about a mile of a level 1 trauma center. In one case, it was an 8th month pregnant woman suffering a severe brain injury. Both she and her child are alive because of it. Yet many of those injured found that their insurance was insufficient to cover weeks of hospitalization and months without income.

And what does right wing radio do? Vilify the victims who were guilty of doing nothing other than driving home from work on a public highway. How dare they mention that their insurance was insufficient! But that kind of argument only sells to the know nothings. To others, you can appeal to the common good. Democrats should stop being afraid to do that.

The tax increases will be offset by reductions in premiums to people with kids.

And it will be more than offset by an increase in preventative care to avoid the most costly medical expenses, as well as the increased risk pool, reduced buck passing and paperwork by insurance companies.

The conversation needs to be about the overall economic and cultural costs to a society of the uninsured and unhealthy, who avoid preventative care, post natal care, regular checkups and nutritional health for children and adults, and so on, until they're stricken by serious illness and chronic poor health, becoming an economic and cultural burden to everyone.

It may not cynically be in the short term interest of a small business or poor individual to pay for health care for themself or employees, figuring that the overall system won't improve and they'll just have more bills.

But it's in the interest of all businesses to collectively insure everyone, to improve the entire system by improving preventative care, which then lowers medical bills, and improves public health and the health of their employees and neighbors for secondary benefits to the culture and economy.

If we really want a "Shining City on a Hill" and a "rising tide to float all boats" then universal HC is the way to do it. Tens of millions of uninsured, a lack of preventative care for adults and children, rampant obesity, chronic illness, and expensive medical procedures after disease has set in, those are hurting all of us directly through higher insurance premiums and corporate bureaucratic waste and cost externalization, as well as indirectly through the many costs to our society and national achievement.

Only thing I would quibble with is this bit:

Bob Blendon says its the middle-class that is worried about losing something; here I disagree with him. I'd say it's the upper-middle class.

I don't think that most truly middle-class people (as defined by median joint income of $52,000 per household) are feeling that happy or secure with what they have.

Purely anecdotal, but thinking of a few family members in that income range, their health insurance is extremely important to them, and it's taken some wrangling to secure it. 

They might not feel that happy or secure with what they have, but I would say they are very, very skeptical that the government could provide them with something better. 

A plan that they feel threatens what they already have in return for something that experts claim will be better -- doesn't matter if the case is made via reasoned arguments, emotional stories, statistics, or yodeling -- will not sway them.

Re: Which is one thing I like about Hillary's proposal -- though it keeps private insurers in the game, it forces them to compete with a government plan that might eventually put them out of business.

I don't see that happening (private insurers going out of business) for the same reason public schools, though free, have not put private schools out of business.

Re: They don't want Medicare (or private insurers) to tell them that it they want a second MRI , a "cutting edge" $10 million procedure that has never been proven to be effective , or a drug they saw advertised on TV, they'll have to pay for it themselves.

Private insurance plans, even "very good" ones already have quite a track record of telling people "No" and I very much doubt that the upper middle class, or even the upper class, is spared this response. However people with money can afford to pay for a lot of things on their own if the insurer balks. And that is where you have to be careful. The 1993 plan forbade people to pay out of pocket for covered (but denied) services. Any new plan must allow this "security blanket" option, as well as the option to purchase private coverage.

.> The 1993 plan forbade people to pay out of
> pocket for covered (but denied) services.

Can you give us a pointer to that section? My understanding is that the The New Republic article "No Exit" claimed that to be the case but the claim was false.

sPh

That's a bogus meme. Those jobs stink, are anti-growth, inherently inefficient to the consumer, and easily offshored.

They'll be offset by more and higher quality, economic pro-growth jobs, such as medical technicians and clerks actually providing health care rather than denying it, which are also more domestically rooted physically in doctor's offices.

Sure, and lack of exercise, driving, and fatty foods in huge quantities has nothing to do with it.

The funny thing is that my intestine starts secreting hormones to create fatty tissue whenever I eat a lot and don't exercise, and the opposite is also true. Which has become especially apparent since tracking in a spreadsheet my weight, body fat and muscle mass, exercise habits and motivation levels, and nutrition.

Regardless, more efficient HC Insurance will allow more people to be healthier, and those who aren't to still get the medical attention they need at more efficient costs.

One of the reasons we haven't seen any progress on health care (to name just one critical public issue among many) is that the folks who "know" have been in charge. All the reformist "experts" and gurus are so closely wedded to the system that exists that they can't get anything done of any real significance because they don't even consider those actions that would produce real reform. Why? Because it would create too much controversey and conflict, etc... In other words, the battle will be very difficult and no one wants to risk their own position so the greedy interests remain in control ad infinitum.

It is increasingly clear that no compromise with the predatory health insurance companies will serve the public well or be anything but more and more costly to our people as time goes on and the present malignant system remains in place. The ONLY reform that is going to be worth doing and that can produce results for all Americans is throwing the insurance companies on the scrap heap of history. Socialize health care and do it in one fell swoop. If you don't take that approach you'll never get anything done. Make Medicare universal and expand it to take care of all medical problems. Let the insurance companies "compete" with that and let's see how long they last eh?

The very idea of "compromise" or striking a "grand bargain" is preposterous given that the nation is going to be relying on the Democratic Party for reform. Any such "bargain" or "compromise" undertaken by Democrats will mean only that the little people will get screwed even worse. Congressional Democrats seem to think that the word "compromise" means they must "capitulate". Collectively, there isn't one stiff spine amongst them. As a group, they are so utterly compromised they fail at even the most simple tasks where clear, obvious actions need to be taken and this occurs even when the public is lopsidedly in favor of their position! It is appalling. They have demonstrated this over and over and over again throughout this year.

It's hard to overstate the ineffectiveness of the Democrats on all issues at this point in history. It is not, however, difficult to see why they are so ineffective. One cannot reform a system that one is completely beholden to. You don't bite the hand that feeds you in politics and the dirty truth is that our Democratic members of Congress are, by and large, owned by the corporate interests they say they are willing to fight. Bah! They haven't invented an interest evil enough that the Democrats will fail to bow and scrape for.

The entire system is rigged in favor of everyone who has power, privelege and money which excludes about 90% of the American public. If we took the enormous sums paid out by employers and employees alike (as well as those paying for their health insurance on their own) and applied that massive sum to one, unified and uniform health care system, we would not need to be forcing anyone to pay "more" than they currently pay and we would be providing health care for all.

The Massachusetts Plan was doomed to fail from day one. Who in their right mind, acting rationally in an economic sense, is going to fork over huge sums to be insured if they aren't wealthy and aren't sick right now? It would be economic suicide. These compromises are just not viable. Only a radical departure from the for profit health care system we now have will ever meet the needs of the citizenry at an acceptable cost.

Until the time when we have a President with the guts to say that it's time to shut down the rapacious insurance industry, stop treating health care as another profit center for investors and focus on keeping Americans healthy we will never see any meaningful or worthwhile reform of the health care system in the United States. This will require that the Democrats do what they have been afraid to do now for about 35 years which is to go after the corporations and other greedy interests and fight for the average American man and woman and their families. I'm not going to hold my breath and I wouldn't recommend anyone else do so either.

I don't think that most truly middle-class people (as defined by median joint income of $52,000 per household) are feeling that happy or secure with what they have. But many upper-middle-class people (defined as families with joint income of, say $70,000 to $110,000) do have pretty good insurance (or at least think they do.)

They are afraid of real health care reform. They don't want to see the system cut waste so that we can afford to insure everyone. They don't want Medicare (or private insurers) to tell them that it they want a second MRI , a "cutting edge" $10 million procedure that has never been proven to be effective , or a drug they saw advertised on TV, they'll have to pay for it themselves.

Right, which is why the support for a single payer might trend the other way. My question, though, is since your benefits package is part of your wages, which is how they cost it, then who is going to get the excess? Employers claim that their average contribution to an employee's health care is @7800.00 with the employee paying @3500. then who benefits from the lower payments?

If health care is provide for “free” by the government, the labor costs go down for companies offering health care as a benefit. That savings would naturally be distributed as lower prices, higher profits, and or higher wages based on market forces, just as other cost savings are. I suspect that companies will have to pay higher taxes to pay for the free government health care so there would not be a lot of savings.

Maggie,

Your post is framed within the context of health care reform not being inevitable within the next two to four years. I would just like to point out that if you go just beyond that time frame that there is one important difference between the Federal government situation politically and that of Massachusetts. The biggest generation in our history is set then to start accessing Medicare, while at the same time more and more big employers are loath to keep their retirees within their health care groups to give them gap coverage. This sets a different political and budgetary dynamic for the Federal government than for the one in Massachusetts. It would be interesting if as you investigate more on what the Clinton/Edwards plans entail and what they considered in creating their plans, how much they considered this dynamic and how they think it will play out.

if we can send several hundred soliders to Iraq for a surge we can certainly do the same in health care.

To boldly go...

as an activist, I certainly agree but wars are ended when soldiers no longer want to fight-- that's why I think the military spends money on things like predator drones that mechanically kill.

at some point, I think universal care will come about because anything else would just be too complicated. at some point, I just believe that the boomers will break down the barrier and common sense will prevail.

To boldly go...

This is an informative and thoughtful post but I want to point out one area of confusion that needs to be corrected.

You write "How can they say their own care is very good if they put off treatment due to cost, and sometimes the delay was serious?"

I think you have blurred your "they"s. The numbers you've quoted actually are:

1) you write [or quote]: "Nearly 60 percent are satisfied with their costs" - that's one group of "they";

and

2) 28% of those polled put off treatment due to cost -that's a second and likely completely different "they".

That only adds up to 88%. So both statements can be true with no one contradicting himself or herself.

You also speak in terms of nearly 90% being satisfied with their care but 70% of the 28% having put off treatment due to cost saying the delay was serious. That leaves a slight overlap - 10% by my count (70% of 28% being about 20%, subtracted from 100% leaves 80% vs. 90%). That could be explained in part by (a) compounding the individual margins of error on each question, plus (b) I don't know what the "nearly"s add up to and (c) for some of the respondents, even though they put off care, when they got the care, perhaps they were satisfied with it under the circumstances at the time the care was delivered. (C) depends on how the question was framed, how the respondent understood it and whether those both are the same as your interpretation of the question and the answer.

So, bottom line, I don't think the answers are all that puzzling or contradictory.

This part of your post is worth selecting out & quoting:

if I were czarina and I waved a wand and made the whole insurance industry disappear, we'd save just 4.4%. And it would be a one-time saving.

This gets at why I have recently been converted from someone who once thought single payer instituted all at once was best to something incremental or transitional moving towards single payer. That, along with the "rationing" problem you describe. If private plans have to compete with a government program for a while, everyone will learn from experience that with the high tech & new treatments constantly developing, that BOTH will have to "ration." If single payer was instituted soon, especially with the demands of the huge aging baby boom, the single payer would get all the blame for the "rationing." People have to have time to figure out that everyone except the very wealthy cannot in the future get every treatment WHETHER private or government!

The countries that have universal government care are struggling with the very same problem--costs and demands are going to go up up up. It is better that people see for a while and understand the problem, that all insurers will be "rationing," both private and government. Transitional also gives the government plan(s) time to work out the glitches and, ahem, to "steal" the best that the private plans come up with, if they manage to come up with anything popular at manageable cost, that is. They will be more supportive of a single payer after learning from hard experience.

In addition, those medical care professionals who are truly pro-single-payer and fed up with the private cos. can put their money where their mouth is to speed the transition along and opt only to take patients with government plans.

It seems that Massachusetts tell us that the hardest hump to get over, as we see with SCHIP, will be the first step, the idea of mandating coverage for all and get the money to pay for those that cannot make the premiums. I will point out, though, that we managed somehow to transition to expecting all drivers of automobiles to be insured when once that was not the case. Almost everyone now accepts "no insurance, no drive."

If they can afford cable TV, they can afford a few thousand a year for health insurance.

Right now my DirecTV bill is $74/month. According to CareFirst, my local BC/BS provider, the cheapest individual policy would set me back $600/month.

So if I lose the TV and somehow find an extra $526 a month, problem solved!

Guess I should move to Massachusetts, apparently the land of cheap health care and sticker-shock cable rates.

ONE OUT OF THREE HEALTHCARE DOLLARS ARE WASTED ON UNNECESSARY TESTS AND TREATMENTS

I suspect that in many cases doctors are overly cautious. It's the movement of the art of medicine to the science of medicine. Even for the most minor complaint, a doctor will order a battery of expensive tests in order to confirm what they already suspect.

At the same time, many doctors use tests to substitute listening to patients. They pop in for two minutes, order some tests, and hurry off to see other patients while the tests are run. Then they pop back in and write a prescription.

On the other hand, you have doctors who treat every patient as a hypochondriac trying to get a scrip for oxycontin, who, because they've already eliminated the patient as a reliable witness to the symptoms, rely solely on tests to determine a cause of illness, as though they are coroners trying to determine a cause of death.

Last Thanksgiving, I came down with pneumonia. The first doctor I saw, at a minor emergency clinic, was of the third type. She completely missed the pneumonia and told me I had a sinus infection.

Three days later, deathly ill, I visited my family doctor, who immediately suspected pneumonia and ordered a chest x-ray. He wanted me to come back after finishing the antibiotic for a follow-up x-ray, which I did. But at that appointment, he wanted me to follow-up two weeks later with yet another chest x-ray, "just in case," and even if I didn't think I was sick. I declined. Although he is our family doctor, he is of the first sort. I don't know how many times my wife and I have undergone x-rays and ultrasounds because some blood test was a couple of points high. We have slowly learned when to comply.

But what are people supposed to do if the doctor wants to order a test? We aren't doctors, we don't know and likely the doctor can't explain it. We listen to the doctor because he or she is supposed to know better than we do. Health care isn't a product to be carefully weighed and chosen by knowledgable consumers. How can we possibly know what is unnecessary or wasteful?

As you suggest, it's not a simple problem, but it frustrates physicians as much as patients. On one of my mailing lists, dealing with trauma and critical care medicine, there are frequent references to VOMIT: Victim Of Modern Imaging Technology. Overall, imaging is a wonderful and lifesaving tool. In the real world, there are unnecessary surgeries because someone sees something unclear on, say, a CT angiogram.

Other patients are endangered because if one imaging study, such as FAST (an acronym) ultrasound suggests bleeding, more imaging studies are ordered, where the safer course of action is to take the patient to the operating room and get an actual look at the problem.

Confusing things even farther is that some tests, generally regarded as safe, do have risks -- and also benefits. The newer "multislice" CT scans give much more accurate images, but it has been demonstrated that they deliver enough radiation to cause a slight but real increase in the incidence of some cancers. MRI proper is extremely safe, but the gadolinium-based contrast media often used, and thought inert, are now known to threaten the kidneys of certain patients.

I can't say it's necessarily easier when the patient does have a meaningful opinion on a test or proposed treatment. Since I've moved from DC to Cape Cod, I've been given reminders that there are different resources. I disagreed with my primary physician about changing one of my drugs, and suggested a blood chemistry test to see if I could use a higher dosage of a related drug. He looked at me and said "Howard, that may be readily available at the medical schools you'e used to, but I literally don't know where I could even find form to order it around here." As it was, he did agree with my reasoning, once I gave him a written analysis of the pharmacology involved, with solid literature references.

Maggie and I have mused about the rarity of a patient who can speak Doctor, and how it may skew my judgment. I have housemates with chronic medical conditions, and am appalled at some of the treatment they are receiving. Now, a patient does have the right to bring an advocate to a visit, but they are very reluctant given that when I suggested they ask a specific question, the response was "and who is the doctor here"?

When I'm there in person, I can often get beyond that point, not just because of the first question, but quickly making followup observations that demonstrate full understanding. I can't easily transfer that knowledge to a bright individual that indeed knows some of the vocabulary, but doesn't have all the nuanced interconnections.

--
Howard

*equal opportunity offense to both extremes*

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

Incidentally, there are plenty of facts on the Physicians for National Healthcare Reform site that refute your claim that we'd only save 4.4% and all of that in the first year. That claim sounds wildly off to me.

http://www.pnhp.org/facts/single_payer_resources.php

"Sure, and lack of exercise, driving, and fatty foods in huge quantities has nothing to do with it."

the problem is: "treating weight problems when people are younger makes sense since, when they are older, recovery is more complicated and expensive."

I lost 75 lbs and plan to never put it back on but I know people who have put weight on because of back, knee and hip problems, etc... and they can't exercise to lose the weight.

My question: is it better for an insurance company to give someone a good exercise machine-- worth $5,000, or wait until they need $100,000 worth of medical care?

Which has become especially apparent since tracking in a spreadsheet my weight, body fat and muscle mass, exercise habits and motivation levels, and nutrition.

Since I commute about 40 miles a week, by bicycle, I don't have to track that.

And, my elliptical trainer tracks the "number of hours" I use it; I'm almost up to 365 hours which is about 20 minutes per day over three years and, by my anniversary, I might be up to 25 minutes a day.

My rowing machine (a concept II) hasn't seen much use lately since it's down in a closet and it takes effort to set it up; But it also tracks hours rowed, heart rates, etc...

So, in general, I don't really need a spreadsheet, the numbers are easy to look up. I also have a "total trainer," "weighted bars," a BOSU trainer, hand weights and a stability ball which I use occasional-- after I burn away too much muscle!

Because I exercise and my diet is much better these days, my blood pressure dropped from 140/90 down to 110/60 and why record that? I just smile and keep treating myself right!

I did have my body fat and V02 max tested and was labeled "ready to train for a marathon." In January, I'll have these stats measured again but I only do it once a year so I can get an idea of "what's normal?"

I totally agree that people should track stuff, either unofficially like I do-- without a spreadsheet, or like you do but they don't...

I consider my $10,000 investment to be cheap because I'm happier and more active than ever-- and that's priceless. I wish others wouldn't be so cheap with themselves!

To boldly go...

Thank you all. This is a good thread.   I'm going to start with the most recent comments and scroll my way back up to the top--

Ex-Brit: I'm sure of the 4.4% figure;  see the pie chart at the beginning of my book, Money-Driven Medicine. The book has been out for more than a year; no reviewer has questioned the number.

I'm also very famliar  with Physicians for National Healtcare Reform , have interviwed and sometimes quote them. They point out that insurers tend to spend 80% to 85% of the revenues they receive on health care, the rest goes to cover their administrative expenses, advertising, exec salaries and profits. That 15% to 20% works out to about 4.4% of the 2.2 trillion we spend on healthcare.

Ex-Brit, you write: "It's my understanding that although there'd be a tax hike, outrageously high health insurance premiums would disappear, and the tax increase would be lower than the premiums the insured are paying now. I pay $5,700 a year in premiums, with an additional $2,000 in copays. I doubt "

First of all, if (when) there is national health insurance,if you are under 65, you will still be paying premiums--even if you're paying them to Medicare or the Federal Employees Plan (YOur employer will also be contributing to the premiums. ) And you will have co-pays and deductibles--just as Medicare patients over 65 have co-pays and deductibles. (For example, Medicare patients must pay $1,000 out of pocket each time they're hospitalized.)

People at Medicare estimate that they might be able to offer a better insurance package for perhaps 10% less than private insurers charge for their most comprehensive policies. There is no free lunch. And in addition to paying  premiums that might be 10% less than you pay now, you'll pay higher taxes to cover the 15% of the population that has no insurance, and the millions of others who are underinsured.

The only way that premiums will come down is if we stop covering many of the treatments and pocedures that many Americans think they need: MRI tests if your back hurts, PSA testing for Prostate cancer (even thought there is no evidence that PSA testing and early treatment saves lives or extends life), angioplasties (when what they really need is bypass, or simly to diet and exericse) annual physicals (see the most recent post on my blog www.healthcareblog.org about why annual physicals really don't do us that much good-- and cost a fortune.  We also would need to cut many specialists' salaies (which means that some--maybe many---will refuse to treat patients on govt' insruance, and negotiate signifcant discounts when buying from drug-makers and device-makers. But to have any clout in those negoations, the government will have to refuse to buy drugs and devices that it thinks are overpriced. This means telling Americans that they can't have some of the most popular drugs, and some of the articificial knee implants that their doctor assures them are the best. (The doctor has served as a well-paid consultant for the company.)

    You can see how this won't be easy.

     It will take time to wean Americans off the notion that "more care is better care" , that "the newest, most expensive technology must be the best ."  So I wouldn't expect health care costs to drop sharply anytime soon. But if we do a good job of educating people, we could hope to put a lid on the growth in health care costs--so that, after adjusting for inflation, healthcare might be less expenjve 10 from now. And it would be a lower percentage of GDP, giving us more money for other things: education, the environment, etc.

HoppyCalif, you wrote: "The public, in general, is never going to accept being forced to pay a commercial entity for something, whether they need it or not"   But we do all pay for car insurance, and the folks who sell it to us are definitely commerical operations. ..

Hoppy, but as you know, I would greatly prefer to see all health insurance come from not-for-profit companies and the govt. I think that will happen eventually--if for-profit insurers are forceed to compete with govt's sponsored health insurance on a level playing field. (See Art Appraisor's post at 3:20 today)

BTW I completely agree when you say: "We are not Republicans. We can actually think and reason things out." I think that is  a real difference between Conservatives and Progressives. btw--have you read Greg Anrig's book "The Conservatives Have No Clothes"? That's his point (Full disclosure: Greg hired me to work at The Century Foundation. But I'm not plugging his book because he hired me. He offered me a job, and I took it, because are views on political issues are very similar.)

Hoppy--while I'm talking to you, let me respond to your earlier post. I agree about Medicare as a model --I always talk about Medicare for all as an ideal way to move to national health insurance. People are already familiar with Medicare and most like it. But Medicare would have to stop covering ineffective, unnecessary tests and treatments, and that will be tough. See my response to ex-Brit above on this post.

But the problem is this: a large number of people in this country don't trust government and are very afraid that Medicare-for-all would mean a "govt take-over" of health care.That's why it would be very hard to get medicare-for-all through Congress right now. But I think we could get Medicare for all competing with private insurers (giving individuals the chocie between public sector and private sector plans). I would love to see this happen in the next presdient's first administration. But if he/she doesn't have the landslide needed to get the votes on Congress, he/she could get it in his/her second term. It's very important that our next (porgressive) president has two terms. There is so much damage that needs to be undone. It will take more than 4 years.

Dragonfly DC-- You got me.  Cable TV was a poor example. (Though I pay about $140 a month for calbe --about half of what I could pay for basic pretty good health insurance in Mass )  Insurers (mainly non-profit)  in Mass working with the reforjmers  came up with some pretty good relatively affordable heatlh care plans .

HCBerkowitz:   I agree, doctors also are frustrated with our broken system. In fact, they are far more dissatisfied than most American. The people who have responded most favorably to my book, and to what I write online are often doctors.

Most people are not seriously sick, so they don't realize how borken the system is. That's why the majority say they are satisfied with the care they receive--and don't want to change it.

 Doctors, on the other hand, see what is going on, day after day. The good ones (which is the majority) are horrified. I would  go so far as to say say that if Congress only had to worry about what doctors thought, it would enact national health care. (That would still mean pissing off the lobbyists. But right now, Congrressmen have to worry about Both the lobbyists and the voters in their state who think they like what tey have--adn fear  losing it.)

Jeff C-- I completely agree You give an excellent descirption of how waste occurs and why consumers (i.e. the patient) aren't in a good postion to say no. We  need to move away from the fee-for-service system that encooouages doctors (often subconsciously) to do too much, we need to change the way they are trained in med schoo,  we need an independent institute comparing the effectiveness of various tests and procedures and deciding what shoudl be covered,  and we need malpractice reform that would discourage defenisve medicine--probably by setting up arbitration panels made up of doctors, very knowledable patinets, nurses, medical ethicists, etc.

Art Appraisor--- I agree that the aging of the boomers will make a difference. But they won't age all at once--they'll age the way they were born, over more than 2 decades. And many will be quite healthy in their  fifites. So short -term, the fact that they are aging won't have that much impact on the need for care. On the other hand, boomers want (demand) a lot of care. If their employers stop offering health benefits, boomers in their late 40s and 50s will be very upset. That could create real momentum for change in the next presdient's second term--if not sooner.  

Ellen --you quoted me saying "

But uninsured citizens earning more than 300% of the poverty level are expected to purchase their own insurance. The state hoped that 228,000 of its uninsured citizens would sign up; as of last month, just 15,000 had enrolled.

and then wrote:

No; the state didn't hope. Doubtless, the state was told/advised of that estimate by experts who are either clueless or liars

I think that "either clueless or liars" may be a bit harsh. But I agree: looking at the small size of the penalty for not signing up, Mass. reformers shoudl not have been surprised that so few people are signing up. Their "experts" failed them. Though I hope Blendon is right--that targerted advertising and "moral suasion" will persuade more peple to sign up.

I'm breaking for dinner, but I'll be back--mm

Does anyone else see something wrong with the picture of handing something brilliant to the president?

--
Howard

*equal opportunity offense to both extremes*

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

I hope you will go on talking. I'll be back tomorrow evening (Must go to sleep and go to work tomorrow).

Thanks again for your comments., I don't agree with what everyone here says, but it's clear that you care about the topic, and are thinkng about it."   m.m.

Thank you all. This is a good thread.   I'm going to start with the most recent comments and scroll my way back up to the top--

Ex-Brit: I'm sure of the 4.4% figure;  see the pie chart at the beginning of my book, Money-Driven Medicine. The book has been out for more than a year; no reviewer has questioned the number.

I'm also very famliar  with Physicians for National Healtcare Reform , have interviwed and sometimes quote them. They point out that insurers tend to spend 80% to 85% of the revenues they receive on health care, the rest goes to cover their administrative expenses, advertising, exec salaries and profits. That 15% to 20% works out to about 4.4% of the 2.2 trillion we spend on healthcare.

Ex-Brit, you write: "It's my understanding that although there'd be a tax hike, outrageously high health insurance premiums would disappear, and the tax increase would be lower than the premiums the insured are paying now. I pay $5,700 a year in premiums, with an additional $2,000 in copays. I doubt " [I'll pay as much under Nat'l Health Insurance.

First of all, when there is national health insurance,if you are under 65, you will still be paying premiums--even if you're paying them to Medicare or the Federal Employees Plan (YOur employer will also be contributing to the premiums. ) And you will have co-pays and deductibles--just as Medicare patients over 65 have co-pays and deductibles. (For example, Medicare patients must pay $1,000 out of pocket each time they're hospitalized.)

People at Medicare estimate that they might be able to offer a better insurance package for perhaps 10% less than private insurers charge for their most comprehensive policies (plans that are comparable to Medicare). . There is no free lunch. And in addition to paying  premiums that might be 10% less than you pay now, you'll pay higher taxes to cover the 15% of the population that has no insurance, and the millions of others who are underinsured.

The only way that premiums will come down is if we stop covering many of the treatments and pocedures that many Americans think they need: MRI tests if your back hurts, PSA testing for Prostate cancer (even thought there is no evidence that PSA testing and early treatment saves lives or extends life), angioplasties (when what they really need is bypass, or simly to diet and exericse) annual physicals (see the most recent post on my blog www.healthcareblog.org about why annual physicals really don't do us that much good-- and cost a fortune.)

 We also would need to cut many specialists' salarues (which means that some--maybe many---wouldrefuse to treat patients on govt' insruance,) and negotiate signifcant discounts when buying from drug-ma Anw we would need ot neogiate significant discounts with drug -makers and device-makers.

But to have any clout in those negoations, the government will have to refuse to buy drugs and devices that it thinks are overpriced. This means telling Americans that they can't have some of the most popular drugs, and some of the articificial knee implants that their doctor assures them are the best. (The doctor has served as a well-paid consultant for the company.)

    You can see how this won't be easy.

     It will take time to wean Americans off the notion that "more care is better care" , that "the newest, most expensive technology must be the best ."  So I wouldn't expect health care costs to drop sharply anytime soon. But if we do a good job of educating people, we could hope to put a lid on the growth in health care costs--so that, after adjusting for inflation, healthcare might be less expenjve 10 years from now.    

    And it would be a lower percentage of GDP, giving us more money for other things: education, the environment, etc.

HoppyCalif, you wrote: "The public, in general, is never going to accept being forced to pay a commercial entity for something, whether they need it or not"   But we do all pay for car insurance, and the folks who sell it to us are definitely commerical operations. ..

Hoppy, but as you know, I would greatly prefer to see all health insurance come from not-for-profit companies and the govt. I think that will happen eventually--if for-profit insurers are forceed to compete with govt's sponsored health insurance on a level playing field. (See Art Appraisor's post at 3:20 today)

BTW I completely agree when you say: "We are not Republicans. We can actually think and reason things out." I think that is  a real difference between Conservatives and Progressives. btw--have you read Greg Anrig's book "The Conservatives Have No Clothes"? That's his point (Full disclosure: Greg hired me to work at The Century Foundation. But I'm not plugging his book because he hired me. He offered me a job, and I took it, because are views on political issues are very similar.)

Hoppy--while I'm talking to you, let me respond to your earlier post. I agree about Medicare as a model --I always talk about Medicare for all as an ideal way to move to national health insurance. People are already familiar with Medicare and most like it. But Medicare would have to stop covering ineffective, unnecessary tests and treatments, and that will be tough. See my response to ex-Brit above on this post.

But the problem is this: a large number of people in this country don't trust government and are very afraid that Medicare-for-all would mean a "govt take-over" of health care.That's why it would be very hard to get medicare-for-all through Congress right now. But I think we could get Medicare for all competing with private insurers (giving individuals the chocie between public sector and private sector plans). I would love to see this happen in the next presdient's first administration. But if he/she doesn't have the landslide needed to get the votes on Congress, he/she could get it in his/her second term. It's very important that our next (porgressive) president has two terms. There is so much damage that needs to be undone. It will take more than 4 years.

Dragonfly DC-- You got me.  Cable TV was a poor example. (Though I pay about $140 a month for calbe --about half of what I could pay for basic pretty good health insurance in Mass )  Insurers (mainly non-profit)  in Mass working with the reforjmers  came up with some pretty good relatively affordable heatlh care plans .

HCBerkowitz:   I agree, doctors also are frustrated with our broken system. In fact, they are far more dissatisfied than most American. The people who have responded most favorably to my book, and to what I write online are often doctors.

Most people are not seriously sick, so they don't realize how borken the system is. That's why the majority say they are satisfied with the care they receive--and don't want to change it.

 Doctors, on the other hand, see what is going on, day after day. The good ones (which is the majority) are horrified. I would  go so far as to say say that if Congress only had to worry about what doctors thought, it would enact national health care. (That would still mean pissing off the lobbyists. But right now, Congrressmen have to worry about Both the lobbyists and the voters in their state who think they like what tey have--adn fear  losing it.)

Jeff C-- I completely agree You give an excellent descripton  of how waste occurs and why consumers (i.e. the patient) aren't in a good postion to say no. We  need to move away from the fee-for-service system that encourages  doctors (often subconsciously) to do too much, we need to change the way they are trained in med school' and we need an independent institute comparing the effectiveness of various tests and procedures and deciding what should be covered. Finally, we need malpractice reform that would discourage defenisve medicine--probably by setting up arbitration panels made up of doctors, very knowledable patinets, nurses, medical ethicists, etc.

Art Appraisor--- I agree that the aging of the boomers will make a difference. But they won't age all at once--they'll age the way they were born, over more than 2 decades. And many will be quite healthy in their  fifites. So short -term, the fact that they are aging won't have that much impact on the need for care.

On the other hand, boomers want (demand) a lot of care. If their employers stop offering health benefits, boomers in their late 40s and 50s will be very upset. That could create real momentum for change in the next presdient's second term--if not sooner.  

Ellen --you quoted me saying "But uninsured citizens earning more than 300% of the poverty level are expected to purchase their own insurance. The state hoped that 228,000 of its uninsured citizens would sign up; as of last month, just 15,000 had enrolled.

and Ellne then wrote  the state didn't hope. Doubtless, the state was told/advised of that estimate by experts who are either clueless or liars."

Ellen-- I think that "either clueless or liars" may be a bit harsh. But I agree: looking at the small size of the penalty for not signing up, Mass. reformers shoudl not have been surprised that so few people are signing up. Their "experts" failed them. Though I hope Blendon is right--that targerted advertising and "moral suasion" will persuade more peple to sign up.

I'm breaking for dinner, but I'll be back--mm

Re: People should not be taxed at a flat rate.

Here I adisagree. It should be a flat rate tax, just like Social Security (but no income cap). And the rich will still pay more that way.

If you want a plan with broad based support, how do you achieve that by electing more leftist representatives and forcing it down the electorate's throat?

You either have to educate the electorate or use political organizing to force the issue, you can't have it both ways, especially in the same comment.

You write" Mt57: 90 percent said they were satisfied with the quality of their care. 28 percent of that same group said they had to delay treatment because of cost, and it caused problems --so how could they be happy with quality fo care they received? That's the contradiction."

Maybe I wasn't sufficiently clear. Your treatment can be delayed and the delay can be problematic, but you can still be happy with the quality of the treatment you receive once you get it. The source of the delay (lack of insurance) and the source of the treatment (a healthcare provider) are probably two different people and that is probably how some poll respondents view them to create an overlap. It's only a contradiction if you conflate them into a single entity called the "healthcare system" but if they're two separate organizations, it's really mor of an apples and oranges comparison.

I am not saying the healthcare system is self-evidently optimal, just that it may be the poll-framer rather than the respondents that is responsible for the perception of confusion.

Also just to keep being anal, it wasn't 28%, that said it was a problem, it was 70% of 28%.

These are just quibbles because we have all seen how easy it is for debatable statistics to mutate into truth in the healthcare debate and I think it is constructive in a minor way to be anal about it. Thanks again for a thoughtful and realistic post.

The confusion comes from comparing premiums paid for a services vs. a progressive tax that is not voluntarily paid for a service. You in all likelihood will not pay an additional $7,700, but a few others are likely to pay an additional $77,000 if the tax is at all progressive.

We are talking about safety of life situations here. What should be the financial mechanism that finances fire services, and, for that matter, building inspections? How are they different from healthcare? Clearly, people do not always make the "lifestyle adjustments" that lower fire risk; we have a lot more wooden than concrete buildings, and few residences are sprinklered.

There was a time where fire departments operated on an insurance basis, but it soon became apparent that an uninsured building on fire jeopardized the insured ones around it. People forget that Underwriters' Laboratories were established by the insurance industry to lower their risk by certifying safe equipment whether in their insured building or not.

Now, contrast that uninsured building to an uninsured case of multidrug resistant tuberculosis, and its potential to spread.

--
Howard

*equal opportunity offense to both extremes*

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

Since government can use their power to tax, they can make the private sector look much worse than the public sector, but there does need to be a private sector allowed to exist as a comparison.

MM points out many reasons why the electorate resists health care reform, then goes on to suggest that the way to get it is to get more leftists in office. I didn't here anything about addressing the opposition.

It is entirely possible to get a left wing government in reaction to other issues and use tha government to ram through natinal health care, fine but it may not have broad based support.

Gadolinium - eek, don't remind me.

I went for an MRI once, had the gadolinium injection. On a pain scale of 1-to-10, I would rate that experience a 9.9. I suspect the technician missed my vein and infejected it directly into the muscle. Ye-gods it hurt. I called off the rest of the MRI.

Whether or not "they" can buy a piece of equipment varies with the state licensing authorities. In some cases, Maryland especially coming to mind, doing things such as changing trauma center levels or getting major new capital equipment in not-for-profit hospitals does require approval.

Sometimes caseload and waiting times are a justification. In other cases, such as interventional neuroradiology or cardiac catheterization labs, the issue is one of whether the travel time to a given form of treatment is possible within the maximum time in which the treatment will be effective. Not all medical decisions are made by for-profit entitities. I see plenty of problems in the "industry", but I also fail to see every decision as motivated by profit.

--
Howard

*equal opportunity offense to both extremes*

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

Re: For people clinging to their rung in the middle of the ladder ($52,000 join income for a household) "holding onto you inssurace for dear life" isn't selfish--it's about survival.

If you fairly healthy, changing insurance is really no big deal (assuming the new insurance is not significantly worse or more expensive than the old). People nowadays change jobs a lot and every time they switch jobs they switch insurers. I've done this seven times since I left college in 1992.

Thanks again for the comments--

  This evening I  am scrolling back up on the thread,  to respond, individually,  to earlier responses, addressing some of the very good points that many of you have made--and trying to answer some questions.  

    Scroll up (or search today' s date) and you'll see my most recent comments.

Robert Brown--

   I actually do think we need to do both things. Electing a Congress that is  on the left means focusing on bringing out the black, Hispanic and blue-collar and union vote. (The Democratic party's traditional base.)  Here, I'm talkng about bringing out the vote--persauding people that if they vote, they won't just get another GWB. That things could change. It also means driving elderly people to the polls, etc.

   I also agree that  uilding broad support means educating the public: letting people who have insurance with their employer understand that they won't be forced intoa  govt' plan, that gov't involvement in healthcare won't mean that they can't choose their own doctor, ec.

JPF 311--   You wrote: "???
"Wouldn't the currently uninsured be paying their own premiums, possibly via some sort of payroll tax or maybe via a VAT"

 Many (not all ) of the uninsured are truly poor and would need a complete gov't subsidy. In addition, many of the under-insured (people who have Swiss Cheese policies that contain many holes) can't afford comprehensive insurance. So yes, govt' subisides would be needed.

Secondly, we can't cut provider reimbursements for family docs, pediatricians, internists and ObGyns. While some specialists are overpaid, they are underpadi--and we need more of them.

Finally, we really need to say "no" to many treatments and tests. These are procedures that aren't helping people. Instead, they are exposing patients to more risks than benefits.. And  the Medicare Payment Advisory Commission (which advises Congress on Medicare payments) has already made it cllear that  this is what must be done. (Or Medicare will go under.)

Once  Medicare begins to say "no" private insurers wil follow.

Okay, Good Point.

But they probably will have to pay more in taxes to subsidize a public sector plan.

Not if there is a tremendous savings due to efficiency gains in single payer, which can shift payments from bureaucrats and paper shufflers to more HC providers, to provide more health care for those previously uninsured.

Again, we spend about double what most developed nations spend on HC. the idea we need to spend more, or that any sector will need to spend more, is just backwards to the whole concept of a more efficient system.

What's going on with all the poison pill memes?

As I said in the original post MOST HEALTH INSURERS IN MASS ARE NON-PROFITS.

That's really disappointing to hear you say that. I remember some months ago you made another similar distinction, which I think is fundamentally false, and contradictory to what you've said regarding support for universal single payer, Medicare for all, and such.

Profit or non-profit still isn't single payer. They both still seek to externalize costs, have bureaucratic redundancy, and are tremendously wasteful. Any system which seeks to preserve private HCI for base coverage will always be inefficient, which leads to the dilemmas Mass faces, as to who gets stuck with the gigantic bill.

The only way to escape that dilemma, is to make the system more efficient, so more people can get insured for the same or less in the short term, and in the long term the system becomes far more efficient due to increased preventative.

The place for private insurance is in supplemental care.

The way to efficiency in base coverage is single payer.

It's a plan that would never work at the national level. Essentially, Hillary Clinton's plan would be very similar to what Massachusetts is offering now.

But I cannot understand why politicians fail to grasp the simple concept that you cannot place the burden of responsibility on lower middle class or poor citizens and expect them to shell out money they do not have for medical insurance that is so expensive that it amounts to a legalized racket.

I get health insurance through my employer, but being 24 years old and in perfect health, I can guarantee you that I would not pay for health insurance out of my own pocket regardless of whether or not the government passed a law requiring me to.

The only plan that would work would be a system that allowed individuals to choose their own plan while pooling everyone else (the poor and those who do not choose to sign up for a plan on their own) into a large bracket.

The key to the plan being that nobody should be forced to pay out of pocket. Take it out of taxes, but it makes no sense to bleed the impoverished.

Re: Many (not all ) of the uninsured are truly poor and would need a complete gov't subsidy.

If that's the case then they are already on Medicaid so their costs are already part of the system. The majority of the unisured are working class and middle class people.

Re: Secondly, we can't cut provider reimbursements for family docs, pediatricians, internists and ObGyns. While some specialists are overpaid, they are underpadi--and we need more of them.

Um, yes we can. Medicare and Medicaid do it all the time. In fact private health insurance does it too. Look at amn EOB sometime and noticet he differece between what was billed and what was paid.

Re: These are procedures that aren't helping people.

Agreed. But you seemed to imply we would deny necessary care.

Re: Once Medicare begins to say "no" private insurers wil follow.

Private health insurance already does this. For the more expensive stuff they require an authorization or precert which they may deny up front. For smaller stuff they simply refuse to pay because the procedure is not medically appropriate, or should not have billed separately.

It seems that if you can elect a large enough number of leftists, there would be little incentive to educate since that can be very difficult. Much easier to simply pass the reforms into law and put those who do not comply in prison.

Kozmik--

    If you actually look at the numbers in any of the comparisons of our health care spending to spending in other nations published in Health Affairs, you find that the big difference is not between "single payor" systems and systems that are not single payor.

    In fact,  most Euorpean system are a mix of private sector and public sector--more like Hillary's and Edwards' proposals .

    This is not about memes; it's about facts. When you actually examine the numbers, you will find that the difference between us and other  countires boils down to these three factors:     

       a) We pay higher prices for the same services --more for an MRI, more for a visit to a specialist, more for devices, and more for drugs. In other countires someone decides which are the most cost-effective drugs and devices, and tells patients: these are the ones we will pay for. (For example, in Canada they don't pay for PSA testing for prostate cancer because they don't think it's effective. We pay for it --even though the American Cancer Society tells doctors isn't not appropriate to recommend PSA testing because we have no evidence that it saves lives.)

    In other countries, the govt puts a cap on specialists salaries--either by regulating the salaries or by putting  a cap on  how many procedures a surgeon can do each year. (This limits the unncessary anigoplasties, etc.)

   b) We perform more complex, specialized procedures. We use  more cutting edge technology (often before it's been completely tested.) Americans don't spend more time in hospitals than people in other countries but more happens to us when we are there. More tests, more procedures, and you are seen by more specialists.

    We also put more people in intensive care units, and our end-of-life care tends to be much more intense.

c) We have higher administrative costs not simply because of private insurance, but because our system is so FRAGMENTED. We have many more solo pratictioners than most countries, and each of them have to hire staff to fill  out paperwork etc. There is no economy of scale.

By contrast, at a place like Kaiser or the Mayo Clinic paperwork  can be handled much more efficiently by a single back office.

We also have many more insuers offering many different types of plans, which makes filing the insurance claims much  more complicated and time-consuming for hospitals and doctors. In other countries, even where they have private insurance, patients don't have nearly as many "choices" of types of plans which makes administrative costs much lower.

Jeff C-- you wrote "But what are people supposed to do if the doctor wants to order a test?'

    You are exactly right. This is why doctors must be on the front lines, trying to cut waste. Patients usually aren't in a good position to do it. Though patients can question the need for a test, etc. And then, a doctor who was practicing overly-defensive medicine may feel free to say--"okay, you don't have to go-I'm recommending it, just to play it safe, but I don't think it's essential."

I agree that income taxes offer the best, more progressive way to raise money for national health care. But one thing stands in between you and me and an income tax hike: Congress. If a Congressperson votes for a tax hike--almost any tax hike-he knows that a fair number of his constiuents will hold it against him. And his opposition will bring it up--again, again and again, the next time he runs. Most Americans hate paying taxes. This isn't rational, but it's part of our national heritage. (Think Boston Tea Party.) At the national level, I think we'll have to raise funding in a number of ways--cigarette taxes, probably, income taxes, corporate taxes, and refusing to cover unproven drugs and treatments. Mass tried to make funding progressive by providing subsidies to people below 300% of poverty. Of course it all depends on where you live in Mass as to whether $60,000 means you are living on a shoestring or not. My own income is much less than you might suspect (I work for a non-profit foundation. Put it this way, when I came here, I bought a comfortable chair for my office.) And, over the course of my adult life, I've been in several very different brackets so I have a pretty clear practical idea of what it is like to live in a particular bracket . . Ultimately, I think Mass will have to up the subsidies--which will mean raising taxes to find the money.

 JPF 311--

I wrote : "Many (not all ) of the uninsured are truly poor and would need a complete gov't subsidy."

You wrote: "If that's the case then they are already on Medicaid so their costs are already part of the system."

Unfortunately, that isn't true. IN many states you can be very poor--earning, say $11,000 a year, and not qualify for Medicaid unless you have children. (At some point in the past someone decided that the "deserving poor" were people who reproduced.)

     Secondly, most of the working poor earn enough that they don't qualify for Medicaid and don't earn enough to pay for insurance which, if you don't have a large employer wealthy enough to pay for it, averages close to $13,000 a year for a family.  Medicare could charge somewhat less--but not that much less if it is going to provide full preventive coverage and management of chronic diseases.

No, we can't just cut reimbursements to family docs, pediatricians, etc. You are right Medicaid has done this. And the majority of U.S. doctors in private practice now refuse to take Medicaid patients. So they are seen either by very,very dedicated doctors who have devote their careers to helping the poor (a small group) or by doctors who have a hard time attracting patients word of mouth, often because they are not very good.

Medicare cut fees to doctors only once in recent years, and it created a huge backlash. Right now, in NYC many doctors refuse to take Medicare patieints. If Medicare cuts fees to generalists again, Medicare patients will find themselves in the same position as Medicaid patients--they won't be able to find a doctor.

The average med student graduates with $130,000 in debt. If he becomes a general practitoiner in New York he may earn $105,000, if he goes to work for a hospital. If he tries to set up his own practice, he will need deep pockets  . .

"Necessary care" is in the eyes of the beholder. Rudy thought treatment of his prostate cancer was "necessary care" that saved  his life. The medical evidence that we have at this point does not show any benefit to treating early stage prostate cancer --only risk. The National Cancer Institute says that there is no evidence that early detection and treatment changes the course of the disease.

Private insurance now covers a great many treatments for which there is no proof. They simply are popular, have been talked up in the media, etc.  See the discussion of the annual physical on my blog-www.healthbeatblog.org. It's an eye-opener. (Particularly the comments by doctors)

Robert Brown--

    Perhaps you misunderstand what I mean by leftists.

    The U.S.  has a history of pendulum swings between left and right.

On the left, I would count FDR, LBJ (think of what he did for the civil rights movement and his Great Society programs) and Jimmy Carter. Robert Kennedy was a candidate on the left who might possibly have been elected if he hadn't been shot.

On the right, I think of Hoover, Reagan and both George Bushs.

Nixons a complicated case (in every sense)--. Eisenhower was a moderate presiding at a time when the country was pretty conservative. He tried to warn us about the industrial military complex --no one listened.

Clinton seemed to start out left of center (health care reform) but was beaten back by Congress, tried to appease moderates, and finally had to spend too much energy fighting scandal to accomplish what he wanted to do.

Looking at the front-runners for the Democratic nomination, Edwards is clearly left, as is Obama (though I don't understand him as well) and HCR is left-of-center though trying to appear moderate.

It seems pretty clear that we will elect one of these three, and I think the country is ready for another pendulum swing to what I call "the left."

O.K. fine. But, if the pendulum swings left, why is it necessary to come up with a reform that has broad support? Simply enact the laws and use police power to enforce it, that is what governments do.

I must again respectfully take issue here.

The obstacle isn't Congress.

The obstacle is the cowardice of many Democratic members of congress.

If Congressional Democrats had the guts and courage to do what is right, the average person would not have to pay more than they already contribute to their employer's plan or, if they didn't have it before it would be a very modest tax. In point of fact, had they had any courage we would already have had national health care in this country.

In terms of indivicuals, the bulk of the health care taxes should be paid by those with lots of wealth and that is not a huge number of voters. Keep in mind that something like 5% of all the families in the nation have the vast majority of income and wealth in this country. Given their 20 year long bonanza of high profits and low taxes, it would be difficult now to tax them enough to cause them much real pain. Sure they would squeal--they always do but so what? Few would have much sympathy for them if the tax wasn't impacting them dramatically. Likewise, employers should contribute the amounts they previously paid to health insurance companies in taxes to pay for the national health plan. Given that it would eliminate the profit of insurance companies, employers might actually be able to contribute less in taxes than they do in premiums to the insurance companies.

If most voters don't feel the pain it is easy to point this out to them and tell them quite clearly that the opponents are the fat cats and rich people who have been profiting and enriching themselves, lo these many years, in part, by preventing universal health care for every citizen and keeping their wages so low that they couldn't afford medical care on their own.

So let the rich pay for once and let them complain about it and let our representatives fight for the average person for once and make it clear to all of us--wealthy and not wealthy alike just whose side they are on. The trouble is that too many Democratic members of Congress are unwilling to unabashedly fight for the common man and woman and their families because they are in bed with the wealthy special interests. Sad, I know, but very very true. So let's not play the game that the obstacle is voters who would be angry that the rich pay more. That's an obstacle easily avoided. No, let's be honest and call it like it is here: the Democrats don't have the guts.

Re: IN many states you can be very poor--earning, say $11,000 a year, and not qualify for Medicaid unless you have children. (At some point in the past someone decided that the "deserving poor" were people who reproduced.)

Can you document this? I am aware there are stringent rules about income and assets but I've never heard of a "Must have kids" rule. Indeed, I've known childless people who had Medicaid. An 18 year dishwasher at a resturant where I worked (20 years years ago, I admit) was on Medicaid. And what about all those old people in nursing homes who go on Medicaid? I doubt they have minor children.

By the way, I am thinking in terms of a payroll tax (or maybe a VAT) not the outright payment of premiums by the poor. I agree 100% that most of the uninsured can't afford that. Even many middle class people can't. But since many (most?) uninsured people are fairly young and healthy (and since the costs of the unsured ill are being paid for somehow already, if only through the bankruptcy courts and cost shifting) would not bringing them into the system even with token payments on their part add money to the system since they'd still be paying in more than they'd be taking out, on the whole?

Several bioethicists I know use the term "research burden" to describe what is overwhelming complexity, for many people, to get into potentially beneficial research trials. Part of the problem there is that many studies have multiple sub-protocols, each requiring its own "informed consent".

I have a fairly dim view of most informed consent forms in research. They neither present risk in terms that a layman easily can grasp, nor that a person with substantial medical knowledge can truly tell what is being proposed.

There is an ethical parallel here, going back to the ability to have the person needing the services meaningfully participate in the system.

--
Howard

*equal opportunity offense to both extremes*

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

Maggie-

A heartfelt thanks to you (and I am sure I speak for many others) for being probably the most responsive blogger on health care reform.

You are a real treasure to all of us who are waging this important war.

We will win-soon! You can count on that!

Please Be Well,

Dr. Rick Lippin
Southampton, Pa

The most important thing to keep in mind with those systems however is that they're defacto single payer.

By that I mean they're so standardized and regulated, they may as well be the same giant agency. It just happens that they're operated by many small quasi-independent shops that were never for profit to begin with.

It's a bit like rural post offices in co-located in mom+pop shops. Yes, they're technically independent, but all their procedures, forms, rates, etc are standardized. They receive a regular stipend for the service. And they're not capable of expanding or franchising outwards. So, it's only a very limited notion of private, which arose under very different circumstances.

End providers for basic care, absolutely must be standardized to be defacto-single payer in order to be efficient and competitive globally. Any for-profit entities are going to be trouble as they inevitably push to make the system less efficient to increase profits. And to a lesser degree even so called "non-profits" have similar problems as their self-interest may be at odds with the larger risk pool, cost efficiency, and so on.

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