Phrases like "failures in the health insurance market" drive me nuts. Can't we talk about health CARE here not care for insurance companies and care for markets? This isn't an insurance company failure or a market failure. It's a failure to care for and care about people.

"Reform the system"? What are you talking about. That's just spin. "Find multiple ways to assure everyone is covered". More spin. All those multiple ways do is virtually guarantee that people who can't deal with navigating all the red tape and confusion of "multiple ways" will fall through the cracks. "Multiple ways" to provide coverage tend to turn into "multiple ways" to deny coverage. But the politicians get to pretend that they've accomplished something.

The huge "elephant sitting in the middle of health care room" is how to reduce runaway costs which threaten our entire economy-especially what GAO head David Walker calls the economic tsunami of 77 million boomers hitting Medicare. (Everything else is secondary including mandates vs. non-mandates)

So I agree with Reed Hundt that

what people sign up to is as important as how they get signed up.

Reducing costs however is very dangerously close to denying "treatment" so politicians are very circumspect when talking about it.

As for me. I believe both individual(health behaviors)and institutiona(public health) prevention is our only way out of this fiscal crisis.

Prevention musy be implented incrementally and always with compassion

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

People who are mandated to buy auto insurance and fail to buy it have their license to drive revoked, so a refusal to obey the government's command to feed the trillion dollar health insurance boondoggle will lose. . .their right to life?

Anyone who has seen "Sicko", which was all about people who are supposedly "covered" by health insurance, knows how bad the health insurance racket is. They're basically in business to take premiums and deny care. But hey, that's where the profit is.

In this election cycle Clinton has received $2,340,461 and Obama $1,828,152 from health industry PACs*. Mandated or not, Clinton or Obama, the health insurance industry expects to get a huge return on these investments. The next highest Dem candidate, by the way, is Biden at a paltry $153,050.

It's a trillion dollar industry--and they want more. The whole mandate issue is a purposeful distraction from the wrongs of the health insurance industry itself. What's the alternative?

Congressman John Conyers has sponsored H.R. 676, the United States National Health Insurance Act (USNHI) which establishes a unique American universal health insurance program with single payer financing. The bill would create a publicly financed, privately delivered health care system that improves and expands the already existing Medicare program. Every person living or visiting in the United States and the U.S. Territories would receive a United States National Health Insurance Card and ID number. This program will cover all medically necessary services and there are no co-pays or deductibles under this act. Families and businesses would pay much less for health care than they are currently paying.
http://www.house.gov/conyers/news_hr676_1.htm

*health professionals, health services/HMOs and hospitals/nursing homes; data from opensecrets.org

ecotourism
WeGoEco.com

they’ll be automatically enrolled in an insurance plan

That's a great idea. Then to reduce costs and charges of favoritism make that insurance plan Medicare, and to eliminate billing costs have the government pay. Then everyone, except those liking their current HMOs and private doctors enough that they're willing to continue to pay them, will go this way and (with proper financing) we'll have state-of-the-art health care like every other advanced country.

Could a hospital decline to treat those who did not comply with a mandate?

The issue is preexisting conditions. You can’t force insurance companies to issue flood insurance after flood, you can’t force medical insurance companies to issue medical insurance after heart attack or cancer detection. Therefore if Obama doesn’t require people to buy insurance, he can’t require medical insurance to cover preexisting conditions. If he does require insurance companies to cover preexisting conditions, he is being dishonest.

I DO want to pay for them with my tax dollars just like I DO want to pay for my local elementary school, middle school, high school, community college, state university, my streets, highways, bridges, parks.

I DON'T want to pay for war, for foreign adventures, for a bloated military industrial complex.

Defend the lives of ALL Americans. Provide them health care. Tax me.

I think what he wants is what Kucinich is proposing: single payer.

Of course, we all know that's not "serious" and that "serious" proposals reform the system, because in America employers pay for health insurance from private providers.

How the hell did we go from being a country founded on revolution to one that supports the irrational status quo in healthcare (and college football championships, presidential caucuses/primaries, the electoral college, etc. etc.) simply because it is the status quo?

At any rate, the answer to the problems in our health insurance system is actually pretty simple: end it, don't mend it. The difficult part is the politics.

Most of Krugman's comments are not mentioned here. The same criticism against Obama covers also social security and the mirage of bipartisan policy. Krugman, and rightly so, states that Obama runs with Republican ideas under the disguise of a liberal Democrat which he is not.

How the hell did we go from being a country founded on revolution to one that supports the irrational status quo

It's easy to explain:
The proletarians have nothing to lose but their chains. They have a world to win.
I don't know about you, but I have a lot to lose, and not much to win from the goverment, therefore I don't want revolution. I just want from the President don't screw up much, or at least don't screw up as much as Bush did. That's all.

duplicate.

It is good to see, and not a moment too soon, some serious questioning of the extremely likely to have an impact but totally unfair attack by Krugman on Obama (disclosure: I have contributed several times to Obama's campaign). I see that some of these attacks are repeated in this thread, such as charges that Obama is "dishonest" without stating the specific fact and what specific statements contradict it -- like Krugman, we are to take the harsh moral judgment largely on faith.

I can understand a serious debate over the issue of mandates. An EXCELLENT article that was first posted on Huffington Post on Nov 30 by RJ Eskow discusses the issue rationally and in depth. I highly recommend it:

http://www.huffingtonpost.com/rj-eskow/health-mandates-why-pau_b_74915.html

[I know you have to cut and paste this rather than just click it]

The key point, as Eskow says is not that Obama is fundamentally opposed to any mandates ever for adults (the plan includes universally mandatory coverage of all minors), but rather a question of what to put first, in terms of policy foundation:

The main difference between Obama's plan and his rivals' is this: They would mandate health coverage first and fix cost problems later. Obama would do the opposite. While both approaches are problematic, there is a strong case to be made that Obama's plan is fairer - and more politically progressive.

This point is particularly important given the nasty statements and innuendos made in lieu of substantive argument about Obama's plan. (further disclosure: I favor single payer, and as a socialist am much closer to Kucinich's position on this issue, while realizing it isn't about to happen in the US; I also am NOT deeply familiar with the different plans of the mainstream Democrats and their implications). For all this claptrap about Obama parroting rightwing talking points, the notion of trying to avoid the areas of the largest likely popular opposition to a plan, even if it makes the plan a little more expensive per capita covered (as Krugman suggests) is hardly closet reactionary thinking. It is political realism, and we need more political realism rather than what has struck me as unfairly attacking Obama, perhaps driven in part by his evoking a stricter political morality than others
(something often deeply resented).

Also, nowhere have I seen ANYONE parse HRC's repeatedly deployed number that 15 million would be left out of Obama's plan, where that number comes from and what the different substantive rather than merely food fight positions are about this number and its purported basis.

Early on, I also contributed to Obama. A young enthusiastic person with a lot of promise. I don't think experience is important.

Since then several things happen. I see heralding bipartisanship as a naive and dangerous stance. The Republicans are not partner to anything as of today. Then came the vouchers that are shorthand for decreasing money to public education. Then the half baked health plan. (The stories about the cost are beautiful but immaterial - take it from Iraq.) Finally came the social security canard. I don't even mention the support for the Iraq war in 2004-2005.

Is Krugman unfair? I don't think so.

The result is the same in straight bucks (setting aside likely lower overhead in single-payer), but you may be right about palatability. Also aiding the soft hit is the delay in onset, or at least not-obvious linkage, for the necessary tax offset.

But this sort-of-truth is only the case when all other things are equal, and they aren't. As mentioned, overhead could be much lower with less clutter in the process. Another savings would be less money wasted in ER treatment of minor issues. More money is saved when prevention avoids costly chronic diseases.

As a resident of Massachusetts and avid watcher of local politics, I can assure you that our mandated healthcare plan (AKA RomneyCare) is going to fail miserably for a number of reasons, many of which have not been noted in this thread.

First, the state is going to charge those who do not sign up 50% of the lowest premium they qualify for every month that they are not enrolled. In other words, if you are young and healthy and make $30K, you might qualify for a $200/mo policy. If you are not enrolled, the state revenue department is going to charge you $100/mo. that is going to be withheld from your tax return and potentially garnished from your wages.

Second, you will lose your personal state tax exemption for all on your tax return who are not covered - about $300/year per person. (2 parents + 2 kids = $1200)

Third, the subsidies to pay for the poorest resident's insurance are quite generous, but the second you hit the 3X poverty level, they completely disappear. Few families of 4 who make $65k/ year can afford the $700+/month *mandatory* coverage after they pay the mortgage and buy food. The subsidy curve is too steep.

Fourth, Massachusetts is a small enough state that those who are mobile enough can move 50 miles to Vermont, NH, Connecticut, RI, or NY and avoid the whole mess altogether. I live in a border town (North Adams, MA) and know of several working class folks who plan to move to Vermont or NY while keeping their jobs here in MA.

If this plan implodes the way I expect it, there will be one of three outcomes -
1) The state will fix it properly by reigning in the insurance companies and setting one-size fits all rates;
2) The state will cave on the enforcement of the mandates and make the problem worse;
3) The whole thing will be scrapped and the cause of Healthcare for All will be set back by a decade.

What happened the last time a government plan for healthcare collapsed? -We got Speaker Gingrich.

This is too important to screw up. Edwards is right - No penalties. Both Obama and Clinton are wrong.

Better yet - Single Payer.

I see it the problem is in understanding the way our economic system identifies costs, who causes them, who pays, and who benefits from the disassociation of these three issues.

First, we are all paying for those who do not pay when they go to the emergency room and other offices and do not pay already.

This is said but there are many others that do not receive care and die, what is not understood by the public about this word, die because of lack of care or medications!

There would be an additional expense in truth to allow them to live. Thus it would be an increase in numbers of individuals who would receive treatment. The increase in heath care expense would depend on either paying more to treat them or reducing the causes of bad health.

I have said before that we have the best environment for profit of any other developed country. Others brag on this, but not in the way I see it. We allow poisons in our environment because it costs too much it is said to use safe chemicals.

I see workers sawing concrete without even a simple mask to protect their lungs. City workers blowing out stoplight control boxes filled with cancerous chemical dust and sand remains from passing exhausts with no mask or respirator. Need I go on? You hear the story every day. The EPA did not regulate…. OHSH does not exist it seems anymore… If we reduced the environmental problems, practiced safe working conditions and made the industries clean up their chemicals our deaths and lingering illnesses would be reduced.

There was an author on NPR talking about why the EU controlled the environment better than us even though they have as entrenched industries that have even more power than ours. The answer was that since the government had the money go through them they controlled the things that caused disease. That is to say they made the desease causer in the economy clean up their problems. In America we allow them to make a greater profit at the expense of the health of humans and the out of pocket health expenses of others.

Look at your family and friend and say to them, I agree to let you have a greater chance of disease, retardation and/or death because I want the business of America to have more profits! That is what we are doing!

You may think you have the greatest heath coverage but you cannot protect your family and friends. You may think you have coverage now but you never hear the statistics of how may will have gaps in coverage and for how long during their life time.
This truth is never revealed!

At present when even wounded Iraqi soldiers are not helped how far before insurance companies are allowed to drop the sick in mass as the expense of paying for treatment costs the company too much….

Remember to say I have my coverage and not to help expand health care to all is like saying, I am not going to save fellow human being from death when for insignificant changes to my income.

What is a life worth? Will it be yours or a loved one with cancer because of chemical in the food or in the environment?

Think about how many will die tonight because of money. Maybe we should declare “hording money" as one of the major causes of death in America!
-Ask yourself as I do the same, am I hording money tonight?

-----------------------------------------------
Today, are we searching for I deals or Ideals?
-Thinking

What we want to do is reform the system, and then find multiple ways to assure that everyone is covered. Everything about behavioral economics tells us that multiple ways to sign up are necessary, because one size doesn’t fit all in health care, and what people sign up to is as important as how they get signed up.

What we want to do is send everybody a membership card, and pay for it with the income tax. This will increase the takehome pay of everyone who currently has insurance through their employer (because the cost of health care will be cut in half), and provide coverage to everyone.

Multiple ways to sign up means higher costs.

And, yes, one size does fit all for health care. That's part of the point here. If you get sick, you need to be treated. Everybody gets sick. Everybody needs to be treated. And it's cheaper, overall, if everybody pays for all the costs of treating everybody through a universal tax that provides universal coverage.

This is not a debatable issue. The US pays twice as much for worse care under a system that assumes silly things like "one size doesn't fit all" for health care than does the rest of the OECD.

Right.

This was discussed somewhat in Mahar's HCI thread recently. Where I was surprised she seemed to be endorsing the Mass system somewhat.

HCI costs must be made more efficient before more people can afford to enroll.

Private insurers, profit or non-profit, are too bureaucratically redundant, incompatible, and focused on cost externalization. They generate tremendous additional HCI costs to themselves and to doctors, which is then passed on to consumers through premiums. They are incapable of providing base coverage efficiently at rates everyone can afford.

Simply mandating enrollment of base HCI with such wasteful insurers won't work, and will fail politically.

I believe both individual(health behaviors)and institutiona(public health) prevention is our only way out of this fiscal crisis.

Right, they go together. Public policy must increase preventative, which also includes medical lifestyle advice and tools to patients to help themselves. Especially for children, the earliest and best opportunity for disease prevention.

Any form of "universal" health care will cause the majority of Americans to pay more than they would have without that program.

I think you meant to say "without any insurance."

Presently, Americans with insurance are paying about double what other countries spend to insure thier entire country with better care. The reason is much of what we pay is wasted in companies very efficient at making a profit, but inefficient at delivering health care.

The efficiency of Medicare, or the single player systems other developed nations use, isn't due to a tax subsidy. That's not it at all nor would that even be an efficiency, just a different source of funds. To be clear, Europeans, Japanese, and other developed countries with HC better than ours, pay about half, in total, including taxes, as what we pay per capita, to insure their entire population, with better HC. Japan for example has more MRI per capita than the US. Many European countries have family health care that is unimaginably good by American standards. Pre and post natal care is thorough, and includes in-home care.

American Health Care insurance, even the PPOs common to the $100-200K income brackets, are pathetic compared with what many other developed countries have for less cost, universally.

The efficiency of universal/single payer systems comes from:

1) Cutting the paperwork: increased standardization and compatibility reduces bureaucracy, paperwork, and doctor's office costs.

2) Non-profit stops the bleeding of the public health to Wall Street. Wall Street should profit by a healthy population and economy in a virtuous cycle, not by denying health care and beginning a vicious cycle.

3) Cutting costs unrelated to medical care: Reduction in marketing, executive packages, and other costs unrelated to health care.

4) Larger and more stable risk pool allows better management and efficient allocation of funds to predictable health care demands.

5) Ending predatory practices. Ending practices of cherry picking and cost externalization, which winds up costing the consumer a lot.

6) Increased preventative. The universality of care greatly increases preventative which reduces medical costs, AND raises quality of life and economic output.

7) Better medical records maintenance due to standardization, which both cuts costs and improves patient care.

8) Less Emergency Room visits and catastrophic disease. Everybody has insurance so the terribly expensive critical care, due to neglect of health, is greatly reduced.

9) Greatly lowered drug costs due to negotiated bulk buys.

Those are all efficiency gains. There are more, that's just a short list. That is why other developed countries are able to buy far more than we're getting, for far less than we're spending.

Every income bracket in America will save money and get better care

Del

Of course that's not the way it works in practice.

Three-quarters of the public wants us out of Iraq. Neither major party's leadership does, however. So next November we'll once again have to choose between two pro-war candidates or "waste" our vote by voting our conscience and supporting a minor party candidate.

For what it's worth, I'm not in favor of this mandate. If there are any, there are very few issues where the federal government mandates some action by individuals. Usually, we leave individual mandates up to the states, and I am a bit bothered about federalism when it comes to the insurance mandate. Especially since the government would be requiring us to purchase insurance. It's definitely weird to think that the federal government is going to tell us what to do with our money outside of a tax.

The fact is that none of these proposals are "universal" health care in the true sense of the word. If they want to claim universality, then propose a goddamn single payer system. That's what I want. That's probably what most of us want. Enough of this other bullshit.

Besides the spin coming from the pols, too many bodies out here have their health insurance paid by their employers. Until they get cut off and are forced to join the rest of us bottom feeders there can be no effective storming of the DC fortress. Pols aren't going to do diddly-squat until the rebellion's numbers get big.

It was predicted that when the patient/consumer no longer paid his doctor/hospital/insurance co. directly the costs of health care would eventually be prohibitive. (Not to mention having the big, fat greedy feet of the insurance industry in the mix.)

The argument was based on the idea that the consumer can and does keep costs in check but only if he knows what they are, feels the bite will he react. Paid for by the employer, they're hidden and painless.

It was also predicted that as their costs for employee's health insurance rose, employers would cut, or not increase wages. We've had years of stagnant or decreasing wages.

(And then there's the recent $6.5 million donation to the Dems and $4.8 million to the Repubs from the health care industry - doesn't bode well for health care reform soon.)

Davai doesn't have any parties to choose from. He's an Israeli, not an American.

Right on, sph!

I am an unashamed socialist and have no problem with (shiver) "socialized medicine".
It would REALLY make sense to have single-payer, with a steeply progressive tax paying for health care coverage for all. Obviously, the fact that a significant % of the public would at least perceive it to be in their interests not to buy insurance, and would therefore be highly resistant to any "universal mandate" is a key factor that at least Obama has considered. Whether or not you disagree with his position (and as a supporter of a preferably nonprofit single payer system I do disagree with his position ultimately), it is simply hyperbolic of Krugman OR ANYONE to suggest that, by virtue of opposing mandates for adult coverage, and insisting it is better than 'universal mandate', Obama is "mudslinging".

I think a lot of people, in the hostility towards Obama reflected in this thread, are hostile to the very notion that anyone with sufficient integrity to be worth supporting can possibly win. That may be true, but it is worth at least giving it a shot.

At any rate, one key question I have is whether or not these health care plans will be open to LATER modification to a single-payer plan without massive dislocation, one of the strengths that I perceive to have been the case with Kerry's approach.

------------------------------------

One other issue about employer-based health care -- with companies using bankruptcy to ditch economic obligations, it is too unreliable even for those Americans regularly employed full time on the books by employers who provide complete medical coverage. I am given to understand that the latter includes the majority of Americans. (Without private plans, MedicAid, Medicare, etc -- MOST Americans, it seems [correct me if I am wrong] would not have coverage, and not 'merely' 40+ million.

There is one way to reduce costs per person covered...

I'm not sure that this statement is actually true, Bruce. If the American people would give some serious thought to fixing the unhealthy incentives that exist in their health care market, they'd be able to not only lower the costs-per-person of health care insurance, but would also be able to significantly increase the quality of health care that taxpayers receive.

Our so-called Private Health Care System (heavily dependent on government-guaranteed excess market power) creates incentives that have driven up costs, limited advancements in quality, and have compromised the care that patients receive. Prior to the arrival of Managed Care (HMO's), America's health care system gave doctors a financial incentive to over-prescribe treatment. With private insurance, physicians were hardly discouraged from over-prescribing care. Recommending more tests and procedures tended to increase their incomes. Private insurers didn't ultimately worry about this so much because they could always shift their increasing costs onto the backs of policy holders. The result? Skyrocketing increases in health care costs over several decades.

Then came Managed Care. Suddenly, the incentives for doctors were reversed. Now doctors received a fixed amount of income through their HMO contracts for services in a given time period. Under these constraints, doctors now had a financial incentive to under-prescribe treatment at a certain point. Yes, this approach did manage to slow down the growth of health care costs, but then we started to hear patients complain about receiving inadequate treatment and physicians complaining about the restrictions that were being placed on them by HMO numbers crunchers. Total health care costs were being "brought under control" to a certain degree, but they were only being limited through a reduction in the quality of health care being received.

This evolution in the incentives of America's health care providers should make it rather apparent to us that we need to create a system that gives primary care providers the right kind of incentives. How might it be possible to set up a health care system that would give physicians a natural incentive to give patients the best care possible while not also tempting them with financial incentives to over-prescribe care? The answer is to put doctors on a salary.

If a physician gets paid a generous salary for "just being a doctor", for "doing what a doctor does" [a certain number of hours per day] then she will not receive any extra revenue if she prescribes extra tests & procedures. Nor will she be rewarded financially for under-prescribing care. When physicians are on salary, they are freed from their concerns about financial matters and are able to fully invest themselves in the most idealistic inspirations of their calling. They can simply focus on healing people and not worry about all of the administrative headaches.

Great Britain has a health care system that creates the right kind of incentives for their providers. In spite of the bad press that it receives in this country (by the same people who give bad press to Democrats & Liberals), England's National Health Service (NHS) has actually proven itself to be perhaps the most efficient provider of superior health care in the free world. According to the OECD, both the NHS and America's private health care system produce roughly equal health outcomes. Unfortunately, America’s private health care system costs Americans more than twice as much as the NHS costs the citizens of the UK. In 2002, UK citizens spent only about 8% of their GDP on health care ($2,160 per citizen). This compares to the approximately 15% of GDP that Americans spent on health care that year ($5,267 per citizen). See why I doubt the accuracy of your statement, Bruce?

While the Brits enjoy a quality of health care that is superior to that enjoyed by Americans in many respects, the overall quality of their health service lags behind America’s in one important respect: they must put up with far longer waiting times for elective surgery. Is there something inherently flawed in the Socialized Medicine model that causes these long waiting lists? No, not at all. It's underfunding, pure and simple. If the British were to decide tomorrow to start spending the same percentage of their GDP on the NHS that Americans currently spend on their inefficient private health care system, they would be able to dramatically reduce waiting times for those elective procedures. If you hire more doctors and build more operating rooms and support services, then you will reduce wait times. It's just that simple.

Turning to the Socialized Medicine Model would not only solve our problem with incentives, it would also reduce our health care costs per person while at the same time dramatically improving the quality of care that most Americans receive. Remember, a big part of the quality equation is eliminating all of the frustrating paperwork (no insurance policy comparison headaches, no frustrating discussions of "ability-to-pay" prior to the provision of health services) and eliminating all of the money worries that parents and patients and loved one are overwhelmed with in American when someone gets sick or injured or is in need of dental work. At the point of service, adequately funded Socialized Medicine provides the best quality of care available.

Re: Obama, could someone please tell me how it is that all/most of the major Democratic contenders embrace a 'solution' could not possibly be more Republican. The classic Republican solution to the problem of uninsured citizens: force those who cannot afford insurance coverage to buy it anyway from private insurers, who are automatically able to enrich themselves further at the expense of the poor. If you subsidize the poor, then you are forcing the hardship on the poorest of working Americans who make just enough to not be classified as 'poor.' You know, the ones that have gone without insurance in order to take care of their families. Outside of the poor, who is in a worse position to handle a forced expenditure on health insurance? Why do we hate those Americans?

How do other countries handle elder care?

My mother-in-law was crippled but otherwise healthy. She started out with what we assumed would be more than adequate savings. She ended up being completely wiped out, and then I ended up being almost completely wiped out.

How would this scenario have played out in, for example, the UK or France?

And who is going to give me my money back?

In Tennessee, we have a Mandate to own car insurance. If you don't have it, and you have an accident, you pay a fine. I suspect that's what in health insurance mandate would do. People resist it at first, but like anything else, they get used to it and eventually accept it. You'll always have some who will never buy in, just like you always have some people who don't buy car insurance.

However, I think a health insurance mandate is a wonderfully awful idea IF you don't tie it to some kind of univeral state-sponsored health care coverage that actually is as good or better than private insurance.

There is also the fundamental issue of the lack of primary care providers (GPs, internists, family practitioners) in the US. The medical school process and incentives would have to be radically restructured to try to reverse the current split between primary providers (few) and specialists (many).

sPh

Great Post James Kroeger

I too as a Doc believe all Docs should be on a salary so we can become professionals again.

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

Not to speak for Dr. Lippin, but can you clarify your question? School teachers are typically working for the local school district, paid for through local property taxes. They are not federal employees.

Why do you compare doctors to teachers? I suspect you might be hoping to show that public schools are bad so public doctors are bad. Forgive me if I guessed wrong, but it would explain the otherwise weird question. Health care is very different from education, although both benefit society as a whole when offered unversally.

How do other countries handle elder care?

Generally with a whole lot more compassion and safety net planning than we do. In regards to old age health crisis, which we're all headed for in one way or another, it's covered.

A weird but neat example: Japan's average population age is increasing somewhat, so they're looking for efficiencies in elderly care. And they don't mean "cheap" care which is generally what Americans tragically think "efficient" means. They mean high quality care with innovations to reduce costs.

One mundane but expensive problem for the elderly is simply bathing. Assisted bathing requires the attention of a nurse which is expensive and undignified. An elderly person may need several years of assisted bathing, which may take as much as an hour each day, which may be 20% of a nurse's productivity. So, one elderly patient may incur the costs of a man-year or two of labor, just for bathing!

Realizing that, the Japanese government launched various competitions in the private sector develop new ways of addressing old problems.

A Japanese robotics company invented a robotic, self opening and closing, walk-in, seated, shower/bath thing, with intercom, and communication functionality, and safety features designed for the elderly. It's got a bunch of swiveling jets and is designed to allow an elderly person to bathe unassisted in safety. Trials show it not only is far more cost efficient, and does the job, but the elderly love it because it restores some degree of self sufficiency, privacy, and dignity, and allows them to bathe at their leisure.

Economically, it's production creates good tech and manufacturing jobs, but is still many times less expensive than the nursing costs. The nurses can do other more important and skilled tasks in the saved time. Elderly patients like it better.

Who would have thought something like bathing the elderly could have been elevated to such a challenge and success story? To me, that's just a beautiful thing. It's so mundane in a way, but it's a win all around.

In America we're not planning ahead enough for these issues. Companies are watching their short term stocks, there is no national leadership on health care, and generally the assumption is we'll just import cheap labor from Mexico to do the washing, or won't have to because there will be enough poor and unskilled Americans already. Great thinking. We really should do better. What happened?

Re: Under these constraints, doctors now had a financial incentive to under-prescribe treatment at a certain point. Yes, this approach did manage to slow down the growth of health care costs

Not sure I agree that doctors have an incentive to underpresribe treatments. Most treatments (Rx, diagnostic tests, specialist referrals) are things the family doctor never did get paid for anyway. What managed care creates is an incentive to take on as many patients as possible, and spend as little time with each appointment as possible. We've probably all experienced the over-booked MD who rushes in, looks at your chart, asks a question or two, writes a script and leaves.

Corvid

The problem with making health insurance voluntary is, as Dr. Krugman pointed out, that temporarily healthy people will tend to opt out while the sickest people will all be in. Result: an enormously expensive system that is absolutely, undeniably set up to fail.
.
If voluntary participation is such a wonderful idea, why not have voluntary car insurance? It's exactly the same principle. For instance, I've never been involved in a car accident, hence I don't need insurance. Of course, if I should happen to plow into your car tomorrow and both cars are totaled and we both end up in the hospital chewing $500 aspirins, tough luck. It's vastly more important that I get to exercise my freedom of choice. Like hell it is.
.
Look, if one is so thoroughly obsessed with this fetish that American society should be completely, utterly atomized in each and every sector and the individual's freedom of choice must always, always take precedence over every conceivable consideration of the broader health and cohesion of society, let's at least do the voluntary aspect of health care this way: At an early age, say 25 or a bit younger, everyone gets to choose, ONCE--either full health coverage for a lifetime or NO possibility of ANY coverage EVER, either public or private.
.
Now THAT'S a choice. Should keep even the libertarian nuts happy.

And you know this how? I myself recall comments on M.J. Rosenberg's threads where he said he's a naturalized American, a proud immigrant. In the end, we're all mostly communicating with people using pseudonyms here, who can create any character for themselves that they wish, but at least we can try to be accurate as to the character they are portraying, hmmm?

Sorry, I can compare only American and Soviet healh care system. Actually I can't say that Soviet health care or public education was bad.
However, I'm afraid that it's very hard to maintain high quality huge public sector in US given opportunities in private sector for bright, educated people.

And if we can't get that "politically" then we might as well just forget it for now and wait until we can. If anyone is picking their candidate on mandates versus no mandates as a policy issue then they might as well flip a coin. It's a bad idea all around, and so I lean a bit towards not making paticipation in the bad idea mandatory. But honestly, who cares? It won't do a thing other than further empower the insurance companies that are the ultimate enemy here.

I agree, with you, therefore everybody must have medical insurance.
However, I don't think that goverment can run unsubsidized medical insurance, that anybody can buy, that would be higher quality and cheaper than private medical insurances.

If everyone has insurance, you mean the difficult pre-existing cases are covered? So who is paying for those costly plans? If the patient and family can't pay for it, who does? You are, right now, in your property taxes, to cover the emergency treatment of poor patients at the county hospital.

Now if the government tried to run an insurance program with the same oevrhead and profit margin of commercial insurance, you would be right that the result would be equivalent to now. You are wrong in that the government need not pay billion-dollar CEO compensations or dividends to shareholders, so it saves money there. It also need not have thousands of employees figuring out how to deny a claim.

And, as pointed out above, if coverage produces prevented disease, everyone comes out better off.

Yes there will be subsidy of in insurance for the poor.

However, to repeat myself, with universal care also comes a more efficient insurance system which allows everyone to be insured, including the subsidy for the poor, at less cost to everyone, including the rich, than they're presently paying.

i.e. You, me, and everyone else with top income bracket PPO can actually pay less and have better care, by subsidizing the poor and building a system of universal health care. It's simply far more efficient at controlling costs, preventing chronic illness, and preventing emergencies.

Healthcare is expensive in the USA, not because we're getting so much good care, but because we're getting so little and such poor care. That's the important concept to understand.

Corvid

AND THE OTHER, EVEN BIGGER AND PINKER ELEPHANT sitting in the room is asking, Just whom do you want deciding HOW to reduce costs? Three possibilities: Our famously tender-hearted, profit-driven health insurance industry; finger-to-the-wind politicians and distracted, underfunded, dried-up little government bureaucrats, or actual human beings with actual health-care problems.

That's wrong. Medical insurance for base coverage is an exception, it's a natural monopoly

Sure. So what?

Want to buy your own police force, too? BTW, competition does not deliver food to those that lack money.

We are not talking about toilet paper. To be fair, your country had a very difficult early period, and a calamitous war that was not exactly a help, and add in the opaque politics, with no opportunity to throw out the ineffective officials, and it's of course not surprising your economy had major problems of delivering goods. And we had those handy slaves to get us started.

But the better comparison is not your country but the wealthier states, such as Britain and Sweden, that set up some socialized services.

Among other very good arguments that health is different from cars and iPods is the nature of public health. If I decline a flu shot, as is my right, I am nonetheless placing my fellow citizens at higher risk, since I may now act as a carrier, even if I don't get sick. Sanitation also requires a less-than-free market, since allowing one citizen to foul the river and groundwater is bad for all.

The problems your country faced were political corruption and no elections, not the socialism. The Central Committee setup is unrelated to socialism as such. See Sweden for fairly elected socialst politics.

Also consider that we nearly had our own National Health Service, as proposed by our president Truman. Some wealthy businessmen with allies in Congress killed that, likely with communism scare stories.

BTW, competition does not deliver food to those that lack money.

And we had those handy slaves to get us started.

'Mandatory' is a false right wing argument. Income taxes are mandatory. Sales taxes are mandatory. Car insurance is mandatory. All good things leading to better results.

Yes, a mandate may not be politically obtainable yet but Obama is doing his best to delay that time by attacking the idea.

I don't want a closet centrist elected as President by people who think he is a liberal.

If Obama is making a trade-off to get insurance for the millions who do want it he should not lie and claim that his is a universal proposal.

Davai:

It is argued above that governments in Europe are already providing better medical care for their citizens than our market driven system is doing for us.

Drop your ideological blinders and do a reality check.