Universal Care: Getting The Right Mix
At Saturday's health care forum for presidential candidates, John Edwards was bold, detailed and specific--but didn't diagnose the problem.
Barack Obama was vague--but stressed that no president can do it without the people.
Dennis Kucinich diagnosed the problem, and pushed immediate transformation.
Hillary Clinton, surprisingly, forcefully adopted Kucinich's diagnosis (before he spoke).
Put them all together--in the right way--and you have a winning health care plan.
I was at the forum in Las Vegas where the Center for American Progress and SEIU made a real contribution to the political debate by getting seven Democratic candidates together to discuss health care.
In a political system where presidential candidates, not party committees, formulate policy for the parties, forcing the candidates to refine their views early--before a crowd of party and union activists--is not a bad thing. Irresponsibly, CSPAN didn't cover it live, but CAP streamed the event live on the web, and will soon have a transcript available.
Everyone expected former senator Edwards to stress the specifics of his plan for health care for all, and he did. The audience was not so prepared for Obama's vagueness, but the Illinois senator stuck to principles on the grounds that he was still working on his plan.
But the real surprise was Clinton's forceful diagnosis of the health care problem--and of her failure to win coverage for all in her husband's administration.
The New York senator pointed to the power and greed of the insurance industry. She told the Nevada crowd that the failure of her proposal for universal coverage in 1994 made her more determined to achieve the goal now.
As reported by Robert Pear in Sunday's New York Times, Clinton declared, "[My experience] also makes me understand what we are up against. We have to modernize and reform the way we deliver health care. But we have to change the way we finance it. That's going to mean taking money away from people who make out really well right now."
Pressed to explain what she meant by moderator Karen Tumulty of Time, she complained that:
...Insurance companies make money by spending a lot of money, and employing a lot of people, to avoid insuring you, and then if you're insured, they try to avoid paying for the health care you receive.
(Monday's front-page story in The New York Times offers a particularly vivid example of that in the long-term care industry.)
With that, Clinton established a strong starting point for an explanation that most Americans can understand about why health care is in crisis. She also announced she would soon introduce legislation to "require that every insurance company had to insure everybody, with no exclusion for pre-existing conditions."
And with that, Hillary left open the question each of the major candidates need to answer: If the insurance industry is the problem, do we want them to be the centerpiece of an expanded system of subsidies and regulations to try to "incentivize" or force them to cover everyone? And if we go down that road, will we ever get health care costs under control?
Even Edwards, with his admirably frank and detailed plan, does not really answer that question. He builds his coverage-for-all plan around both private insurers and a public, Medicare-like system, claiming that the public's choices could eventually lead to the private companies losing the competition.
Kucinich was very clear in his response: Even if you set up a public program to compete with private insurers--and even if you regulate the private insurers (as Clinton and Schwarzenegger want to do)--the private insurance companies will find ways to "cherry pick" and cover only the youngest, healthiest and richest parts of the population. And, the representative from Ohio warned, you will end up with only the oldest, sickest and poorest people in the public system--and that is not level competition.
Kucinich's other warning: Private insurance, with its advertising and administrative costs (necessary to do their "cherry picking" and claims-denying) can never be the basis for an efficient health care system that can get overall costs stabilized.
Kucinich's problem is the public's resistance to rapidly imposing his "single-payer" system on everyone--even those (represented memorably by Harry and Louise) who are happy with their current health plan and don't want to change.
But Clinton's diagnosis of the health care problem could lead her (or Obama or Edwards) to embracing a gradual shift to a Medicare-style public plan for everyone (individuals and corporations) for whom private insurance is not working.
There was a lot of agreement on important fundamentals at the debate: Edwards, Clinton and Obama all agreed that requiring employers to either insure their workers or pay into a fund to cover them ("pay or play") is probably the way to go.
So if you put them all together in the right way, you just might come up with a winning health care plan, a winner for the candidate and for the American people.
P.S. - I'm glad I went out to Las Vegas rather than trying to get the streaming video to work. Being there made me realize how for the Democratic Party this health care vision is very much a work in progress. People need to understand that we have the power--though our tough questions, through the lines we chose to applaud and through our own strong advocacy of what kind of health program the candidates should adopt. We have the power to shape the program and the message, and the winning strategy.
P.P.S - I told the taxi driver who took me to the Cox Center at the University of Nevada at Las Vegas about the debate about to take place inside. He hadn't heard about it but thought a health care solution was really needed. Hospitalized with a serious illness--and no health insurance--he ended up with $250,000 in medical debts and had to declare bankruptcy.
After he got well, he tried to get a job (one with health insurance) at one of the big unionized hotels on the Vegas strip, but the hotel turned him down for the job because his credit records indicated he had declared bankruptcy!
This kind of Catch-22 health care system is undermining everyone's economic security and Americans are looking to us for an alternative.
Cross-posted at TomPaine.com and blog.ourfuture.org
Roger Hickey- Thanks
All seven DEM candidates were credible. I resonated most with Chris Dodd's comment to not "stovepipe" healthcare issue. He is correct.
To stovepipe the health care issue is the feed the $2 trillion plus dollar unquenchable beast.
We must all recognize that factors like jobs and the general economy have far more to do with the health of U.S. citizens than the treatment based disease care system/industry we currently have in this nation.We have been duped by paternalistic organized medicine into dependency.
See for my complete blog coverage of Saturday's good event.
Dr. Rick Lippin
Southampton, Pa
PS- At the very least don't let the U.S. healthcare industry harm you!
March 26, 2007 1:45 PM | Reply | Permalink
At the very least don't let the U.S. healthcare industry harm you...
yeah, over the past two years I've made a $10,000 investment in home exercise equipment and subsequently dropped 70 lbs.
This investment included diet guidelines, like the "Zone Diet," and literature about how diabetes happens (Dr. Ray Strand) and books from Dr. Duane Graveline who compiled research about the really negative side effects of statin drugs like lipator.
It will probably take another few years to consistently eat properly. In one video, I saw Dr. Ray Strand make the comment: "if you could only buy one car to use for your entire life, how well would you take care of it?"
The big problem with preventative medicine is: "the insurance industry would probably use the collected data against you," but, at least here in Minnesota, the big companies are being smart and working with people to manage their health issues so they don't get out of hand.
I recently watched a very profound video that discussed why insurance companies love "employee sponsored insurance." The main thought was: "the insurance industry loves the current system because sick employees quit or retire and then lose their insurance." Thus, the movie proclaimed "get an HRA" because it's not employment based, i.e. you use tax free dollars, while you're working, to pay for your own policy that doesn't terminate with employment! Hence, if you get sick, you won't have to buy insurance based on your current health...
Of course, people want to make the system expensive and take their cut and that's why I applaud folks like Dennis Kucinich who want to cut the administrative fat.
March 26, 2007 2:38 PM | Reply | Permalink
good for you! msc!
And thanks for the URL tags
Dr. Rick Lippin
March 26, 2007 2:49 PM | Reply | Permalink
Heres the link to the video I saw on HRA's: Take Control With HRA's"
One of the interesting statistics, and I don't know if it's really true, is "the cost of health care for the fortune 500 companies exceded their combined profits last year."
Another interesting statistic was that 28,000 Ford employees were put onto HRA's last year.
And it highlights the coverage hole ("donut hole") in health insurance between the ages of 55 and 65.
The video is mainly an interview with Paul Zane Pilzer, a fairly charasmatic speaker, about his book:
The New Health Insurance Solution: How to Get Cheaper, Better Coverage Without a Traditional Employer Plan
It would be interesting to hear other people's comments on the video...
March 27, 2007 10:16 AM | Reply | Permalink
Thank you for the video. These are my ideas:
1. The only way a "middle man" ie -- a company that doesn't provide any care whatsoever, or any other service for the provider OR the recipient of service -- can make a profit is by collecting money and denying as many expenditures for services as they can possibly justify. This "middle man is the insurance industry. It does not provide one single service, and yet it scrapes billions into its coffers by denying services and requiring referrals, pre-authorizations, etc. The hoops that we all must jump through are a waste of money and effort, and accomplish nothing except a way for an insurance company to deny a payment, and thus make a profit. They DO NOT PROVIDE ONE SINGLE SERVICE!!!!!!!!!!!!
2. The only way that medical care can be provided to all of our citizens AFFORDABLY is to share the risk: young and old; sick and well. It is called the "common good." Every modern country in the world recognizes this except ours.
The video struck me as something kind of sneaky, and I didn't like it; it seemed like a corporate snow job. OK, I had to go and do some cooking in the middle, but that is my impression about what I saw.
Should I watch it again, or did I get the gist?
Jan Knaus
March 27, 2007 7:10 PM | Reply | Permalink
The video struck me as something kind of sneaky, and I didn't like it; it seemed like a corporate snow job. OK, I had to go and do some cooking in the middle, but that is my impression about what I saw.
The main thing that I liked about the video was the 55-65 donut hole in coverage. When the boomers start to retire, the "uninsured" numbers should be interesting and I think we'll here more from those who are "considered sick" and, therefore, need to pay higher premiums.
Should I watch it again, or did I get the gist?
Only if you want to...;-) In general, my financial choices have been better than the ones that my "financial advisor" gives me; he likes ones that "line his pockets." I once determined, via spreadsheet, that I wouldn't make a dime for 3 years. Putting my money into a CD, compared to his recommendation, was clearly a better choice.
So, even though the movie was "slick" and "corporate" looking, I think that there's some benefit to going after "individual common sense" rather then the "in you I trust" approach.
March 28, 2007 2:31 PM | Reply | Permalink
As an attendee at the last two Take Back America conferences, and as a TPM Café, addict, how nice to see you blogging here, Mr. Hickey, and especially nice to see you get bumped to the front page. I don't get to the reader's blog area as often as I should
Seeing this post give me a chance to once again agitate for one of my little dreams. I'm going to be at Take Back America again this year. How about a party for TPM Café habitués? Politics with lots of caffeine, of course.
aMike
March 26, 2007 5:50 PM | Reply | Permalink
I took an "Economics of Health Care" course in graduate school that just might have been the most enlightening economics elective I ever took. The research paper we were assigned was especially challenging. We were asked to "solve" the health care crisis in America, given all that we had learned about America's health care industry and the comparative health care systems found in Canada, England, France, Germany, and Japan. The model I ended up embracing was certainly not one that I had originally thought might be among the final two contenders.
What led me to my ultimate choice was discovering that there were a couple of fundamental principles I could logically base my choice on. Indeed, I eventually realized that there was one principle above all others that the Democratic Party ought to be embracing and promoting as primary vs. all other considerations. We need to fix the incentives that drive our health care providers. I guess economists tend to focus on the importance of incentives more than most people.
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", but they were only being limited through a reduction in the quality of health care being received. Seeing this evolution in the incentives of America's health care providers focused my attention on the 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 gives providers 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.
Once it became clear to me that incentives should matter more than any other variable when Americans discuss health care reform, I was led by logic to the "Socialized Medicine" model that Great Britain has embraced for over 50 years. In spite of the bad press that the National Health Service (NHS) has received in this country (by the same people who give bad press to Democrats & Liberals) it has actually proven itself to be perhaps the most efficient provider of superior health care in the free world.
In spite of roughly equal "health outcomes" (OECD), 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). While the Brits enjoy a quality of health care that is superior to that enjoyed by Americans in many respects (no insurance policy headaches, no frustrating discussions of "ability-to-pay" prior to the provision of health services, no paperwork hassles) 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.
What is wrong with the Socialized Medicine model practiced in the United Kingdom that causes these long waiting lists? Nothing. It is not perverse incentives or imagined "inefficiencies" that are to blame for the waiting lists; it’s the conservative legislators in Parliament who have used their influence and pressure to underfund the NHS. If the British were to decide tomorrow to start spending the same percentage of their GDP on the NHS that Americans 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.
Adopting the British model of health care provision would dramatically improve the quality of care that most Americans receive. It would be able to reap many economies of scale and eliminate much paperwork. It would also bestow a great favor on perhaps a majority of our nation’s physicians, many of whom would probably love to be freed from the headaches of being "business owners" and be allowed to simply practice medicine.
Is this something that could be done in 2008 if the Democrats win the Presidency? Probably not. We all understand the powerful lobbying efforts that would be launched to defeat it. But in the long run, staking out your ideal vision and defending it is the best approach for the Democratic Party. You don't start off your fight for expanded health care by first proposing the compromise position that you are willing to settle for, like the Clinton Administration did.
Perhaps the best long-run strategy is to try to win over the doctors, first. Tell them that we'll guarantee them an income that ranks in the top 5% in the nation and then take all of the "non-medicine" burdens off of their shoulders. Then, with hopefully the support of a majority of physicians, we could take on the insurance industry. The pharmaceutical industry may be the most guilty of running up our health care costs, but it may be best to take them on last.
For more on the topic of Government bureaucratic waste vs. Private Sector efficiency, see this...
March 27, 2007 10:27 AM | Reply | Permalink
Good post JK, however these statements appear to be contradictory could you elaborate please? Do we need to spend the same to get the comparable quality of the UK in the USA?
March 27, 2007 11:25 AM | Reply | Permalink
We need to fix the incentives that drive our health care providers. I guess economists tend to focus on the importance of incentives more than most people.
the problem with incentives is that they are imperfect and studies show that incentives actually distort things as much as they fix things.
for example, enginnering incentives might be given for speed of development, cost of product and size of product and studies have shown that if you incent one aspect, other aspects get less attention.
another example: when home builders try to lower construction costs, they might "cut corners" on quality. thus, the home buyer inherits higher repair costs in the future.
"market based economics" are the "holy grail" simply because the marketplace chooses the winners and losers. the implied incentive in this case is the "ability to compete."
March 28, 2007 2:26 PM | Reply | Permalink
This sort of plan has zero chance of ever being accepted in the US. Can we lose the obsession with finding the perfect health plan and instead work on one that is good enough? Universal coverage should be only the mantra, and anything that does that, even with those mean old insurance companies still in the loop, should be something we can all support.
March 29, 2007 5:46 AM | Reply | Permalink
I have to say I think it is politically foolish to propose the 'compromise' you are willing to accept at the beginning of a debate. That is essentially what the Clintons did in the 1990's. Once the Republican politicians and the insurance lobbyists and the pharma lobbyists and the AMA all started shouting and repeating the slander that the Clinton plan was a nightmare of Soviet state planning, the 'compromise' crashed and burned rather quickly.
The 'swing voters' out there heard the volume of criticism and the alarmist tone of the criticism and concluded that the Clinton proposal would be a mistake. I assert that the only way it is going to be possible to overcome the impact that the Republicans/lobbyists will have on the debate in 2009 is by steadfastly presenting to the swing voter an ideal that they would find so appealing, they'd find themselves more 'naturally inclined' to dismiss the objections of the right.
I say push for the whole package---the 'ideal solution'---and then accept a compromise at the end of the discussion is it is actually necessary.
March 29, 2007 7:38 AM | Reply | Permalink
I don't recall saying anything about compromises (though they are inevitable when crafting major legislation). I only said we should be focusing on universal coverage as THE goal in healthcare reform, not anything else. Above all, I see no reason to insist on absolute perfection instead of being content with something that is "merely" good enough.
As for the Clinton health plan, it (or something based on it) would have succeeded quite handily if Bill Clinton (I blame mostly him, not his wife who had no political power at all back then) would have supported it with the same determination he supported NAFTA and deficit reduction. It wasn't the GOP or the insurance companies that defeated the effort in 1994, it was the Clinton administration's utterly tepid support for it.
March 29, 2007 11:03 AM | Reply | Permalink
But the only way for "universal health care" to work is by SHARING THE RISK across the board with a single payor. And the only way to do that is to PUT EVERYONE IN THE SAME POT. Only when the young/healthy balance out the old/infirm, (and other healthy vs sick populations) can a system work! As long as the system is for profit, how can an insurance company allow people in who have a history of cancer or heart disease if those people pay an affordable premium? What if one insurance company gets a disproportionate number of those type of patients?
You say that our country would never tolerate this, but look at what our country has tolerated for the last 6 years. Universal Health care is for the benefit of the common good. What has happened in the last 6 years has been a tragedy for all of us.
What would make us tolerate one and not the other:
TALKING POINTS/SCARE TACTICS/FALSE LABELS/LIES.
That pretty much sums it up.
Jan Knaus
March 29, 2007 6:39 PM | Reply | Permalink
Re: But the only way for "universal health care" to work is by SHARING THE RISK across the board with a single payor. And the only way to do that is to PUT EVERYONE IN THE SAME POT.
Any universal coverage plan shares the risk across the whole population (that's simply true by definition: see "universal"). But what I was reacting to was the concept not of single payor (which would be ideal, but is probably not doable right now), but rather single-provider whereby the US would have a system like Britain's NHS not just a government insurance system like Canada.
And again, I have to ask, if we can get everyone covered, why do you care so much about the details? I have to wonder if some people here donlt have a very different agenda. They don't really care that much about people who needs medical care; they just want to stick to insurance companies.
March 29, 2007 7:53 PM | Reply | Permalink
I respect your argument: Get universal coverage and then hammer out the details!
Having slogged through a few years of private coverage I have a view of "being covered" that not everyone appreciates. Through huge deductibles, co-pays, pre-authorizations, and changing definitions, insurance "coverage" can end up not covering very much health care at all. Before I got my current employer-provided insurance, my yearly deductible was $5,000, in order to make my monthly premium (of $330) affordable.
So, yes, I had "insurance." But I had to pay almost $9,000 out of pocket in a calendar year before my insurance would cover ONE penny! And if I had paid that much by December of a particular year, the clock would go back to zero hour on January 1.
So, I disagree with your idea of just saying let's get everyone covered first, because I know how hollow that coverage can be. When a politician can stand up and say that 100% of our citizens have health insurance so where's the beef...just try to get any improvements through. Look at the Medicare prescription mess. It is so complicated and stupid -- why? Because drug companies wrote the rules.
If we just work with adding people to what we already have I guarantee that it will not be a good system; it will not be cost-effective; and it will be just enough to prevent the wholesale change that is needed.
Jan Knaus
March 29, 2007 8:26 PM | Reply | Permalink
Re: So, I disagree with your idea of just saying let's get everyone covered first, because I know how hollow that coverage can be.
When I am talking about "coverage" I am certainly not talking about the type of faux-coverage you have had issues with. As for "universal", I don't think there's much wiggle room there at all: it means everybody, period.
March 30, 2007 5:44 AM | Reply | Permalink
you sound like Santa Claus! resources are limited and, of course, a system change scares people who think they currently have it good because they worry about getting less.
I think that most politicians are willing to settle on defining "universal care" as meaning "nobody is without insurance" but then what happens when someone's money is tight and he/she couldn't afford the co-pays and deductibles? that political distincion, I think, will be harder to argue.
politicians, for example, love touting low employement rates but have a harder time with "living wages." They're satisfied with the likes of Wal-Mart and Circuit City.
-M
March 30, 2007 10:20 AM | Reply | Permalink
And again, I have to ask, if we can get everyone covered, why do you care so much about the details?
because it all depends on what the meaning of universal is and what the meaning of coverage is.
Howard Dean was pushing watered down options because he didn't think, in my opinion, that Americans would accept the right thing.
If we're going to make changes, let's debate them and, as a country, make the choice.
typically, the entrenched insurers try to scare us into thinking that a different system would "cost too much" when, in reality, a world without their overhead would be nice indeed.
March 30, 2007 12:13 AM | Reply | Permalink
I think you've just reinvented real HMOs (such as Kaiser Permanente when it first began, not the insurance company parodies) and the VA health system. Both can work very well under the right circumstances, but they take a sensible balance of funding for prevention, patient education, and a sensible application of the latest technology and the latest drugs.
I prefer a mix of options for patient care, running the gamut from government and voluntary clinics and hospitals that provide comprehensive care for no additional cost to the patient to private care that is paid for by a mix of patient, private insurance and government payments, much like our college funding system is supposed to work. As long as the government pays for an acceptable level of quality care for all, I don't care what people decide to do with their money afterwards.
March 29, 2007 8:25 AM | Reply | Permalink
James, i have to go with the voices of the citizens and all the brits i know have negative comments about the NHS, and many of them have purchased private policies -- the same for my Irish friends who describe their national system as "ghastly". Full disclosure these are upper middle income folks, so it's not a scientific sampling.
Americans separate the system we have from the costs. We've got the best medical care available in the world, which is why foreign citizens travel here by the thousands for treatment every year. If we could control the costs of the present system better, most Americans would opt to keep things as they are.
March 29, 2007 12:20 PM | Reply | Permalink
I have no doubts about the likelihood that a government-run health care bureaucracy would not be popular with 100% of the electorate. Then again, America's privately-run health care system is not popular with 100% of Americans, either:
A recent CBS poll produced the following results:
I can also say that I'm not at all surprised that those with incomes in the top 20% would find the NHS more "ghastly" than the lowest 20%. I can report to you that 77 percent of users of the NHS's outpatient and community health services reported their care as excellent, very good or good.
If you want to be fair in considering all of the pros and cons of both systems, then you should make an effort to understand that the only reason why the NHS is inferior in some ways to the kind of health care that America's richest citizens can buy is because the NHS is seriously underfunded. To be fair, you should compare America's current system to the kind of services that the NHS would be able to provide if England were to double the amountof money that it spends on the NHS.
Seriously.
March 29, 2007 2:39 PM | Reply | Permalink
British conservatives like to point out that they are spending as much per citizen as other European countries with far inferior results. Is that true according to your research?
Also, what do you think of the MA model that Romney put in for his state?
March 29, 2007 5:00 PM | Reply | Permalink
Sorry for the delay in responding. I don't know where the "far inferior results" comes from; if British conservatives are like America's Republicans---and I'm sure that they are---the claim probably comes from a selective culling of statistics for a couple of unfavorable comparisons.
What I do know, from taking another look at the table data I cited above, is that two of the most frequently mentioned European neighbors of Britain---France and Germany---spend significantly more per citizen on health care than the Brits do:
2004 total expenditures on health, % of GDP
France 10.5
Germany 10.6
United Kingdom 8.1
If Britain's health outcomes are 'far inferior' to those in France and Germany, such a spending differential could easily account for much of it.
While I confess that I lack a comprehensive knowledge of the details of the MA model, I have a problem with the idea of forcing poorer folks to get health insurance that they can't afford. Doesn't sound like much of a solution to me. There's a reason why so many millions of lower-middle-class Americans have chosen to roll the dice an go uninsured. They don't have the money to pay for medical insurance AND pay all of their bills.
Perhaps my biggest objection is that the MA model does nothing to improve the quality of health care that Americans receive. I would dearly love to live in a country where you could take yourself to a doctor or to a hospital and not be immediately scrutinized for your ability to pay the bills. I find that aspect of our culture both frustrating and morally bankrupt.
March 30, 2007 7:48 PM | Reply | Permalink
Re: if British conservatives are like America's Republicans---and I'm sure that they are
Actually no. The British Tories are more like America's Democrats. They are in favor of gay rights (even gay unions) don't give a damn about abortion, and have even become strongly "green". Outside of Russia there simply is no major poitical anywhere in Europe that is anywhere near so far to right as our GOP.
March 31, 2007 12:23 AM | Reply | Permalink
My understanding of the MA plan is that it provides premium assistance to the poor. Maybe someone reading from that area could fill us in on more details, and how the program is working.
i would urge you to study the Tenncare program in my state we've had since 1994. The plan was designed to provide universal coverage for state residents. Those who were uninsurable or means-tested poor were eligible.
After 12 years the results aren't a complete disaster, but none of the beneficial promises of coverage came true, while a lot of unforseen consequences did. The major problem was costs that mushroomed out of control. When you make healthcare "free" -- people use it to the point of abuse. You had non-emergencies in the E/R, patients demanding as many prescriptions as they wanted, problems with fraud and milking the system etc... Doctors began to limit the number of Tenncare patients they would see, and some refused to see them at all.
The costs of the program became such a looming crisis for the state, our governor ended up booting several hundred thousand off the plan to keep it solvent. TN is a red state where the voters will not tolerate high taxes to pay for health coverage or anything else. A small increase was all the legislature could get passed.
The middle class was supposed to see a benefit from the plan of lower premiums and lower health care costs in the state (because everyone was going to be covered). None of those promises came true. Our costs went up, our premiums skyrocketed, and we had our taxes raised.
I'm not saying we shouldn't look at the option of UHC, but what I'm hearing from candidates and my real-world experience leads me to believe none of these candidates really understand what it is going to take to put a workable plan in place, or they are too afraid to divulge the projected costs prior to election.
April 1, 2007 5:51 PM | Reply | Permalink
Re: When you make healthcare "free" -- people use it to the point of abuse.
Care was not "free" under TennCare and the problem was not overuse as such. From what I have read the problem was something else: too many employers (especially those employing lower income workers) raised their employee insurance copay rates to exorbitant levels, thereby forcing the employees out of company plans and onto TennCare, so that TennCare ended up having to cover far more people than initial estimates of the "unisured" suggested. Any universal healthcare plan that keeps employer-provided insurance on the table will suffer this result, so it needs to be planned for. IMO, we need to move away from employer-provided insurance anyway, so this may be more of a feature than a bug-- but it must be anticipated and funded from the get-go.
April 2, 2007 11:08 AM | Reply | Permalink
I use the term "free" to describe the coverage that provides care without co-pays or deductibles. Employer co-pays have been going up across the board to try and reduce premiums (as well as deductibles), so the charge that it was a deliberate attempt to push employees onto Tenncare is not clearly substantiated. I'm sure it may have happened at some companies.
I really think the idea of a British-style UHC is a bridge too far. It's a huge political battle and a major paradigm shift, with uncertain results, and it is going to come with a tax increase -- there's no way around that.
I favor an idea tossed out by Kerry (who never backed it up) for the federal government to provide catastrophic coverage. For example, if your bills rise to $ 35,000 in a calendar year, the government steps in at that point as a re-insurance partner with private companies to pick up a portion of the costs above that level.
This takes a huge risk factor off the table for private insurance... that being the risk that one person out of X number of people is going to get very sick and require $500,000 of treatment. They have to calculate that risk and raise the premiums for the entire group to allow for that, but if we start to cap their costs at $ 35,000, the small percentage of folks that get catastrophically sick won't require the group as a whole to suffer. This should translate into serious premium reductions.
April 2, 2007 6:27 PM | Reply | Permalink
Re: For example, if your bills rise to $ 35,000 in a calendar year, the government steps in at that point as a re-insurance partner with private companies to pick up a portion of the costs above that level.
$35000 is well beyond "catastrophic" for most people in this country, almost half of whom do not even that much (gross) in a year! For some people even $5000 would be too much. I rather liek the way my employer (one of those evil corporations) does it with our health insurance: both the employer portion of the premium and the out-of-pocket limit are pegged to the employee's salary. That's how it should work.
April 3, 2007 11:30 AM | Reply | Permalink
i was referring to insurance carrier risk here not the employee. Employee risk would be no more than now, but insurance carrier risk would be substantially reduced.
April 5, 2007 5:19 PM | Reply | Permalink
For Nye Bevan, in putting together the NHS, the biggest stumbling point was the consultants. His solution was to 'stuff their mouths with gold', guaranteeing them decent salaries and the opportunity to do some private work while contracted to the public system.
In the US, the biggest stumbling point is the insurance companies. Hillary's right: there are a lot of parasites who suck the system dry doing inefficient paperwork, screwing people over pre-existing conditions, declaring treatment to be not covered, etc.
But no-one likes health insurers other than the people working for them or making money off them. They need, quite simply, to be put out of business. Or made to do business on state terms. The way to do this is, to put it bluntly, to bribe the practitioners, starting with the richest doctors.
March 31, 2007 10:22 AM | Reply | Permalink
I'm receptive to Paul Krugman's defense of Edwards's plan, as geared to not assaulting private insurers' existence directly or as creating a two-tiered system but in the long term effectively driving them out as superfluous or a lousy choice. One could argue that Clinton's plan is actually less able to lead to a single-payer scheme, since it asks the private firms to deliver the universal services they don't now and thus puts them at the center; it also asks them to accept everyone without making it clear what incentives they have to do so and what will happen if they can't stay profitable that way, that is, who picks up the slack.
However, I'm basically with those who think every candidate and participant acquitted him/herself well. I'm open to ideas and to learn, I know this is technical, hard stuff, I know the system is hard to budge, and I'm thrilled the Democrats are all on this page. It's another reminder that, well, no, they're not RINOs except for Kucinich.
John
http://www.haberarts.com/
March 27, 2007 11:05 AM | Reply | Permalink
ITA, insurers should be driven out of the healthcare industry. There should not be a middle man, who gets to determine what care you get based on cost vs. quality.
This is the most politically expedient plan for Clinton as a member of the DLC, she would not eliminate the insureres. She also lacks the negotiating skills and flexibility to bring about any working consensus which is why her plan failed previously. It was not the plan it was creating a working consensus in Congress that resulted in the colossal failure.
March 27, 2007 11:29 AM | Reply | Permalink
The big question is-
"WHERE IS OBAMA ON HEALTH CARE REFORM?"
I don't think Obama knows yet?
He is learning "on the job"- his soft underbelly on many issues?
Dr. Rick Lippin
Southampton, Pa
March 27, 2007 12:18 PM | Reply | Permalink
It seems pretty obvious to me that the major problem in health care delivery in this country is the involvement of private, for-profit insurance companies at the basic care level. That, and the employer based model of providing coverage needs to be eliminated for any progress towards and equitable, efficient and cost effective system to be made.
The obstacle that requires removal can not be a part of the solution. The idea that mandating some sort of universal private insurance will solve our difficulties is simply illogical. What needs to be done is to devise a way of phasing out private insurance in basic care, not expanding it. Let private insurance be for supplemental coverage for those who wish it and can afford it not a means of universal delivery. Thus, any plan that increases the role of insurance companies is seemingly bound for failure.
The stumbling block is that these companies are huge, well entrenched, enormously powerful politically and able to exert tremendous influence over the debate by virtue of their ability to spend nearly unlimited money in both advertising and political contributions. The plan that appeals to me will have to find some way of managing a withering away of private insurance, while not running into insurmountable opposition from the insurance industry. If the Edwards plan does indeed lead to giving people a choice between single payer and current private insurance plans, the cost savings and surety of coverage inherent in single payer would naturally result in a waning of the employer based, private insurance model.
That may be the strongest thing recommending it.
March 27, 2007 1:45 PM | Reply | Permalink
I won't back Senator Clinton this time.On health insurance she folded and gave no fight the last time around. My support goes to Kusinich and the single payer system,with private insurers out of the picture. If they are part of the equation, they will do everything to disrupt it, especially when profits go down.
March 27, 2007 4:57 PM | Reply | Permalink
The basic facts of UK vs. USA spending on health care can be interpreted in a number of ways. One conclusion that I have already mentioned is that the UK could increase its spending/taxes in order to fix the one blemish that their system suffers from---long wait times for elective surgery, giving them a health care system that is clearly superior to America's, not just 'roughly equal' in terms of outcomes.
Another logical conclusion from the basic facts is that Americans could reduce by maybe half the amount of money they spend on health care and still end up with roughly the same health outcomes that they enjoy now. We know this because the British are already doing it. They continually demonstrate that they are able to produce health outcomes comparable to the USA on half the expenditure.
One reason it costs Americans more for their health care outcomes than it costs the British is because our health care 'market' is not a price-competitive market. Price-competitive markets are the only kind of markets that are actually more efficient than government bureaucracies. But we do not have a price-competitive health care market. Various interest groups have conspired to limit competition in a number of ways.
The phamaceutical companies, for example, have been able to persuade the government to grant them monopoly power through patents of excessive duration. Through the AMA and other various lobbying efforts, physicians have been able to limit the supply of doctors in the market. They understand quite well that the only way they can continue to command extraordinary fees for their services is because they have been able to restrict the number of competitors they must deal with.
Insurance companies have no market incentive to compete with each other on price; instead, they invest themselves in efforts to outperform their competitors in executing sophisticated obfuscation schemes. Insurance consumers are asked to juggle three or four hopelessly complicated variables---premiums, deductibles, co-payments, and % coverage---in order to select the best deal. This has enabled them to avoid competing on price for an indefinite period of time.
Ultimately, all three sectors of the health care provider industry are able to exploit the urgency that citizens feel when they need health care and their willingness to 'pay any price' in their moments of great need. In a state-operated health care system, these costs are controlled over the long run simply because various providers are not able to exploit any of the market power they used to have in a so-called 'free market' health care system.
I would guess that the best option for the American people is to keep spending about the same amount of money that they currently spending on health care and simply focus their efforts on reaping the efficiences and quality improvements that state-run health care systems can provide. Taxes would increase in order to finance a state-run health care system, but since it would no longer be necessary for households to spend money on insurance, hospital bills, and physician fees, most middle class families would have more than enough to pay the higher taxes. (Most middle-class families are currently spending $5,000-$10,000 per year on insurance premiums, co-payments, deductibles and other expenses not covered by insurance.)
These families would end up saving money by changing 'providers' and agreeing to pay the government for a better health care deal (fewer headaches, a health care system that puts people first before billing issues).
Is this the kind of elaboration you were looking for?
March 28, 2007 8:33 AM | Reply | Permalink
On the topic of waiting lists...
One major criticism that is often voiced re: "free" (at POS) health care systems is the long waiting lists (for elective surgery) that inevitably develop. In America's current system, the only reason why we don't have waiting lists for many procedures is because those services are rationed according to the disposable money wealth available to individuals/families. Those who do not have sufficient financial resources to obtain the 'best care' are simply priced out of the market. Rich people fear the 'first come, first serve' approach to rationing scarce medical services because they are afraid they will not be able to get the "best" care when some misfortune befalls them. They are afraid that they will be forced to wait in line like everybody else. I think we can assuage their fears by pursuing the following approach to rationing scarce health care services:
Create a health care system similar in many ways to England's National Health Service. Grant every citizen a 'first come, first serve' right to obtain scarce elective services (and even spots on the patient lists of the 'best doctors'). Have the 'list managers' create a market that gives those with high positions on a list (shorter waiting times) the opportunity to trade their places in line with those who are lower on the list for some kind of mutually agreed upon compensation. This could be done in a number of ways.
If I'm rather poor and have only a week to wait for my knee replacement surgery, I might be willing to trade my position in line with a very wealthy citizen who might otherwise have to wait for 6 months. What this would end up doing is eliminate the single greatest concern of the wealthy re: 'socialized medicine.' They would be able to use their wealth to still get the best doctors and best 'quality' of health care, if they are willing to pay the market price, and I'm willing to bet that they would.
At the same time, a poor individual would still have an "equal right" to the best quality medical care that every other citizen has. If prompt treatment is what a poor individual wants, then that is what she is going to get. But if she chooses the option of waiting, instead, at least she will be compensated for her longer wait. She might also be willing to 'settle for' treatment by an intern instead of by an established physician who has a great reputation.
My prediction is that we would still end up with basically the same result that we have today, i.e., that the wealthiest citizens will still obtain the the best medical care on the planet, and they will still be paying a premium for the privilege. They may have to pay more for the privilege than they do now, but they would not have to 'do without.' The big difference, of course, is that those who are poor can get compensated directly for accepting poorer quality medical care, instead of simply being relegated by fate to the status of the "underprivileged."
I think this kind of approach to rationing health care services would be morally superior to the situation we have right now. When it comes to emergency services, the financial resources of the patient are usually a secondary consideration (not a variable usually considered when making triage decisions). We consider seriously wounded people to have an equal right to the best care immediately available. My proposal would simply extend that kind of moral reasoning to the provision of scarce medical services.
March 28, 2007 1:35 PM | Reply | Permalink
It strikes me that comparative outcomes would be a better measurement of the two systems. How do they compare in mortality/longevity, adjusted for all the various factors which can influence those figures? What about numbers prematurely leaving the workforce because of injury or illness? What about pain management and discomfort indexes? I suspect some work on this has been done and maybe one of our medically inclined readers can provide some interesting data.
aMike
March 28, 2007 7:53 PM | Reply | Permalink
Here are some of the statistics you referred to from the OECD (Organisation for Economic Co-operation and Development):
Total health expenditures (% of GDP) in 1995:
United Kingdom 7.0
United States 13.3
Total in 2004:
United Kingdom 8.3
United States 15.3
Number of practicing physicians per 1000 population in 2004 (most recent statistics):
United Kingdom 2.3
United States 2.4
Life expectancy (years) in 2003 (most recent):
United Kingdom 78.5
United States 77.5
Infant mortality (deaths per 1000 live births) in 2003 (most recent):
United Kingdom 5.3
United States 6.9
These are the most frequently cited statistics used to compare the health outcomes of different health care systems. I have not adjusted fo all the various factors which can influence those figures.
From the same data base, it also shows that the UK lags significantly behind the USA in the number of MRI's. This is not a comparison of outcomes, but it does reflect the degree to which Britain's NHS is underfunded. If they would spend a couple more percentage points of GDP on modern diagnostic equipment, they could easily match the USA in such statistics.
March 29, 2007 6:55 AM | Reply | Permalink
So, preliminarily, it seems that spending a bit more than 1/2 as much as a percentage of GDP, The Brits still live a little longer and lose less infants. For that result, I'll take a little longer for elective surgery.
aMike
March 29, 2007 7:00 AM | Reply | Permalink
Don't forget that many of our investigative tests are done for medico-legal protection.
If you don't have to fear that your life savings will be depleted for health care needs you might be less litigious; as are the Brits, the French, and all other citizens whose health care absolutely will not cause them to go Bankrupt.
I was taught to only order a test that I would expect to affect therapy. Just doing a test to prove what I already knew was discouraged. By the same token, one might also filter a test based on the likelihood of it having a result that would be useful, based on symptoms, etc rather than throwing the most advanced test at every patient. For example, you don't order a cranial CT scan on every patient with a headache.
I guess what I am saying is that if English MD's order fewer MRI's than American ones it is not necessarily an indication that there is a problem across the pond. We may be ordering too many.
Jan Knaus
March 29, 2007 7:22 PM | Reply | Permalink
At the same time, a poor individual would still have an "equal right" to the best quality medical care that every other citizen has...
Because the doctors have freedom of association, they don't necessarily have to "work for the system."
So what happens if the best doctors just "drop out of the system," charge more for faster service and take more days off?
March 28, 2007 2:18 PM | Reply | Permalink
Doctors may have freedom of association, but democratically elected governments have the power to insist that all those who wish to practice medicine do so within certain specified parameters of behavior. A law could be passed that requires all practicing doctors become employees of the state if they want to be licensed to practice medicine in the USA.
Understand that those individuals who become recognized within a state system as 'the best' doctors in their specialty would not be forced to accept the same salary as those who are merely 'average' physicians. Employers have long had the ability to recognize and reward exceptional performances by their employees. In a government-run health care service, the best doctors would certainly receive higher salaries than those who are just starting out.
Also, there is no reason why a great deal of flexibility in scheduling hours couldn't be practiced within a government-run system. If you want to be only a part-time doctor, why not?
Of course, those who do not wish to practice medicine under these conditions, even though they would be guaranteed an income in the top 5% of all income earners, would be free to pursue some other kind of career. We can only hope that such individuals would take up careers in other fields and leave the practice of medicine to those who are motivated by more noble aspirations.
March 28, 2007 3:07 PM | Reply | Permalink
but democratically elected governments have the power to insist that all those who wish to practice medicine do so within certain specified parameters of behavior.
This is possible?
March 28, 2007 10:15 PM | Reply | Permalink
It happens right now. The state says you need to be licensed to practice medicine. If you can't meet the requirements set by the state, you can't legally offer your services to the public. I'm merely proposing an extension of the current restrictions that are placed on those who practice medicine.
Having said that, I'm not necessarily opposed to the idea of allowing individual physicians to set up their own practices. Of course, the only ones who are going to be able to 'compete' with the federal government are those who have such glowing reputations, millionaires would be willing to pay extraordinary amounts of money for their services.
I'm not sure this would be a problem.
March 29, 2007 6:08 AM | Reply | Permalink
H-LHillary is absolutely correct. The starting point is to make insurance companies insure EVERYBODY! Thus, they would have to compete on economies of scale or some other risk factor.
The insurance industry works relatively well in the non-voluntary market. A set price based on a sundry of underwriting factors such as age, geographic area, and so on. If insurance companies had to accept EVERAYONE and used a composite rate for EVERYONE, the true priciples of sharing risk would be employed.
March 29, 2007 9:47 AM | Reply | Permalink
mcs asked why doctors won't drop out, putting added pressure on the system and leading to still further delays. The same question would have come up before the widespread change in employer coverage to HMOs, with stricter limits on payment schedules. And in fact some did drop out, becoming a class of luxury-care providers, while others entering the system in schools moved toward higher-paying specializations.
However, overall, the system still worked, and mostly doctors just packed more office visits into the system (which, admittedly, is itself a price to health-care consumers). After all, there were limits on the number of consumers at the luxury end, and there was sufficient money to be made from the broader system.
It would seem to me that the same dynamic will exist under universal care. In fact, universal care would cut further the "luxury" market, which in fact includes some people without coverage and thus unable to set prices. In addition, universal care would increase payments to physicians, since no one would be denied procedures in the manner that the current screening processes permit.
John
http://www.haberarts.com/
April 2, 2007 10:58 AM | Reply | Permalink