Hatrack River Forum: Universal Health Insurance is Coming to the US

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Posted by Lavalamp (Member # 4337) on :

Apparently, the "talk" in Washington is that we're going to have this...and soon. Big business is pushing for it, conservatives are pushing for it, liberals are pushing for it. Insurance companies and hospitals are pushing for it. The plan I'm hearing about outlines as follows:

1) Mandatory minimum coverage for every US Citizen
2) Individuals pay for their own coverage
3) Treat the entire population as one huge insurance pool
4) Subsidize minimum coverage for the poor, at least partially through a 4% tax on employers
5) Individuals and employers can opt for increased coverage through supplemental providers

The big question appears to be how to pay for it, and even there a consensus seems to be developing that says we definitely do not want to do this through any sort of borrowing. In other words, we pay for it now with current dollars instead of mortgaging the future.

Now...here's what I don't get. A few years ago on a talk show I heard an insurance executive explain how such a plan "could never work." That it would be more expensive than if people were just insured through their employers -- he basically denied that a giant pool like the entire population of the US would have access to better rates than smaller pools through employers would. I didn't understand it then, and apparently this thinking isn't general among the folks floating trial balloons now.

So...anyway, what do you all think of this? I see major benefits in improved healthcare for many, and reduced costs for hospitals (that currently have to "eat" the cost of caring for uninsured folks who come in through the Emergency Department. I think it solves a particularly nagging problem related to children growing up in poverty in the US. And I think it provides a benefit to employers, especially small companies that never get good rates and seeming have to renegotiate their coverage every year, seeing double digit inflation and essentially having to decide whether or not to keep that benefit for employees.

I'm particularly interested in how Libertarians and fiscal conservatives are going to react to this proposal. Supposedly the political insiders are saying that this is going to happen, no doubt.

Sorry, no link, I've condensed from days of radio reports.

Posted by Tante Shvester (Member # 8202) on :

May it be so, and speedily.

Posted by lem (Member # 6914) on :

I thought we already had universal health insurance with Medicare and Medicaid.

Posted by Will B (Member # 7931) on :

Well, you may be right, Lavalamp, but things gleaned from media are often just the bias, rather than the facts. I'm sure that someone is talking about this idea, but that it *will* happen and that everyone supports it will need some confirmation.

Libertarians will hate the idea, of course, of putting government in charge of yet another private decision, and won't like the fines or jail time that go with dissent. Conservatives won't like that either, nor the new tax and the new entitlement program. I suspect once we start getting prosecuted for not buying the right type of insurance, we won't either.

Anything's possible, but this would be a big jump, and a lot of people will notice that micromanaging the purchasing decisions of the middle class can't help the poor pay their bills. If we *did* want to make other people help the poor with their medical bills, we'd have some sort of government program to do that. Come to think of it...

[ February 11, 2007, 12:23 PM: Message edited by: Will B ]

Posted by The Pixiest (Member # 1863) on :

I think the lovely insurance I have through my employer will be reduced to whatever the gov't says is the minimum.

I think this will hurt research by harming the profit motive.

I think we will end up paying more and getting less.

I think we will end up with longer lines at the emergency room because every little thing is covered.

This is the worst idea for individuals since Withholding.

On the other hand, it'll buy a TON of votes.

Posted by andi330 (Member # 8572) on :

First of all, to lem, Medicare and Medicaid are only for specific segments of the population. Medicare is available only to older people, or to people who are disabled, not the population as a whole. Likewise Medicaide is only available to people who are poor, and I mean really poor. For example, as a single woman, I would have to earn less than $9800/year in order to qualify for Medicaid. During the year when I earned about $15,000 for the year, I had to pay for insurance out of pocket, and a Blue Cross HIPAA policy (I have pre-existing conditions) was costing me about $120/month. I could manage to pay the insurance, so that if I had a car wreck or something I wouldn't be paying out of pocket for the cost of the Emergency room but I couldn't afford the co-pay for regular visits to the doctor or my medication and ended up with pneumonia as a result.

On to The Pixiest, I don't agree with a couple of your statements. My understanding of the way Universal Healthcare would work means that while everyone has that option, it's not a requirement. Private companies would still exist, and you would have the option to take something else, this just guarantees that a BIG segment of the population, which is currently uninsured, finally has some option on healthcare and that employers would at least have to give their employees the option of the Universal Healthcare benefit.

I adamently disagree that Emergency Rooms will become even more overcrowded, this should actually lessen the wait. One of the primary reasons for overcrowded Emergency rooms today is that people with no health insurance go to Emergency rooms for things which aren't emergencies. The reason this happens is that emergency rooms are required by law to treat anyone regardless of insurance coverage status. So people go to the Emergency Room for things that they should be going to a GP for because they can't go to a GP, becuase they can't afford to pay the full bill out of pocket.

Posted by Lavalamp (Member # 4337) on :

<edit: I was writing this as andi posted. She covered much of what I say here...better!>

WillB and Pixiest. I notice that both of you are objecting to things that are explicitly NOT in this plan. I'm wondering if that's deliberate -- like you just believe it'll be so screwed up that the worst will happen -- or if you're just attacking the idea of it all rather than the (admittedly not completely specified) proposal that is supposedly under consideration.

Supposedly, conservatives DO agree that something is needed and they are happy that it will not be put entirely on the backs of employers (4% of employee gross is more than some employers pay now, but a lot less than others pay for employee healthcare). I'm just repeating what was said in the radio program, though, I don't know which conservatives are liking it, and whether or not they could be viewed as just pandering for votes.

One of the specific reasons that supporters have given for this proposal is that it would NOT cover everything and that Emergency Departments of hospitals would see some relief because at least some stuff that is covered would be handled in doctors' offices rather than waiting until it became an emergency situation.

Hospitals with EDs face a huge crisis now because they are the primary source of medical care for a lot of uninsured/underinsured people. The number of people using the ED as a birthing center, for example, has been growing steadily and points not only to further unrecompensed costs for those facilities, but a major healthcare problem as well.

It's pretty well known in the health care field that EDs are a big expense.

Re: Medicare/medicaid -- check the eligibility requirements. While there ARE a lot of people on those assistance types of coverage, there are a huge number of people who do not qualify. Recent trends in legislation have been aimed at shrinking the rolls. What that translates to is a lot of people on the margins slipping from "insured" to "uninsured" with very little safety net.

Economically, fiscal conservatives might find something to be happy about with universal coverage. The cost to the country for caring for the uninsured is growing (see above re: medicare for one reason why). If we found a way to pool the coverage and buy it cheaply enough, we will not only have a net savings by shifting some of the costs away from expensive EDs to cheaper treatment outlets, we'll also save money because of a general improvement in health.

There's a financial "downside" of course in that some of these sick folks get well enough to reproduce and have more children who may end up on public assistance. It sounds brutal to think of it in these terms, but if we're going to pay for this, we need to think of more than just current citizens.

Another question is what to do about illegal aliens. It may also be cheaper to insure them (and require them to be insured) than it would be treat them in EDs. And it'd be healthier. Of course, since we'd end up assisting some that we don't deport, we have the additional burden of deciding where to draw that line. However at present it appears we're only talking about covering US citizens.

As I understand it, the Insurance companies are heavily involved in coming up with this proposal. It appears that they would all insure the minimal coverage at the pooled rate and, as I understand it, they'll all be doing business so you could choose whichever one you want. That's a substantial improvement over the coverage most people have today -- dictated by their company and negotiated without much say, limited severely by the companies' willingness to take on small higher-risk pools, etc.

I can see how this would "win votes" but I don't actually see it as a bad thing designed merely to win votes. I think it'll win votes because most people in this country recognize that their insurance is too expensive, getting worse coverage per dollar invested as the years go by, and that they are lucky to have even that. I think most voters recognize that the cost of medical services has increased in part because so much of the burden IS placed on providers to cover the costs when the person is uninsured and can't pay. If people had access to affordable health insurance (this proposal actually does say MANDATORY), the bills most of pay should decrease.

Posted by Will B (Member # 7931) on :

What was it that I objected to, that wasn't in the plan?

Posted by Lavalamp (Member # 4337) on :

prosecutions for not buying the right type of insurance...

jail time for dissent...

Posted by Will B (Member # 7931) on :

You said "mandatory minimum coverage." If there is no prosecution of those who violate the minimum, what's "mandatory" about it?

I said jail time OR fines, because these are the penalties our legal system applies in prosecutions. Has some other type of penalty been proposed instead for those who don't comply? You didn't mention any alternatives.

Posted by ClaudiaTherese (Member # 923) on :

We cover about 25-30% of the population via Medicare, Medicaid, VA system, Public Health Districts, WIC, etc. We pay more for this per citizen (per every citizen, mind you, not just the ones covered) than other countries pay per citizen to cover everyone.

I fail to see the evidence to support the claim that this should cost more. Inefficiency has been costing us much much much more than anyone else's efficiency for some time now.

Posted by aspectre (Member # 2222) on :

Businesses which provide health insurance for their employees back the plan because their insurance premiums already partially* covers emergency room visits by the uninsured. So those businesses which cover their own employees will have a decreased portion of their premiums being used to provide health insurance for the businesses which don't cover their own employees.
ie Ethical businessmen won't have to pay out so much money to support the rats'patooties competing against them.

WorldTradeOrganization regulations do not allow the discounting of perks (eg health insurance) off the sales price of exports.
WTO regulations do not force businesses based in countries which provide national health insurance to add the value of that free healthcare onto the sales price of their exports.
Putting ethical US businesses at a disadvantage in the competition with British/French/Dutch/German/etc businesses.

* The remaining part being covered the extra premium paid for Medicare, by extra tax paid to cover Medicaid, by individuals who have automobile/medical/liability/disaster insurance, and by those who pay for their own medical expenses.

[ February 11, 2007, 02:31 PM: Message edited by: aspectre ]

Posted by Will B (Member # 7931) on :

It doesn't seem clear that tripling or quadrupling the size of an inefficient program will necessarily make it more efficient.

Posted by aspectre (Member # 2222) on :

Medicare is considerably more efficient than private insurance companies in terms of the percentage spent on actual medical care as opposed to paperwork and other administrative expenses. The VeteransAdministration is even more efficient than Medicare.

Posted by Boon (Member # 4646) on :

Let's talk specifics about those of us on middle ground.

My husband works, and makes decent money. Not a lot, but enough for us to live on with careful budgeting. We fall sort of in the middle, with regards to medical coverage. Our children qualify for medicaid, but we do not. (We went ahead and put them on it just for emergency coverage, but we pay for regular doctor visits out of pocket.) Honestly, we qualify for food stamps, too, though we don't take them. (The kids would also qualify for free lunches and breakfasts at school if we weren't homeschoolers.)

Our budget does not allow us to purchase health insurance through his work, even though he works for one of the biggest health systems in the state. It would cost us over $500/month for family coverage. That's as much as our house payment, homeowner's insurance, and car insurance combined.

We do set aside a small amount every month into our emergency fund, and we pay for our own health care and perscriptions out of pocket (about $50 a month, not including our savings).

How exactly would "mandatory" coverage work for people like us, who don't have the extra money to pay for it?

Posted by Lyrhawn (Member # 7039) on :

I support universal healthcare.

The billions of dollars wasted every year treating the uninsured, and treating people whose problems got out of control due to a lack of preventative care, and wasted through paper shuffling must end.

This is going to be painful up front I think, but in the long run we're talking billions, maybe trillions of dollars in eventual savings. We're going to switch to paperless recordkeeping, so digital files can be transferred at the drop of a hat across the medical care network, saving lives, reducing accidents, cutting down on lawsuits, and reducing the cost of administrative work. We're going to focus on preventative healthcare, an ounce of prevention really is worth a pound of cure, and we're going to prove it. Getting everyone insured, and getting everyone on the road to healthy will save billions more than just treating them when they become too sick to manage by themselves.

We need to put a lot of thought into how we want to build such a system, and how we are going to pay for it, and I think there WILL be a major up front cost for it, and it'll be painful for a few years, but we're going to be very happy with it in the long run. If we can pay a half trillion dollars for the war in Iraq, we can pay a much smaller fee to fix the health of our own citizens. We've got to do this, and we've got to get it right.

Posted by ClaudiaTherese (Member # 923) on :

quote:
Originally posted by Will B:
It doesn't seem clear that tripling or quadrupling the size of an inefficient program will necessarily make it more efficient.

One could try redoing based on principles which are more efficient. It doesn't seem that novel an idea to me.

Posted by Will B (Member # 7931) on :

If we're going to do that, we could do it *without* tripling or quadrupling its size, and save even more money!

Lavalamp, I'll take your word for it that Medicaid is insufficient at present. So let's say we want to fix it. Why not fix it? Why instead start a new program to regulate what middle-class people do with *their* health insurance? You might as well try to fix problems with WIC by starting up a new program for childless rich men.

Posted by aspectre (Member # 2222) on :

The US could also train as many physicians, nurses, technicians, etc as it needs
instead of allowing medical/etc schools to create an artificial shortage of labor to inflate wages of medical personnel
so that the top-ranks / top-earners can afford to bribe legislators into allowing them to run medical/etc schools
in such a manner that an insufficient number of physician/etc candidates are accepted for training.

Posted by Christine (Member # 8594) on :

Universal Health Care scares me to death. I have seen no evidence that the federal government can run much of anything better than private companies and every example of universal health care I have seen has lowered the standard of health care for everyone. If something serious goes wrong and you are in Canada, you want to come to the U.S. Many of them do, if they have the money. (And sometimes if they don't.)

I was not under the impression that Medicare is well run. Administrative costs aside, I was under the impression that they did not negotiate with hospitals for lower costs. Insurance companies do more than pay your bill. If you've ever been uninsured (as I have) you learn a few hard truths. When you walk into a hospital with no insurance they charge you more than they charge the insurance companies!! I don't mean a little bit, either. I'm talking orders of magnitude in some cases. You usually don't see it, it's usually masked, but I once forgot my insurance card when I went to the hospital and had to send in my insurance info later. They sent me the initial bill, though --- $10,000! When I got the statement from the insurance company, it was $1,800. That's not the worst I've heard of, either.

I don't know what the answer is with uninsured people and health care in this country. It's not that I don't sympathize. I have been uninsured (granted, briefly) and I know many uninsured people. My brother in law (uninsured) had his appendix rupture and almost died. He was in the hospital for two weeks and when all was said and done, the hospital slapped him with a $100,000 bill! Now, he makes $10,000 a year, so I don't know what they expect from him. (I believe the current plan is to send them $100 a month for the rest of his life.) I would bet good money that if he had been insured, the insurance company wouldn't have paid nearly that much. Maybe a good start, then, would be to charge regular people like my brother in law the same amount that they really charge the insurance companies.

The trouble with insurance in this country is that no one wants to talk about real problems. Instead, all I see is seemingly sympathetic politicians vying for reelection, spouting nonsense that maybe seems good on the surface. "Come on, country, we can give health insurance to all Americans." Well, there's no such thing as a free lunch, and sometimes lunch isn't worth the cost. (Take the lunch I had yesterday -- worst cheeseburger I've had since McDonadl's and they charged me $10 for it.)

Posted by aspectre (Member # 2222) on :

The middle class would be better off being covered by Medicare than by private insurers.

Posted by jlt (Member # 10088) on :

How do Canada and the UK do it?

Posted by ElJay (Member # 6358) on :

Will B, you keep talking about taking away health care choice from middle-class people. I'm upper-middle class, by virtue of a good job and no dependents, and I don't have any choice in my health care. My company picks an insurance company, negotiates rates, and tells me how much it will cost to be covered. Sometimes they change providers, and some people need to find new doctors, because the old ones aren't covered anymore. Every year the cost goes up, and the company decided how much of the increase they will cover and how much will be passed on to us. I have weekly allergy shots, and with the last change they went from being fully covered to requiring a co-pay.

I'm not complaining. . . I have good coverage, and the cost to me is reasonable and worth it. But I certainly don't have choice, except for to choose to be insured under my company's plan or uninsured. I fail to see how that would be different with government mandated health care.

You can argue the quality of care would be worse, but comparing the US to countries with socialized systems I think we'll see it doesn't have to be. But I don't see how you can argue it takes away choice, for the vast majority of Americans who get their insurance through their jobs.

Posted by ClaudiaTherese (Member # 923) on :

quote:
Originally posted by Will B:
If we're going to do that, we could do it *without* tripling or quadrupling its size, and save even more money!

Not with decent outcomes. Ours are piss-poor for the system in general, at least in comparison.

Posted by ClaudiaTherese (Member # 923) on :

quote:
Originally posted by Christine:
Universal Health Care scares me to death. I have seen no evidence that the federal government can run much of anything better than private companies and every example of universal health care I have seen has lowered the standard of health care for everyone.

That's an odd claim. Why, then, do other countries (such as Canada and New Zealand) have better morbidity and mortality rates?

quote:
If something serious goes wrong and you are in Canada, you want to come to the U.S. Many of them do, if they have the money. (And sometimes if they don't.)

If something goes seriously wrong and it needs to be dealt with quickly, then it is done quickly in Canada. If something goes wrong and can wait to be dealt with, it often must wait.

So sure, if you want bunion surgery done quickly, you might want to go to the States. But that isn't true across the board.

(Witness the morbidity and mortality outcomes for major diseases referenced above.)

quote:
Administrative costs aside, I was under the impression that they did not negotiate with hospitals for lower costs.

That is incorrect.

quote:
"Come on, country, we can give health insurance to all Americans." Well, there's no such thing as a free lunch, and sometimes lunch isn't worth the cost. (Take the lunch I had yesterday -- worst cheeseburger I've had since McDonadl's and they charged me $10 for it.)

As jlt asks, how do you think Canada and the UK do it? They spend less per capita to cover all of their people than we spend per capita to cover 25-30%, and they have better overall outcomes. How do you make sense of this by your lights?

Posted by Dagonee (Member # 5818) on :

How do UK/Canada outcomes compare to outcomes for insured people here?

Posted by ClaudiaTherese (Member # 923) on :

Depends on how you qualify "insured." Are you wanting to compared to people who have at least partial insurance at some time over a one year period, or something more comprehensive? That is, how much coverage counts, and for how long must it be?

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

Edited to add other links that may be of interest to the thread:

Recent cuts to Medicare and Medicaid funding
WHO research tools (including WHOSIS)
The Commonwealth Fund -- on International Health Policy***

***e.g,

quote:
In the article, "On the Front Lines of Care: Primary Care Doctors' Office Systems, Experiences, and Views in Seven Countries" (Health Affairs Web Exclusive, Nov. 2, 2006), the authors report on survey results that reveal striking differences in primary care practice internationally—differences that highlight the importance of having national policies in place to support primary care. According to the survey, U.S. physicians are among the least likely to have extensive clinical information systems or quality-based payment incentives, the least likely to provide access to after-hours care, and the most likely to report that their patients often have difficulty paying for care.[emphasis added]

[ February 11, 2007, 06:31 PM: Message edited by: ClaudiaTherese ]

Posted by Occasional (Member # 5860) on :

Yea, I would like some actual figures on that as well. All I see at the moment is rhetoric - on both sides.

By the way, we tried to pass Universal Healthcare once before. Hillary Clinton was the point guard. All three houses were Democrat. It got nowhere fast. What is so different now that this would actually pass this time around?

Posted by ClaudiaTherese (Member # 923) on :

quote:
Originally posted by Occasional:
Yea, I would like some actual figures on that as well.

On what, exactly? For quantification, you have to be specific.

quote:
All I see at the moment is rhetoric - on both sides.

*smile

I'm pulling together sites with figures in an edit above.

Posted by Lavalamp (Member # 4337) on :

My understanding of the current proposal (which may change -- both the proposal and my understanding of it), is that:

- private insurers offer the insurance. It's not government offering the insurance, it's Blue Cross, PacHealth, HMOs, PPOs, all the same stuff we have now.
- people always have some way of opting out if they can afford to do so (see self-insured motorists laws) -- almost nobody does this because the costs and plans are better inside the system than outside.
- the savings come from private insurers giving EVERYONE their best rates, not hitting small companies and their workers with high rates because they are in a smaller, higher risk group.

Basically, the reason health insurance is so costly in this country is because the risk is spread over small units of coverage. Large employers get huge dividends and can always outcompete. Also, laws are fragmentary so that state to state things are radically different. Even though there are standards for billing forms (set basically by Medicare's example), every other aspect of the system is duplicated 50+ times with varying degrees of success.

Special to Boon: I really don't know what the answer to your question is, but the show said that people who can't afford it will be given subsidies to get the basic coverage. I'm hoping that there's a sliding scale for such coverage so that people can get partial assistance as well, when they need it. But I haven't heard a proposal specifically about that.

Posted by Lavalamp (Member # 4337) on :

Will B: According to what I heard, every person who is currently insured through a company should be able to get the basic portion of their coverage from the same provider for less money. Or, you don't like your current provider, you'll have the option of picking a different one. I suppose there will be a small percentage of people so outraged by the government's having cooked up this scheme that they'll rebel and refuse to go with a licensed insurance carrier. I don't know that this will lead to incarceration or a fine. What was mandatory is that the pool of insurable people included EVERYONE in the country -- that's the unique aspect of this proposal, frankly. They still have to sell their products to all those consumers out there, but the prices are set not one dinky company at a time, but for the entire country, once.

I know someone who is in an informal insurance pool of the faithful. Everyone agrees to send money to whoever gets sick or needs treatment. Last I checked, most states are requiring those firms to incorporate and meet state insurance laws. I suppose if you were planning to set up something along the lines of a non-regulated insurance company, you might have problems. But I don't believe that the FBI is going to come track people down who choose not to sign on with a particular insurance company.

As long as the opt-outs are a relatively small percentage of the population, it won't make a statistical blip on the actuarial tables that are used to set the rates. The companies might use such opt-outs as a way to argue for a (slight) rate increase, but I can't imagine that a good statistician at DHHS couldn't beat them into submission -- let alone an act of Congress.

Posted by Christine (Member # 8594) on :

Lavalamp (and otherss): I think the point I was trying to make (albeit hidden in a bunch of other stuff) is that it seems to me that there are options to fix the problems in our current health care system without resorting to mandatory universal coverage, which tends to limit patients ability to see a doctor. (At least, this is hat people in the UK and Canada have told me....in the UK they see something called a health visitor...a nurse with an extra year training.)

This year, our health care premium went up $50 a month. This is not unusual. It goes up faster than the cost of inflation and I can't imagine what will happen if it continues down this path. Clearly, for both the insured and uninsured, there are problems, but I question that universal health care is the answer.

We are so often given only two choices in this country...in this case stay the same or universal health care. I'm tired of only having two choices. Why don't we have a real conversation about the problem and brainstorm solutions? We might surprise ourselves and find something else.

quote:
That's an odd claim. Why, then, do other countries (such as Canada and New Zealand) have better morbidity and mortality rates?

If I had to guess, I would have to say cultural differences can account for a lot of this. It's hard to say, though, because I don't know exactly what you are referencing here. There are three kinds of lies...you know the rest...if there is truth in statistics it is in the details that are almost always left unsaid.

Posted by fugu13 (Member # 2859) on :

I'm worried about the pool of insurable including everyone in the country. While I'm all for approaches that result in everyone in the country having plans available to them, requiring total population coverage availability for every plan seems a recipe for massive cost barriers to entry into the insurance market and difficulties in tailoring coverage to be more suitable for sub-populations.

edit: And no, insurance companies won't give everyone their best rates, they'll offer everyone rates that allow them to make money given the demand for health care. At least initially those will be higher than their best rates right now. Of course, very few people are directly paying insurance companies' best rates right now, because there's an incentive for employers to subsidize (and siloize) health insurance.

While I support making pools large enough to prevent significant adverse affects, some variation among pools will greatly help with efficient allocation of health care (and coincidentally provide incentive for people to do things that put them in healthier pools, likely improving health in the nation indirectly). For instance, have pools for each state, for age brackets, for large cities, for entire categories of employment (overtime eligible can be a pool; so can not overtime eligible, and maybe people with a commute over a certain distance).

[ February 11, 2007, 07:07 PM: Message edited by: fugu13 ]

Posted by twinky (Member # 693) on :

quote:
Originally posted by Dagonee:
How do UK/Canada outcomes compare to outcomes for insured people here?

Unfortunately my original reference has vanished from the Web -- that, or my Google-fu is weak -- but I read about a fairly detailed study comparing health outcomes in the U.S. and the U.K. that controlled for everything I could think of that would be reasonable to control for.

FWIW, the result was that outcomes in the U.K. were better accross the board. I was surprised -- I would have thought that the wealthiest Americans would have access to better care, but that expectation wasn't borne out. The study was linked on Ars Technica, but the post containing the link has fallen off the bottom of their science journal archives. I've actually posted the Ars link here a couple of times before, back when the post was still there.

Posted by ClaudiaTherese (Member # 923) on :

quote:
Originally posted by Christine:
It's hard to say, though, because I don't know exactly what you are referencing here. There are three kinds of lies...you know the rest...if there is truth in statistics it is in the details that are almost always left unsaid.

I reference WHO data. It's true that statistics can be misrepresented -- data never speaks for itself, of course. However, I'd hazard that you can't even begin a substantive discussion without knowing the standard data that is out there.

Regarding price-fixing by Medicare: Statement of the American College of Physicians - American Society of Internal Medicine to the Senate Appropriations Committee, Subcommitte on Labor, Health, and Human Services, and Education: For the Record of the Hearing on Medicare Reimbursement for Physicians and Hospitals (January 30, 2003)

-----

quote:
Originally posted by Christine:
[QB]...without resorting to mandatory universal coverage, which tends to limit patients ability to see a doctor. (At least, this is hat people in the UK and Canada have told me....in the UK they see something called a health visitor...a nurse with an extra year training.)

Individual anecdotes aside, the comparison population surveys have shown US citizens are not as happy with their own system as other countries' citizens (Finland, Denmark, Canada, UK, Australia, New Zealand, et al) are with their own systems.

Additionally, US patients are more likely to be victims of medical error, either through wrong dosing or laboratory error.

[ February 11, 2007, 07:20 PM: Message edited by: ClaudiaTherese ]

Posted by twinky (Member # 693) on :

CT, you rock. [Smile]

Posted by ElJay (Member # 6358) on :

quote:
Originally posted by Occasional:
By the way, we tried to pass Universal Healthcare once before. Hillary Clinton was the point guard. All three houses were Democrat. It got nowhere fast. What is so different now that this would actually pass this time around?

I read an interesting article about that recently, actually, I'll try to find it. The up-shot was that she pissed off a lot of the Democrats in congress who had been working on universal health care for a long time, and they refused to support her plan. So in that case, it was more a political infighting issue than something wrong with the plan.

Posted by ClaudiaTherese (Member # 923) on :

twinky, I wonder if the article you remember is either

1) "U.S. Health Care Spending In An International Context," Reinhardt et al. Health Affairs.2004; 23: 10-25

or 2) "The United Kingdom and United States Health Care Systems: a Comparison," Home Health Care Management Practice. 2004; 16: 109-116

---

(Hey, thanks! [Smile]

)

Posted by twinky (Member # 693) on :

I think it was more recent than that. I read about it last year, and it seemed to be a recent study. I could be wrong, though.

Posted by ClaudiaTherese (Member # 923) on :

I haven't kept up on the literature in the last year, but I will go check PubMed. I'd like to read it.

Posted by Bella Bee (Member # 7027) on :

I think free national healthcare is wonderful. It's not any where near perfect, of course.

This is the NHS website. It's obviously wildly positive, but it explains the history and set-up of the service.

Yes, we have crazy waiting times for certain treatments. There’s a bit of drug rationing which goes on - if you want certain drugs which have been deemed by the government regulating body to be unnecessary, you‘ve got to pay for them. And a lot of the time, employers still get BUPA or other insurance for their employees - if you can get your employees treated faster, you get them back to work faster and you don't have to pay for unproductive sick leave and temp cover. And there's never enough money to do everything that needs doing, or people, or equipment. But I still have yet to meet anyone in this country who would do away with the NHS altogether. They just want to improve what we already have.

I can go to my GP for anything, without thinking about how much it will cost. If I need a prescription, under my current circumstances, I pay £6, which is about $12.

I'm probably getting quite serious dental surgery soon on the NHS. It's going to take a few weeks until I have a consultation and a few months before I get the surgery, but it's not an emergency, so I don't care (it'd be different if it was cancer, but there you go - nothing's perfect - at least you‘d get treated).
But the fact is, I'm a currently (unofficially - I'm not on the dole) unemployed, recent graduate, with no savings. If I needed insurance, I'd have to ask my parents to pay for it, which would be unfair at this point, after they've supported me through school, or do without it and just pray I didn't get sick. As it is, this won't cost me a penny.

And when, hopefully in the next few months, I get a job, I'll be happy to pay my taxes to make sure other people get the same privilege when they need it. It's good to know, whatever your circumstances, and whatever happens, you've got that healthcare safety net.

To be honest, it bothers me that many people in the US seem to think that it's fine to let other people go hang as long as they personally are okay. It’s a kind of ’pull the ladder up Jack, I’m alright’ mentality. I'm not saying it would be any different in this country, if someone wanted to set up national healthcare today. There would be total outrage, I’m sure - especially from conservatives. The NHS was set up after the war, when everyone was envisioning a brighter future, and there was not the same kind of fear of a nanny-state that you get nowadays. I completely understand that a lot of people don't see why other people should benefit from their hard earned money.

The USA is a great country, and I don't see the harm in dreaming big - in believing that some things are too important to ignore. Yes, maybe some people who would benefit from universal healthcare would be lazy slackers, spongers, losers. Who cares. It's still better than letting them die unnecessarily.
To me, it's just the right thing to do.

Posted by ClaudiaTherese (Member # 923) on :

quote:
Originally posted by Bella Bee:
I'm not saying it would be any different in this country, if someone wanted to set up national healthcare today. There would be total outrage, I’m sure - especially from conservatives. The NHS was set up after the war, when everyone was envisioning a brighter future, and there was not the same kind of fear of a nanny-state that you get nowadays.

*nods

It was a divisive issue at the time of Canada's birth throes of universal healthcare coverage in Saskatchewan. Physicians went on strike, and replacement physicians had to be flown in from outside the province. However, both provincial and national surveys of Canadian physicians place them firmly in the "pro" category as a group now.

Of note, the US almost had universal coverage back in the 1920s, at least for children, but there was a deeply funded push by the American Medical Association to defeat the Sheppard-Towner Act in 1922. The American Academy of Pediatrics was formed when a group of pediatricians separated from the AMA in in specific reaction to this.

Posted by Samprimary (Member # 8561) on :

quote:
Universal Health Care scares me to death. I have seen no evidence that the federal government can run much of anything better than private companies

In the case of this particular idea, there's a phenomenal pool of evidence to show that public healthcare is assuredly superior to our private model. You just have to look at every comparably high-income nation in the world. They treat the populace better, they cover everyone, and they do it for cheaper.

Posted by Samprimary (Member # 8561) on :

quote:
By the way, we tried to pass Universal Healthcare once before. Hillary Clinton was the point guard. All three houses were Democrat. It got nowhere fast. What is so different now that this would actually pass this time around?

The private model is getting ready to train-wreck, works terribly, and is becoming grotesquely unraveled in rural medical networks. There's a large segment of the population which used to be virulently opposed to a social model, but have since changed their ideological tune after having been faced with inarguable evidence, anecdotal and otherwise, of the system falling apart and being an embarrasment.

When a system becomes inarguably inoperable, it cracks even the most stolid ideological blocks. In the case of healthcare, we stuck with the private model until it was not sufficiently deniable that the present system is not acceptable. In a way, we passed the threshold of dissonance.

Posted by Christine (Member # 8594) on :

quote:
Originally posted by Samprimary:

quote:
Universal Health Care scares me to death. I have seen no evidence that the federal government can run much of anything better than private companies
In the case of this particular idea, there's a phenomenal pool of evidence to show that public healthcare is assuredly superior to our private model. You just have to look at every comparably high-income nation in the world. They treat the populace better, they cover everyone, and they do it for cheaper.

Really? Where is your evidence for this? I am from Missouri (really) -- Show me!! I am open minded and willing to look at new ideas. But I have never seen any evidence to suggest that this is the case. I know for a fact that Canada taxes its population at up to 50% (depending upon the province). This doesn't seem cheaper to me.

Posted by twinky (Member # 693) on :

quote:
Originally posted by Christine:
I know for a fact that Canada taxes its population at up to 50% (depending upon the province).

It's up to 47%, actually, and then only if you earn more than CDN$118,000 annually and live in Newfoundland or Labrador. (Canada Revenue Agency.)

quote:
Originally posted by Christine:
Where is your evidence for this?

All of the charts in this post are distilled from OECD data on health spending and various other health-related statistics. The entire spreadsheet (1.4 MB Excel file) is linked on that page, and that's only a subset of the available data (the "frequently requested" health care data). I've further taken a subset of that in the interests of making this post sometime before 2008.

First, spending. The first three columns are total health care spending as a percentage of GDP in 1970, 1990, and 2004. While I've ommitted some countries that are in the full list, if you check the OECD's data you'll see that the U.S. is indeed the highest spender in both categories, by quite a bit -- that is, I haven't doctored the data to make my point.

The second set of three columns is US dollar health care spending per capita. As above, while I've ommitted some countries, the U.S. is the largest spender.

code:

		1970	1990	2004		1970	1990	2004

Austria		5.2	7	9.6		193	1328	3124
Canada		7	9	9.9		299	1737	3165
Finland		5.6	7.8	7.5		191	1419	2235
France		5.3	8.4	10.5		205	1532	3159
Germany		6.2	8.5	10.6		269	1738	3043
Greece		6.1	7.4	10		159	844	2162
Iceland		4.7	7.9	10.2		163	1593	3331
Ireland		5.1	6.1	7.1		117	794	2596
Luxembourg	3.1	5.4	8		163	1533	5089
New Zealand	5.1	6.9	8.4		211	995	2083
Norway		4.4	7.7	9.7		141	1393	3966
Portugal	2.6	6.2	10.1		51	674	1824
Spain		3.5	6.5	8.1		95	873	2094
Sweden		6.8	8.3	9.1		312	1589	2825
Switzerland	5.5	8.3	11.6		351	2029	4077
United Kingdom	4.5	6	8.1		163	987	2508
United States	7	11.9	15.3		352	2752	6102

One caveat: some of the %GDP figures are estimates, though the one for the U.S. is not.

Onward! Infant mortality isn't an unreasonable metric for taking a rough guess at quality of care. This chart shows deaths per 1,000 live births:

code:

		1970	1990	2003

Australia	17.9	8.2	4.8
Austria		25.9	7.8	4.5
Belgium		21.1	6.5	4.3
Canada		18.8	6.8	5.3
Czech Republic	20.2	10.8	3.9
Denmark		14.2	7.5	4.4
Finland		13.2	5.6	3.1
France		18.2	7.3	4.0
Germany		22.5	7.0	4.2
Greece		29.6	9.7	4.0
Hungary		35.9	14.8	7.3
Iceland		13.3	5.8	2.4
Ireland		19.5	8.2	5.1
Italy		29.0	8.2	4.2
Japan		13.1	4.6	3.0
Korea		45.0		
Luxembourg	25.0	7.3	4.9
Mexico		79.4	36.2	20.5
Netherlands	12.7	7.1	4.8
New Zealand	16.7	8.4	
Norway		12.7	6.9	3.4
Poland		36.7	19.3	7.0
Portugal	55.5	11.0	4.1
Slovak Republic	25.7	12.0	7.9
Spain		28.1	7.6	3.6
Sweden		11.0	6.0	3.1
Switzerland	15.1	6.8	4.3
Turkey		145.0	55.4	28.7
United Kingdom	18.5	7.9	5.3
United States	20.0	9.2	6.9

The U.S., though it spends more on health care both per capita and as a percentage of GDP, has a higher infant mortality rate than any other industrialized nation.

That's a start. There's tons of data out there comparing public health care delivery to private -- all you have to do is look.

[Edited to remove a redundant sentence and bold the descriptions of each chart, and add the measurement criterion for infant mortality.]

Posted by Will B (Member # 7931) on :

"What was mandatory was that the pool of insurable people included everyone in the country": if that's all we're talking about, I withdraw any objection.

Someone else:

quote:
I'm not complaining. . . I have good coverage, and the cost to me is reasonable and worth it. But I certainly don't have choice, except for to choose to be insured under my company's plan or uninsured. I fail to see how that would be different with government mandated health care.

That's a pretty big choice. I opted out of my employer's health insurance, and went for a private plan. This is already legal. (I saved money, too.)

There are also people who are self-employed, who should not be required by law to buy insurance they don't think they need.

--

Really, if you're going to argue for universally required health insurance, I think your argument will work better if you don't cite UK, Canada, etc., for two reasons.

One is that their excellent systems make people wait years and years for surgery. They're pretty good at emergency care, but if you can wait, you waaaaaaaaaaaaaaaaaiiiiiiiiiiiiiiiiiiiiiiiit. (Whereas in the USA, we're also pretty good at emergency care -- and it may not be denied -- but if you can wait, you *might* have to wait till you can pay for it.)

The other reason is that they don't have a plan like the one that's being proposed. They don't have universal mandated health insurance; they have socialized medicine. Very different beasts.

Posted by Lyrhawn (Member # 7039) on :

Why do people have to wait?

Posted by ElJay (Member # 6358) on :

You want to post some back-up on waiting "years and years" for surgery?

Posted by ClaudiaTherese (Member # 923) on :

quote:
Originally posted by Will B:
Really, if you're going to argue for universally required health insurance, I think your argument will work better if you don't cite UK, Canada, etc., for two reasons.
...
They don't have universal mandated health insurance; they have socialized medicine. Very different beasts.

What? In what way is Canada "socialized medicine" as opposed to "universal mandated health insurance?"

You have that backwards. Canada is universal health insurance provided provincially. This is distinct from the system in the UK. In Canada, the physicians are in private practice, although they are paid through public sources.

Posted by ClaudiaTherese (Member # 923) on :

Karen Davis, President of the Commonwealth Fund, gave recent Senate testimony on Learning from High Performance Health Systems Around the Globe:

quote:
One-third of all Americans and two-thirds of low-income Americans are uninsured or underinsured at some point during the year. Family health insurance premiums have risen 87 percent since 2000 while median family incomes have increased by only 11 percent. One-third of families now report medical bill or medical debt problems. We spend 16 percent of our gross domestic product (GDP) on health care, yet we fall short of reaching achievable benchmark levels of quality care.
...
The U.S. spends almost $2 trillion, or $6,700 per person on health care—more than twice what other major industrialized countries spend—and spending in the U.S. rose faster than in other countries in the last five years. Yet the U.S. is also alone among major industrialized nations in failing to provide universal health coverage. This undermines performance of the U.S. health system in multiple ways. Forty percent of U.S. adults report not getting needed care because of cost. And nearly one-fourth of sicker adults—those who rated their health as fair or poor or had a serious illness, surgery, or hospitalization in the past two years—wait six or more days to see a doctor, compared with one of seven or fewer in New Zealand, Germany, Australia, and the U.K.
...
On key health outcome measures, U.S. performance is average or below average. On mortality from conditions that are preventable or treatable with timely, effective medical care, the U.S. ranked 15th among 19 countries.
...
U.S. patients are more likely to report medical errors than residents of other countries. One-third of sicker adults in the U.S. reported such errors in 2005, compared with one-fourth in other countries.
...
The fragmentation of the U.S. health insurance system also leads to much higher administrative costs. In 2005, the U.S. health system spent $143 billion on administrative expenses. In 2004, if the U.S. had been able to lower the share of spending devoted to insurance overhead to the same level found in the three countries with the lowest rates (France, Finland, and Japan), it would have saved $97 billion a year.
...
[emphases added]

She draws on data from the WHO, from Commonwealth Fund international Surveys, and from the data on international comparisons out of the Harvard School of Public Health, among others.

Posted by ClaudiaTherese (Member # 923) on :

quote:
Originally posted by Will B:
...don't cite UK, Canada ... they don't have a plan like the one that's being proposed. They don't have universal mandated health insurance; they have socialized medicine. Very different beasts.

This is incorrect.

Canada: physicians are private businesses paid by public funding -- and provinces have the option of opting out of the system, although all currently participate.

UK: most physicians are on contract with the government and paid by public funding. Of note, some physicians are private, and there is private insurance, although it is minimally used by the population.

Thus, although you might well call the UK's NHS "socialized medicine," Canada -- in contrast -- does have universal insurance but private physicians.

Posted by ElJay (Member # 6358) on :

So, I was curious, so I looked myself. This site links to the sites that list surgery wait times for each province. There are separate listings for different types of surgery, so I picked non-emergency hip replacements to check, figuring it would be a relatively low-priority surgery. Depending on province, between 1% - 6% of patients had to wait longer than 6 months. The longest wait times were in the small eastern provinces, which I believe are the poorest. Some of them had a category for up to 24 months, which would qualify for "years," but they only had 1% of patients in it. Which is a trade-off I think I'd accept vs 40% of US adults not getting needed care at all because of the cost, as cited in CT's above post.

Checking cataract surgery in a couple of the provinces showed similar wait times, a median of 13 weeks in Alberta, 22 in um, I think it was Manitoba. Anyway, I have no idea how long it takes to schedule non-emergency surgery here. *shrug* But "years and years" certainly doesn't seem to be representative of most people's experience in Canada.

Posted by Kettricken (Member # 8436) on :

quote:
I think the point I was trying to make (albeit hidden in a bunch of other stuff) is that it seems to me that there are options to fix the problems in our current health care system without resorting to mandatory universal coverage, which tends to limit patients ability to see a doctor. (At least, this is hat people in the UK and Canada have told me....in the UK they see something called a health visitor...a nurse with an extra year training.)

I’m in the UK and am registered with a typical GP practice. If I want to see a doctor I ring up to make an appointment (for the same day if necessary). There is no limit to access to doctors.

Health visitors also exist, but are not a replacement for doctors. I think new parents get a visit to check the baby is OK and to help with any problems. This doesn’t mean you don’t see a doctor if you are ill. People with chronic health problems will also get visits by health visitors in addition to (not instead of) seeing a doctor. For some things you can also see a nurse, but a doctor is always available.

There are problems with the NHS – mainly the funding can’t keep up with demand. However, if I get ill I know I will be treated regardless of whether I can afford it or not. Waiting times are likely to be longer for non urgent treatment than with private health care, but that is a price I’m willing to pay for universal coverage.

Every time I see someone on Hatrack ask a medical question with the caveat “I know I should go to a doctor, but I haven’t got insurance” I’m grateful for our system, for all its faults.

Dentists are more of a problem – there is a shortage and it took me about a year to get a NHS dentist (although there were practices accepting children straight away).

Posted by Samprimary (Member # 8561) on :

quote:
Really? Where is your evidence for this? I am from Missouri (really) -- Show me!! I am open minded and willing to look at new ideas. But I have never seen any evidence to suggest that this is the case. I know for a fact that Canada taxes its population at up to 50% (depending upon the province). This doesn't seem cheaper to me.

Twinky decided to show the brunt of it. Really, that's most of it covered.

The good ol' U.S. of A has decided to stick with a very broken system that has watched its dysfunction exacerbate year-by-year. Even the largest private HMO's and PPO's casually admit that they have no contingency for future decades, and are merely trying to manage profitability in this decade as to be prepared to adapt to a new, expected change in the system which will avoid expected collapse. They are essentially saying "We're maintaining the black in these years and waiting for changes to come about so that the system that we rely upon does not crash and burn." What we have now is a makeshift system that runs the gamut between two extremes: the first side exists for the purpose of appeasing the desire of past legislators to have an actuarial 'free market' model. The second side is a concession by society to attempt to maintain the most tragic potential neglects of the actuarial model, e.g., poor children and the elderly. The end result is neither a free market nor a fully social model, and it's god-awful.

We spend about $5,200 per capita on health care in every year. This figure is over two and a half times the industrialized world's median of about $2,100. The amount of extra cash that we throw into our healthcare system amounts to hundreds of billions of dollars a year. So, what does this extravagant expense buy us? We have fewer doctors per capita than most western countries. We go to the doctor less often than our high-income neighbors. We get admitted to the hospital less frequently. We have worse patient satisfaction. We generally get our problems treated later rather than sooner. Our system is monstrously inefficient, hemorrhaging cash into miles of bureaucracy and care provider tape. We spend more than a thousand dollars per u.s. citizen on healthcare paperwork. You could compare that to Canada, which has a social healthcare system widely and rightfully criticized as being broken and overloaded and inefficient, and yet it only spends about three hundred dollars per canadian citizen on paperwork.

There's more, too. There are developing nations which have better infant mortality rates than our own nation. It's sad. And, lest we forget, all of the other similar high-income nations actually manage to ensure all of their citizens, where we pay into our system of incredible dysfunction, and still leave over forty five million people in our country without any coverage at all.

There's a book out called "Uninsured in America," and it's a damned scary book. It demonstrates through exposure that there is a cold, hard reality that we've put off for too long. There are a group of people in America who, according to Malcolm Gladwell, who I get most of this information from, increasingly look different from others, and suffer in ways that others do not.

Over half of personal bankruptcies are the result of unpaid medical bills. Half of the uninsured owe money to hospitals, and a third are being pursued by collection agencies. Children without health insurance are unlikely to receive proper attention for medical issues and serious injuries, recurrent ear infections, or asthma. The death rate in any given year for anyone without health insurance is about 25% higher than for someone with health insurance. Because the uninsured are sicker than the rest of us, they can’t get better jobs, and because they can’t get better jobs they can’t afford health insurance, and because they can’t afford health insurance they get even sicker.

There's some people who claim that the real problem with our healthcare system is that it isn't a 'real' free-market system, and claim that this would work better. It's not the case. The problems with our system represent all of the failings of a fully free-market system that we are not willing to tolerate as compassionate people, and for good reason. Free-market systems do not work unless you are willing to absolve the medical system from any responsibility to anyone. Remember the uproar about the hospital dumping incident? The hospital treats the man and then unloads him on skid row without a wheelchair. People were furious. With a fully free-market system, there would be no requirement nor incentive for competing medical systems to be required to treat the folks who get dumped at their doorstop every day, nor would there be any backup system or 'charity' which would have the billions and billions required to handle such issues. You would not be outraged by the hospital taking in that paraplegic and dumping him on Skid Row, as he would never be admitted to the hospital in the first place. We are absolutely not willing to set it up in our society so that insolvent folk have no right to care whatsoever and may be left to die on street corners and old folks homes or traffic accident sites, and the system doesn't work in a 'free market' sense unless we're willing to take that step, so anything in that direction should be billed as pure fantasy.

As it is, hospitals receive only about 40 to 45 cents back from every dollar of medical costs that they would otherwise charge patients. Yup, significantly less than half of that is absorbed or transmitted to others. People who are afraid of public healthcare because it means 'but i'll be paying for other people's medical costs!' should relax; they're already paying out the wazoo for everyone else's costs. Under the social system, about all that changes is that they'd cover less costs.

How much is free care? Standard practice is to fully write off all medical costs to people obviously incapable of paying, like the transients and other folk dropped off by the police every single day. Anyone who is uninsured has their costs usually sliced in half in the hopes of receiving a smaller recuperation rather than bankrupting the individual and risking recovery of no payment.

Plus, a free market system must run off of the model of profit motive, which is demonstrated as being absolutely terrible for managing priorities and channeling effective care. A perfect example: not too long ago, the city of New York set up a series of care centers which were designed around providing preventative care for folks with diabetes. The timing was perfect and the need was clear and distinct: with a looming diabetes crisis, it is imperative that the growing population of folks with diabetes go to training centers with dietitians and learn how to manage their disease to prevent the catastrophic end result of neglected diabetes.

The center had phenomenal success with their clientelle; anyone trained in their centers was extraordinarily less likely to have any medical issues and complications and early mortality associated with diabetes. Unfortunately, the vast majority of folks with diabetes were either uninsured, and/or not financially capable of supporting the costs of professional diabetes preventative care, usually due to issues like having diabetes permanently as a 'preexisting condition' after losing employment and benefits from a previous occupation, with few or no new affordable plans willing to cover the costs of managing their diabetes. Furthermore, most insurance companies wouldn't even cover it, seeing as it is, after all, a nonessential program.

So, they go out of business. All of them. They crashed and burned, actually. Major loss. Meanwhile, the companies that amputate the limbs of folks who never learned to manage their diabetes are just raking in the cash, since they deal with the emphatically 'non-optional' end result of neglected patients. And guess who foots the bill for every poor person who ends up with an amputation they can't afford? Yup.

The same issue is prevalent in all fields of american healthcare: we always end up paying more and getting less benefit because we're always managing the costly side effects of issues that were untreated because uninsured and poorly insured folk can't afford to get any sort of preventative care or screenings. HMO's have no motive whatsoever under the profit model to use preventative care to improve the later health of the people that they are covering: on average, people switch their HMO every six years. By providing preventative care, a HMO is only aiding their competitors. Unsurprisingly, preventative coverage ends up slim in nearly all plans. They try to compensate for issues with the current system by trying tricky things to stay profitable; likewise, so do the pharmacos, which attempt things like buying patents to rarely used medical consumables and jacking up their price a hundred fold.

And just in case it's possible that still someone thinks I haven't ranted about just enough things wrong with our present system? Go talk to some doctors in rural support systems. They are in disaster mode. They talk openly about near crisis. A lot of medical-state relations involve coverage requirements that say that there's got to be hospitals to cover even the less populated regions and the poorer regions. These hospitals are required to exist and yet cannot -- cannot -- survive or profit. They are given de-facto subsidy and bailouts, that grow progressively larger year by year, to keep them operating. Even as the quality of their facilities and care declines.

Blah blah blah. There's a lot of text for you. I can kind of rant about this forever. I long for the day when my wealth of information about the dysfunction of this system is rendered obsolete. I expected rightfully that the system would be abandoned once the reality of its brokenness became too painful and costly to ignore at ideological convenience. We're about there. It's only a matter of time. This failed system will be left in the dust and the fact that we clung to it so long will be remembered only as a quixotic oddity in America's past.

Posted by AvidReader (Member # 6007) on :

OMG. With twinky's numbers, covering all 300 million people in the US at Canada's rate per person will cost us $95 billion per year. If we continue to spend the same amount per person, it would be $1.8 trillion.

If I could find the amount of the federal budget, we could take that as a percentage. The next question that needs answering is how many existing services covered by Health and Human Services would be discontinued? We could pick up some significant savings there since HHS is the largest budget drain we have.

I'm curious to know how much this will end up costing us and what we will have to give up in return. I'm willing to give up a lot for the health of every American, but I'd still like to know what we're talking about before I say yes or no.

Posted by ElJay (Member # 6358) on :

So, now I'm looking for stats on surgery wait times in the US to compare to. Not as much information available. I was thinking there would probably be a big urban/rural divide as far as availability of services, but I haven't found much that address actual wait times yet. Here is a study that compares wait times for knee replacement surgery in Ontario to Indiana and western Pennsylvania. "The median waiting time for knee replacement after the operation had been planned was three weeks in the United States and eight weeks in Canada." So, 5 weeks longer. The wait time to have the specialist visit to plan the operation was also 2 weeks longer, total of 7 weeks difference. Still haven't found anything indicating wait times of years and years in Canada or the UK.

Posted by DarkKnight (Member # 7536) on :

Lines like this bother me
"One-third of all Americans and two-thirds of low-income Americans are uninsured or underinsured at some point during the year."
If I change jobs during the year, I would fall into the 1/3 of all American who are uninsured. I have no doubt since this is a statistic's arguement that we will never know how much is truly being spent by us, or any other country

Posted by katharina (Member # 827) on :

I hope and hope it will happen and will work. I hate our current system.

Posted by DarkKnight (Member # 7536) on :

UK Medhunters

quote:
What are the current concerns among patients?

A: The main concern is waiting times to get appointments with specialists and to have non-emergency operations.

Years of government underfunding has meant staff shortages, and the public is concerned at being treated by overworked and underpaid health workers. Many nurses are on short-term contracts to NHS hospitals, so patients are worried about falling standards. Patients also worry about communication problems with staff members who are recruited from countries where English is not the first language.

The underfunding has also resulted in the closure of many rural hospitals, regional restrictions on certain types of treatment for certain individuals (in one case, the NHS refused to pay for chemotherapy for a child with terminal cancer), and a notorious lack of hospital beds (only 4.5 per 1,000 population). Hospital buildings often suffer from poor maintenance, lack of repair work, and cleanliness problems.

Another concern is that the government plans to set up a two-tiered system of hospitals with higher and lower levels of funding, which would require that patients travel to larger centers for specialized treatment. Foundation hospitals would be tertiary-care centers, offering advanced diagnostic and treatment. Trust hospitals, or rural facilities, would offer basic services.

Economic information

quote:
After tourism and finance, healthcare is the most lucrative economic activity in the United Kingdom. The UK Government actively supports the growth of this industry by offering fiscal incentives and drafting investor-friendly policies that attract both domestic and foreign investors. The trade in pharmaceutical products has been profitable for the United Kingdom.

quote:
The U.K. government encourages production of generic drugs in the country by offering incentives to pharmacists and doctors for prescribing them. The over the counter (OTC) drugs market has experienced significant, though erratic growth in the last couple of years. The government’s aim to reduce healthcare costs is expected to result in the movement of an increasing number of prescription drugs to OTC status, thus giving a boost to this sub segment. The country encourages clinical trials through various tax incentives and favorable investment policies. However, low cost countries, such as India and China pose threats to the U.K. clinical trial market. The U.K. government has promised to increase R&D funding from the current 1.9 percent to 2.5 percent of the gross domestic product (GDP) by 2010.

Posted by ElJay (Member # 6358) on :

quote:
Originally posted by DarkKnight:

quote:

Another concern is that the government plans to set up a two-tiered system of hospitals with higher and lower levels of funding, which would require that patients travel to larger centers for specialized treatment. Foundation hospitals would be tertiary-care centers, offering advanced diagnostic and treatment. Trust hospitals, or rural facilities, would offer basic services.

And you think that doesn't happen here? I live in Minneapolis, Minnesota, and have many relatives in South Dakota. I can think of at least three times when I was still living with my parents that we had relatives from South Dakota stay with us while they were in town to get medical treatment in "the city" that wasn't available where they lived. I'm pretty sure that they drove further than anyone in the UK would have to drive to get to a primary medical center.

Posted by DarkKnight (Member # 7536) on :

ElJay, please show me where I said that I think that doesn't happen here? I didn't say it or imply it although I am curious as to why you take immediate offense when someone points out issues with the UK's universal healthcare? No comments about the notorious lack of hospital beds? Part of this thread was on wait times in the UK and issues with the UK's system. I posted that to show that they too have many of the same issues we do. Your comments about how far your relatives had to travel in Minnesota and South Dakota and how far people in the UK have to drive is sort of misleading as the UK is only 94,251 sq mi and Minnesota by itself is 86,943 square miles. We are a much, much larger country so shouldn't we, in some cases, have to drive further to get to a primary medical center? Doesn't that just make logical sense?

Posted by mackillian (Member # 586) on :

Another thing folks might want to consider is how those peoplel who have chronic conditions fare under the current state of health insurance and how universal health care would affect them as well.

The implentation of the proposal of universal health care has me curious as to how the matter of pre-existing conditions would be handled. Right now, if you have a chronic condition, if you want it covered by insurance, you can't ever let your insurance coverage lapse. So when you have a chronic condition, your worry when you face the moment of losing a job isn't just the money, but also the health insurance and how the hell, without a job, will you be able to pay the full premium until you find another job, because if you don't, you'll have to pay for all your doctor visits and medications out of pocket until your new insurance (if you even have it offered at your next job) will deem to cover your condition.

One of my maintenance medications costs over $400 a month at full price. There's still five more that I have to take to be a stable, productive member of society.

We ran into the issue at the end of last year, when nathan lost his job and I was out sick from work on short-term disability. The full premiums for our health insurance were just above $700 a month. However, the COBRA people took forever to finish out the paperwork and notify the insurance company (we'd paid them as soon as possible, meaning, as soon as we got the information from them) and they insisted on doing everything by mail, which added to the time it took to get things done. Two weeks went by, then another week when someone made a mistake on COBRA's end and mis-filed our policy type with the insurance company.

Meanwhile, because it had taken them so long, they wanted the next premium from us, yet all the while, we were paying out of pocket for my medications, so we were already strapped for cash, yet supposedly had health insurance but couldn't USE it. Thankfully, since we've been using the same pharmacy for a couple years, the pharmacist knows the both of us and floated us my medication until the insurance came through (so the filled the remainder of the prescription with just the copay at the end).

Then someone at the health insurance company (after many conversations with COBRA and the health insurance company) finally just said, "You know, common sense says that you can't switch from one plan to another on COBRA. By law, it has to stay the same. I'll just fix it now and then track down where it went wrong in the paperwork."

And this was working with full knowledge of the system, as the job I was on sick leave from is another health insurance company.

That is the type of situation I'd like to see disappear with the implementation of universal health care.

Posted by ElJay (Member # 6358) on :

My apologies if I misread your intent, DarkKnight, but when you just post quotes with no commentaries or opinions, it's hard to tell what your intent is. Most of the people who have been making comparisons on this thread have been doing so to point out that our system is better, whereas I think that that's a much harder judgment to make.

Likewise, I don't think I took offense at your post, I was just pointing out that the part of your quote that I had experience with was not terribly different between the US and the UK. If that was your point, then we're in agreement. As for not commenting on the lack of health care beds, well, it's not something I have experience with or knowledge of. I have no idea how many hospital beds are available per 1000 people in my area. Do you know for yours?

I don't think my comparison was misleading at all. The UK is much more densely populated than South Dakota is, and I don't think it makes sense to have expensive facilities and highly specialized doctors located where they won't be used. I would hope that everyone had basic emergency care within a reasonable distance, but if someone needs to travel six hours for specialized jaw surgery, (one of the things my relatives traveled for) I think that's just fine. My point was that travel for some healthcare needs has been a fact of life for people in large portions of this country for a long time, so it doesn't seem at all unreasonable to me that people in countries with socialized medicine should have to do the same.

Posted by ClaudiaTherese (Member # 923) on :

And it's worth noting that adequately funding a nationalized system would still cost less per capita than the US spends on a broken system.

The fact that other systems -- still with better outcomes than the US system, mind you -- could do even better with more adequate funding isn't a mark for the US. It's a mark for funding systems adequately.

And don't forget that underfunded (thus ultracheaper, not just cheaper) systems are outpreforming the US on the basis of measurable outcomes.

Posted by The Pixiest (Member # 1863) on :

Ok, I read this thread in bits and pieces over the weekend so please excuse me if Monday-morning-fog makes me address something that's already been addressed.

What *DO* they do if you can't afford coverage? If it's mandatory and you can't afford it even with the subsidies or the gov't decides you don't NEED subsidies and you still can't afford it.. What's the penalty? With mandatory auto insurance if you can't afford it, you just don't drive or get a fine if you DO drive without it. And in any event, that's to protect other people. You're not required to carry insurance for yourself, just the person you hit. You can't stop breathing just because you don't have mandatory health insurance.

Will everyone be charged the same rate or will it be based on your age, sex, health, etc? This is a really important question. Either answer leads to problems... If people are charged based on their health, then what about those of us with chronic conditions? Right now, we're part of the pool so we get averaged out with young people who never get sick.

Ok, so how about a flat rate for everyone? But now the government is involved instead of private industry. What if the government decides to start banning/taxing things that run up the rate on everyone. After all, is it fair I pay more because someone else smokes? What if we start putting big taxes on fat and sugar? What if they try to ban meat (which I think is coming down the road anyway, this will just give them more ammunition.) When the gov't starts paying for your health care you're giving them license to meddle even deeper into your life.

And what about controversial procedures? How are social conservatives going to feel about shelling out for a transexual's addadictomy (say it out-loud if you're alone) operation? Or is he just going to have to pay his mandatory insurance premium AND pay for his operation too? And what about Abortion? Are social conservatives going to allow mandatory government insurance to pay for that?

Posted by The Pixiest (Member # 1863) on :

btw, didn't we already have a thread on infant mortality rates and how it was a skewed statistic because we count underweight babies as babies that die and other countries count them as still births?

Posted by Christine (Member # 8594) on :

quote:
Originally posted by ClaudiaTherese:
And don't forget that underfunded (thus ultracheaper, not just cheaper) systems are outpreforming the US on the basis of measurable outcomes.

Posted by twinky (Member # 693) on :

quote:
Originally posted by Christine:
Here's the argument you seem to be making: We have two groups of people (those with and without UHC) and one variable (longevity).

We have more than one variable. There's longevity, there's infant mortality, there are numerous other possible choices as well. I provided you with a link to a great deal of that data on the last page.

Added: Oh, also, researchers doing statistical analysis to look for causal relationships control for other variables that might obscure the effect.

Posted by Mucus (Member # 9735) on :

TP: I might note that you're asking questions as if an American universal health care system is something brand new. As if the US is trying to create a mission to the moon and has to solve all the problems on its own.
But the fact is, many nations have gone ahead and dealt with these problems. It may be more useful to ask how they solved these problems and whether its applicable to the US.

For example, rather than asking " And what about Abortion? Are social conservatives going to allow mandatory government insurance to pay for that?" A more useful question is, "How was the abortion debate handled in Canada. How did social conservatives react in Alberta when abortion was legalised? How is our experience different?" and so forth.

Its just a bit strange in these threads when people ask questions as if they're "brand new information!"

Posted by Christine (Member # 8594) on :

quote:
Originally posted by ClaudiaTherese:
And don't forget that underfunded (thus ultracheaper, not just cheaper) systems are outpreforming the US on the basis of measurable outcomes.

I've been thinking about this assertion for a while now. I looked it up and you are right...the mortality rates in the U.S. are lower than that in many other countries, including those with universal health care. What I fail to see is the connection.

Here's the argument you seem to be making: We have two groups of people (those with and without UHC) and one variable (longevity). Obviously, since longevity is greater in countries with UHC, it is better to have UHC...?? There is no causal relationship there. We could as easily pick another variable...say percentage of people who are clinically obese, and link that the longevity. Granted, I would have an easier time buying that link but that is because countless other studies have proven that being obese adversely affects your health, not because of the observed number of fat people in the U.S.

I found this extensive list of life expectancies:

http://en.wikipedia.org/wiki/List_of_countries_by_life_expectancy

The thing that strikes me about it is the sheer number of countries, both with and without UHC, that have much higher life expectancies than the U.S. A few years ago I seem to recall that they were trying to link Japanese long life expectancies to the fish they eat.

Is it just possible that maybe there is something other than how our health system works that is affecting our lifespans? Like the number of greasy hamburgers McDonald's sells or the number of gym memberships that never get used?

All I do know for sure is that you can't make a causal assertion basd on the data you have.

Posted by twinky (Member # 693) on :

quote:
Originally posted by Christine:
All I do know for sure is that you can't make a causal assertion basd on the data you have.

I know you've double-posted, but I have to say that unless you have extensive background in statistics that you aren't telling us about, you're wrong.

Posted by The Pixiest (Member # 1863) on :

Mucus: We have many more social conservatives than Canada does.

Posted by Dagonee (Member # 5818) on :

quote:
And it's worth noting that adequately funding a nationalized system would still cost less per capita than the US spends on a broken system.

I'm still not convinced this is the case, focusing solely on "nationalized" and not commenting on the government subsidized aspect of it. As far as I know, there isn't any country on the comparison lists provided with better, nationalized health care and nearly as many people as we have - plus we are more spread out. I think regional (with several 1-state regions) systems make much better sense.

I have structure-of-government issues with nationalized health care. Our national government is far less responsive than our state government (partly due to the large number of people per representative we have). I much prefer political questions concerning allocation of resources be left to the states. If necessary, the federal government can do some fund-shifting to assist poorer states, but that should be the limit.

There's a growing tendency to subordinate structure-of-government concerns to outcome-based concerns (not saying anyone here is doing that, but on the national conversation it's certainly happening). I'd like to see such an important issue as health care be dealt with in a manner that addresses those structural aspects as well as the outcome-based aspects. If a structural change is needed, then there are ways to make those changes.

(If you didn't mean "national" per se, then disregard this. [Smile]

)

I tend to favor large-pool insurance solutions, with subsidized insurance payments for those with financial need.

Also, I haven't had time to go thorugh all the studies you posted yet, but I wanted to thank you for posting them.

Posted by Christine (Member # 8594) on :

Apologies...I somehow managed to post have my thoughts before I was done and now we've even got intervening posts! [Smile]

quote:
We have more than one variable. There's longevity, there's infant mortality, there are numerous other possible choices as well. I provided you with a link to a great deal of that data on the last page.

Added: Oh, also, researchers doing statistical analysis to look for causal relationships control for other variables that might obscure the effect.

I saw your link. Thank you. I'm still questioning the data. [Smile]

It's interesting that you bring up infant mortality. A few months ago I saw a study that was quite sure our higher infant mortality rates in this country were due to lack of breast feeding, not lack of health care. Technically, more than one thing can cause the same result but it's just something I thought I'd point out. [Smile]

As for the statistical controls...I still don't trust statistics. Especially when you claim that the wealthiest Americans, with the best access to health care, still have worse outcomes than people in other countries. Now, why would that be? They aren't exactly going to be getting bad care, are they?

So let's assume that a healthy, active, rich white man in the U.S. is more likely to die young than the same person in the UK. They both have access to doctors and medicine, so what's the deal? It's not *access* to health care that seems to be the problem, but rather the quality of the health care itself.

Listen, I don't totally disagree with any of you who want the UHC. I really don't. I see problems with the U.S. current health system and I see a need for some real solutions. But I also believe this: You can't solve a problem unless you know what, EXACTLY, it is. Too often, I think we solve symptoms rather than problems. Perhaps fittingly, I feel the exact same way about my health. If I have an ache or a pain I am often told, "Take some tylenol." Well, my body is trying to tell me something and I want to know what it is, not just mask the pain with drugs. Just after I had my son, I went to three different doctors about excruciating back pain -- the first two told me to take some Tylenol and deal with it. The third told me that I had torn a muscle, that I should do these specific things to help it heal, and then gave me a drug to take the edge off the pain.

If out health care system is failing us (and I will agree that it at least has issues) then let's find out how it's failing us.

Posted by twinky (Member # 693) on :

While health care in Canada is funded federally, it's operated at the provincial level. The federal government transfers funds to the provinces for health care, which the provinces then allocate.

Posted by Dagonee (Member # 5818) on :

quote:
For example, rather than asking " And what about Abortion? Are social conservatives going to allow mandatory government insurance to pay for that?" A more useful question is, "How was the abortion debate handled in Canada. How did social conservatives react in Alberta when abortion was legalised? How is our experience different?" and so forth.

Its just a bit strange in these threads when people ask questions as if they're "brand new information!"

Why shouldn't an opponent of a radical change to our current system pose perfectly legitimate questions about the effects of those changes? If, for example, Alberta's experience has something useful to tell us about government funding of a procedure a very large minority consider akin to murder, perhaps you could post a summary of that experience for us?

(BTW, the abortion issue is one of the prime reasons I want large, private insurance pools. If anything could spur me to a tax strike, this could.)

Posted by Dagonee (Member # 5818) on :

quote:
While health care in Canada is funded federally, it's operated at the provincial level. The federal government transfers funds to the provinces for health care, which the provinces then allocate.

I still have structural problems with that. If I were to propose a single tax reform, it would be flipping the state and federal tax burdens (after removing a few truly national expenditures such as defense). I want most of the tax money collected to be covered by a level of government closer to the people.

Posted by Christine (Member # 8594) on :

quote:
Originally posted by twinky:

quote:
Originally posted by Christine:
All I do know for sure is that you can't make a causal assertion basd on the data you have.
I know you've double-posted, but I have to say that unless you have extensive background in statistics that you aren't telling us about, you're wrong.

I have a year of graduate level statistics. I don't know if that's extensive or not, but there it is for you to tear up at your liesure. [Smile]

Look, I can believe that the statisticians controlled for a lot, but it's nion impossible to control for everything. Even if somehow they manage to get it down to the different health systems, I can't even imagine how they would narrow it down to the public vs private health care. The world is too complex to isolate that variable. Like I said in my last post, I agree that our health system has problems and in that case, the data would say exactly what you've said it does. But that doesn't mean that the problem is in the insurance! It could be the hospitals or the doctors or a dozen other things...maybe it's more than one thing.

Posted by fugu13 (Member # 2859) on :

Dagonee: you and I agree a lot on this issue. We should form a lobby [Wink]

.

I'm particularly interested in preserving the large amounts of health-care related research performed in the US by private companies, one of the notable areas our system does not seem to have underperformed.

Also, I see no reason to imitate other countries when I feel we can do it better by learning from their mistakes; many countries with significant government funding of health care or health insurance are currently feeling the problems caused by rising health care costs, and I think a well-structured system can be far more resilient to those problems.

Posted by twinky (Member # 693) on :

quote:
Originally posted by Christine:
I have a year of graduate level statistics. I don't know if that's extensive or not, but there it is for you to tear up at your liesure.

While not "extensive," it makes me willing to accept that your "I don't trust statistics" is based in reasonable skepticism than in an inherent distrust of all things scientific. That's about as much stats as I have, though I took graduate-level stats in my final year of undergrad since I didn't plan to pursue a graduate degree.

I know far too many people who simply disregard all statistics, particularly ones that say things they don't want to hear.

quote:
Originally posted by Christine:
Look, I can believe that the statisticians controlled for a lot, but it's nion impossible to control for everything. Even if somehow they manage to get it down to the different health systems, I can't even imagine how they would narrow it down to the public vs private health care. The world is too complex to isolate that variable. Like I said in my last post, I agree that our health system has problems and in that case, the data would say exactly what you've said it does. But that doesn't mean that the problem is in the insurance! It could be the hospitals or the doctors or a dozen other things...maybe it's more than one thing.

What I don't see is how the vast differences in cost can be accounted for by any of the other possibilities you're proposing. It's possible, as you say, that some of the differences in health outcomes might be caused by one or more other factors that researchers have thus far failed to control for, but that doesn't explain the cost difference. The only thing that can fully explain the cost difference is the structure of the system.

I'm not suggesting that you should turn your system into a mirror image of ours. What I'm saying is that given the vast difference in cost and the differences in various health metrics, it seems unreasonable at this point to claim that your system is anything other than broken. Given that, and given the high number of uninsured/underinsured Americans, exploring ways to insure everyone -- and thus ensure that everyone at least has access to care, regardless of quality as compared to other countries -- seems to me to be a natural first step. Whether this particular proposal is the best way to do that I don't know, but I find that often when I talk about anything containing words like "universal" or "socialized" or "single-payer" that connote government-run systems with Americans, there is an immediate negative knee-jerk reaction. Having said that, I think fugu's point is well taken: if you're going to make changes to your system, look at other systems and try to make sure you don't make some of the mistakes we did. Underfunding is an obvious example -- we have a doctor shortage at the moment because of government underfunding in the 1990s. If our funding levels had remained a bit higher, I think we'd be in a much better position (particularly given the difference in overhead that Samprimary pointed out above). We're in a decent position, but I think we could have had the best system in the world, and we don't. I'm an idealist in some ways, what can I say? [Wink]

quote:
Originally posted by Dagonee:

quote:
While health care in Canada is funded federally, it's operated at the provincial level. The federal government transfers funds to the provinces for health care, which the provinces then allocate.
I still have structural problems with that. If I were to propose a single tax reform, it would be flipping the state and federal tax burdens (after removing a few truly national expenditures such as defense). I want most of the tax money collected to be covered by a level of government closer to the people.

I don't think that would work in Canada, because of equalization. However, I think we're too decentralized here as it is.

Posted by ElJay (Member # 6358) on :

Dagonee, my concern with having universal health care at a state level is will people in the lower population or poorer states get the same level of care as people in the more densely populated or richer states? I don't want to see states turn into haves and have nots based on health care, and people making decision on what state to live in like they do for school districts now. Minnesota is known in some circles as a Welfare state, and every now and then there are a lot of stories in the news about people moving here from surrounding states because out welfare benefits are better. I think the stories are usually alarmist, honestly, but I don't want to see the same sort of thing happening with health care.

Posted by Mucus (Member # 9735) on :

TP: I know the US has more social conservatives, which is why I specifically highlighted Alberta which I believe would have a comparable number.

Dagonee: Of course I never said that the original question could *not* be asked. I just said that it would not be particularly *useful*.
A question posed in the original manner (Imagine a system like this!), tends to lead the answerer to answer in hypotheticals ("Ok, I imagined it, but I imagined it like this!), which get rebutted with hypotheticals ("But your imagination is wrong like this!"), until the whole conversation is filled with too many hypotheticals to be particularly useful to anyone.
A question asked in the new manner, may be able to find someone with that experience (in this case, an Albertan) who can give, not hypothetical conjecture, but a concrete example of what happened.

I don't happen to be Albertan. But that doesn't invalidate the approach. For example, if I was considering the consequences of a nationalised dental system, I would first consider systems around the globe and then try to extrapolate their experience to Canada. I think this would be much more useful and evidence-based than guessing how Canada would react from scratch with no evidence but my imagination.

Posted by Dagonee (Member # 5818) on :

quote:
Dagonee: you and I agree a lot on this issue. We should form a lobby

I'm all for it. [Smile]

quote:
Dagonee, my concern with having universal health care at a state level is will people in the lower population or poorer states get the same level of care as people in the more densely populated or richer states? I don't want to see states turn into haves and have nots based on health care, and people making decision on what state to live in like they do for school districts now.

"If necessary, the federal government can do some fund-shifting to assist poorer states, but that should be the limit."

quote:
I don't want to see states turn into haves and have nots based on health care, and people making decision on what state to live in like they do for school districts now. Minnesota is known in some circles as a Welfare state, and every now and then there are a lot of stories in the news about people moving here from surrounding states because out welfare benefits are better. I think the stories are usually alarmist, honestly, but I don't want to see the same sort of thing happening with health care.

I think it's right, to a certain extent, to allow states to decide the level of subsidized health care they provide. We have representative government that is supposed to be largely state-based. The allocation of shared resources is one of the primary functions of government. I want that primary function accountable to the people both providing and receiving those resources to as great an extent as possible.

If one state decides that the level of health care needed is lower than another state decides, it shouldn't be up to the rest of the states acting in concert to take that choice out of its hands.

I think it's pretty clear that, at least at the margins, there's a lot of play in deciding hot resources should be allocated. That play has been used on this thread already to support state-sponsored systems. If one state wants to decide that an 8-week delay is acceptable for knee replacement and another 16, I don't want the federal government to override those decisions.

Posted by Dagonee (Member # 5818) on :

quote:
Dagonee: Of course I never said that the original question could *not* be asked. I just said that it would not be particularly *useful*.
A question posed in the original manner (Imagine a system like this!), tends to lead the answerer to answer in hypotheticals ("Ok, I imagined it, but I imagined it like this!), which get rebutted with hypotheticals ("But your imagination is wrong like this!"), until the whole conversation is filled with too many hypotheticals to be particularly useful to anyone.
A question asked in the new manner, may be able to find someone with that experience (in this case, an Albertan) who can give, not hypothetical conjecture, but a concrete example of what happened.

An answer given in the original manner ("You should have asked X instead of Y") has a tendency to inspire responses concerning that suggestion and isn't particularly useful to anyone.

An answer given in a new manner such as "When the Albertans faced this issue, they did X," even when the original question didn't ask for examples, would actually provide relevant information rather than simply scolding someone for bringing up a relevant issue.

Posted by fugu13 (Member # 2859) on :

I suspect that a well-run system with multiple very large groups, where some of those groups were for entire states, would see comparable levels of health care available for cheaper in the least-dense states. Why? Because I suspect the health risks in those states are decidedly less. Having those costs be different is then a good thing; besides being a more efficient allocation, it incentivizes people to move towards places with lower health risks.

Posted by Mucus (Member # 9735) on :

Dagonee:

"Mom, how do I solve this math question?"

"I don't know, not my area of expertise. But maybe you should find a textbook on calculus and find out instead of working out from first principles what formula to use for integrals."

"What? You should have just given me the answer! How dare you ask me to do research instead of giving me a simple answer!"

Posted by Dagonee (Member # 5818) on :

quote:
Dagonee:

"Mom, how do I solve this math question?"

"I don't know, not my area of expertise. But maybe you should find a textbook on calculus and find out instead of working out from first principles what formula to use for integrals."

"What? You should have just given me the answer! How dare you ask me to do research instead of giving me a simple answer!"

Your analogy is so wildly inappropriate I hardly know where to begin. That would have been fine had you not attempted to put it into my mouth. That turned it into a dishonest rhetorical trick.

I'm not sure if the dishonesty is intentional or not at this point. If you truly can't see the difference between a homework problem given to a student attempting to learn how to do something and a potential issue raised by someone skeptical of a plan that others are proposing and advocating, then your dishonesty is inadvertent. I'll let you inform us whether this is the case. Or, you could simply correct your mistake. Your choice.

Posted by ElJay (Member # 6358) on :

quote:
Originally posted by Dagonee:
I think it's right, to a certain extent, to allow states to decide the level of subsidized health care they provide. We have representative government that is supposed to be largely state-based. The allocation of shared resources is one of the primary functions of government. I want that primary function accountable to the people both providing and receiving those resources to as great an extent as possible.

I agree with you in theory, but I have a lower level of trust that representatives actually make decisions based on what the electorate wants. Then again, there's no saying a national system would do that any better, so I guess I don't have a horse in this race.

Posted by Mucus (Member # 9735) on :

Dagonee:
I'm not going to answer that on the basis that you're really just asking a question akin to "Are you still beating your wife?" There is in fact a simple third choice aside from my analogy being false and me being intentionally dishonest. That you simply misunderstand the analogy.

I could in fact turn this around and be similarly facetious, "Are you so obtuse that you cannot understand this analogy or are you feigning indignation to score cheap points?"

Instead, I will assume good faith and that you simply missed the parallel in the analogy.

A student working on a math question often asks "what is the answer to this?" It is often easy to answer "47.1 m^2" or whatever the answer may be.
Instead, the proper way is to lead the student to find out the answer for themselves. This is summed up in the popular saying, "Give a man a fish; you have fed him for today. Teach a man to fish..."

In TP's case, I could have answered the question outright by making something up without evidence. But in fact, I do not know the answer, I merely know where to find the answer, in the Albertan experience.
In fact, TP asked the proper question, "Are you you sure this is relevant?" in the same sense that a math student would say "This math textbook does not have the exact question I'm trying to solve, are you sure this is relevant?" A much less constructive approach would be feeling indignant that one has the audacity to suggest a different approach at asking a question.

In the end, a student would be much better served by asking "How do I find out how to solve this question?" rather than "What is the answer?" Similarly, TP would be better served by asking "What was the X experience, and how could it be extrapolated to us?" or even "Did anyone else have X experience, how can we learn from it?" rather than simply "What about X? I think it might be a problem."

In the end, I was not pushing an agenda. In fact, I suspect that Alberta may not be a good argument to convince social conservatives to accept UHI, but instead would be a cautionary tale. But I do not know for sure.

TP may very well find that the research might lead them to ask "In Alberta, X happened with UHI, with this evidence, would not the problems be magnified by the unique characteristics of the US?"

But in the end, this would be much more interesting, assuming they do not follow your puzzling indignation and avoid the research out of spite.

Posted by Bokonon (Member # 480) on :

I'm interested in why we can't phase in a system over time, starting by targeting some more neutral targets. I'm a big proponent of instituting automatic coverage of preventative and emergency care for minors. I see it as a parallel principle to public education. I also think there'd be much more support for this step, and I think it provides our society a pretty good bang for the buck.

I am also sympathetic to not automatically assuming funding will come from the national level.

-Bok

Posted by ClaudiaTherese (Member # 923) on :

quote:
Originally posted by Bokonon:
I'm a big proponent of instituting automatic coverage of preventative and emergency care for minors. I see it as a parallel principle to public education. I also think there'd be much more support for this step, and I think it provides our society a pretty good bang for the buck.

SCHIP is supposed to provide this for children not otherwise covered.

---

Edited to add: SCHIP is the State Children's Health Insurance Program, which was established in 1997 as Title XXI of the Social Security Act. The US Federal Govenment provides matching funds to State governments to provide and administer healthcare coverage to uninsured and underserved children in each state.

[ February 12, 2007, 06:20 PM: Message edited by: ClaudiaTherese ]

Posted by Dagonee (Member # 5818) on :

quote:
That you simply misunderstand the analogy.

Whether I've understood the analogy or not, your putting it into my mouth is cheap. (And, for the record, I did understand. Your explanation added nothing to it that wasn't obviously there.) It's not what I said; it is in fact very different than what I said.

quote:
the proper way is to lead the student to find out the answer for themselves.

How utterly patronizing of you. You haven't led Pixiest anywhere, and she certainly doesn't need you to do so.

The proper way to help a student trying to learn how to do a math problem is to lead the student to find the answer for themselves. Pixiest isn't your student, or anyone else's here.

Pixiest was not looking for someone to teach her how to do a problem. Pixiest was pointing out a possible problem and giving those advocating the solution a chance to address that problem.

She's not better served by going and doing the research to support someone else's position.

quote:
But in the end, this would be much more interesting, assuming they do not follow your puzzling indignation and avoid the research out of spite.

It would, in fact, be much more interesting if you were to summarize the Alberta experience and make a point based on it, rather than continually hinting that others should care enough about your point to do your research for you.

[ February 12, 2007, 05:48 PM: Message edited by: Dagonee ]

Posted by Christine (Member # 8594) on :

twinky -- about the cost differences between our system and others -- I do find it interesting that health care costs so much more here than it does in other places. My concern on this topic is to ask where, exactly, is all the money going and how, exactly, does UHC fix this? If, for example, all the money is going to insurance companies profits and wasteful spending, then there is a point to be made. On the other hand, I understand that drug companies charge Americans far more for prescriptions than any other country. Many Americans have resorted to buying Canadian drugs for this reason (illegally). Will drug companies charge less if we have UHC?

I don't know what else is affecting those numbers...but I think it is a worthwhile question to ask.

A while back, Pixiest brought up a point that I think is also worth exploring. How do we get charged for this system? Is it based on age, health, or income?

Posted by The Pixiest (Member # 1863) on :

Mucus: Please abbreviate my name "Pix".. It took me a moment to realize that "TP" was supposed to be me.

Anyway, as usual, Dag phrased what I would like to say better than I would have. ((Dag))

Posted by ClaudiaTherese (Member # 923) on :

quote:
Originally posted by Christine:
My concern on this topic is to ask where, exactly, is all the money going and how, exactly, does UHC fix this? If, for example, all the money is going to insurance companies profits and wasteful spending, then there is a point to be made.

From above, to explain a good part of this:

quote:
The fragmentation of the U.S. health insurance system also leads to much higher administrative costs. In 2005, the U.S. health system spent $143 billion on administrative expenses. In 2004, if the U.S. had been able to lower the share of spending devoted to insurance overhead to the same level found in the three countries with the lowest rates (France, Finland, and Japan), it would have saved $97 billion a year.

That's a savings of about 2/3, or in other words, dropping down to 1/3 the current cost.

Posted by Dagonee (Member # 5818) on :

That's 1/3 of the cost for administration, right?

According to the figures you posted on the previous page and google searches for 2004 GDP and population, we spent 1.7-1.9 trillion in 2004 on health care.

So this would be a 5% overall savings, which is far more than I would have guessed. Not bad.

Do you know where the rest is coming from? (And if I'm being too presumptuous asking so many questions, let me know. I find this terribly fascinating but never have the energy to really research it.)

Posted by Kwea (Member # 2199) on :

::::smacks Dag for being presumptuous::::

I find this interesting as well. [Wink]

Posted by AvidReader (Member # 6007) on :

This thread has made me realize that I'm a scary patriot. When I saw Mucus asking why didn't we just see how Canada had dealt with UHC issues, my first thought was, "Why do I give a crap about Canada? I don't want to do it their way."

I wonder how many other Americans suffer from this knee-jerk reaction to America needing to be best. That will be important to framing the debate as it goes forward. We can't just ignore how everyone else did it because some of us want us to do it on our own. But we have to be careful how we present infoon other countries if it's going to turn people off. What a strange dilemma I never expected to suffer from.

Posted by pH (Member # 1350) on :

You know, no one ever answered Pix's question about controversial procedures (beyond this Canada vs. US abortion thing). And beyond that, what about simply unconventional procedures or methods of therapy? Who decides what off-label uses of what drugs are acceptable?

And, as Dag said, if you really think we should consider how it worked in other countries, why not say something about it instead of expecting us to automatically jump to it? Honestly, there are enough large differences that it's probably not as directly applicable as you think. It's like gun control. It's great to say that the US should just do what Country X should do when it comes to gun control, except that Country X did it's gun control thing years ago. We're not frozen in time here.

-pH

Posted by Lavalamp (Member # 4337) on :

quote:
Originally posted by pH:
You know, no one ever answered Pix's question about controversial procedures (beyond this Canada vs. US abortion thing). And beyond that, what about simply unconventional procedures or methods of therapy? Who decides what off-label uses of what drugs are acceptable?

-pH

Why would making sure everyone has health insurance change any of those things. I didn't answer Pixiest's earlier post about this stuff because it just didn't strike me as particularly relevant to the solution that's being proposed, as far as I understand it.

If all we're doing is making the insurance cheaper by putting EVERYONE into the same pool, I'm not exactly sure how this changes anything except for small insurance carriers who may be suddenly exposed to increased competition in niche markets they formerly served.

If, as I suspect, the US system merely makes it so that every insurer offers a low rate for basic (minimum) coverage, I don't really anticipate the social upheaval that would come from government-control.

The big change here is that the insurance pool is larger for everyone, and most people (if not all) should see a lower premium as a result. IF what the insurers have been telling my SMALL company all these years is true, at any rate.

If there was a way for my company to join a larger pool and save money on policies, we'd do it. I don't see that happening without government intervention because there's no incentive for the insurers to pool our risks with anyone else's when they can just hit both smaller units at a higher rate. Insurance sales persons are cheap, so the cost of having a bunch more salespersons around to go bit by bit is just not enough of a cost to make it worth their while to save on that.

Look, the BIG lie in the current Health INSURANCE system is that the insurers tell us that employees in bigger companies aren't subsidized by the higher rates charged to the employees in smaller companies. They get better rates SOLELY because they have a bigger pool, of mostly younger employees all paying premiums but not necessarily using the services. What that is true, it is also true that the insurers lower their rates (relatively speaking) in order to get the business of the larger companies and so they don't make nearly as much profit from those folks as they do from an equivalent person (young/healthy) who happens to work for a small company.

They don't like to admit this, though, because the solution is patently obvious -- form larger pools and bludgeon the insurers into providing better rates to employees currently covered in the smaller pools.

What has forced their hand...I don't know. But something changed recently either in Congress or in the competitive arena of insurance to make people realize that things can't go on like they have for much longer. The insurance costs at small companies are crippling. Not just in terms of dollars spent on the policies either, but in terms of competitiveness and in terms of the amount of time the annual renewal of policies takes up. I won't go into specifics for my company, but I know that there's a lot of low-ball initial pricing going on, with 11th hour "underwriter bumps" when they think you'll be so tired of the whole thing that you'll sign just to have it over with.

On top of that, you can NEVER count on having the same coverage from one year to the next. The insurer from year A just seems not interested in keeping customers in year B. They raise rates, refuse to negotiate, and little companies have no leverage.

Now, contrast that with a system wherein everyone is in the same pool. Suddenly, there's no worries about who you work for. If you work for a giant mega-corp or a mom-and-pop, you'll still get the same rate. And why shouldn't you? What has the size of your company got to do with your personal health? (Okay, it does have a little to do with, but only in specific situations -- larger companies have better Safety programs generally, but we're talking lots of jobs that don't require that kind of thing).

So...
What I'm not really groking to is resistance forming the largest possible pools and thus getting the lowest possible rates.

If that's the basics of this solution, I'm happy.

If, on top of that, the government decides it can afford to subsidize the insurance of more people than it could before, and thus make sure that more people have health insurance coverage, I'm not just okay with it, I think we've done a good day's work.

I don't really see how this ends up creating a huge bureaucracy, gets us out of funding research, meddles with private industry, or personal choice. It's not like the government is the one offering the insurance. No checks will be written to the government.

It just seems like over 1/2 of the arguments against this proposal are about things that aren't being proposed.

Posted by fugu13 (Member # 2859) on :

The largest pools do not lead to the lowest possible rates. An insurance company needs to calculate their expected payout for a given pool, (which will incidentally be higher than the average expected medical cost of pool members, since people who know they will have higher costs are more likely to enroll), then determine rates based off it.

Trying to 'bludgeon' insurers into charging any amount significantly less than that will only result in undersupply of insurance, particularly if the large fixed cost of supplying anyone in the nation is forced. Its all very well to have insurance plans that are cheap enough for everybody when there aren't enough companies willing to employ enough people to make it happen efficiently. You want to know what causes those long waits? The assumption that mandating a price makes that the cost. No, the cost is still the real cost, but part of it is transformed (frequently into waits, such as when there were gasoline controls).

Insurance salesmen may be cheap, but the real suppliers of insurance (the reinsurers) are calculating and efficient. The very fact that insurance costs are so closely attuned to health care costs should indicate how much health care costs determine them.

People previously members of higher average risk pools will see lower rates. People previously members of lower average risk pools might well see higher rates. Combining everyone together does not magically lower the expected payout of the group so that everyone has lower rates.

Furthermore, even if one has large pools it can be more efficient to have multiple ones. For instance, re: dividing up by state, if some rates are higher risk than others, it makes sense to have different insurance rates in those states.

Besides the obvious economic efficiency argument (and the externalities criticism doesn't apply if its reasonably feasible for everyone to be covered), it creates an incentive for people to move to states with lower rates . . . which are also the ones with less risk, which will mean exposing the people who move to less risk (assuming, which is reasonable, that a substantial part of typical risk is environmental), will mean lowering overall healthcare costs and improving overall health.

Posted by ClaudiaTherese (Member # 923) on :

quote:
Originally posted by Dagonee:
That's 1/3 of the cost for administration, right?

Right.

quote:
Do you know where the rest is coming from? (And if I'm being too presumptuous asking so many questions, let me know. I find this terribly fascinating but never have the energy to really research it.)

The rest of what? (The rest of the cost difference in toto?)

No worries about asking questions. I've just been busy at work and in the rest of my life, and also -- though it shames me to say -- I think I've gone over this so many times that I get irritable more easily than ever before. For so many years I would write these long, involved, step-by-step posts that laid out the whole situation as I saw it. And nobody but Rakeesh seemed to read them. *grin

It may be that my best role is to just point the way to resources. I'm really not sure. But, as noted above, it's worth avoiding ticking people off right from the get-go.

Posted by rivka (Member # 4859) on :

quote:
And nobody but Rakeesh seemed to read them. *grin

Hey!

Posted by katharina (Member # 827) on :

I read them, CT. You convinced me. [Smile]

Posted by Dagonee (Member # 5818) on :

quote:
The rest of what? (The rest of the cost difference in toto?)

Yes. Using Canada and UK as examples, we need to cut 40-60% from our costs (rough math) to match them. We get 5% from admin savings, so we need to come up with 35-55% additional savings. I assume we get some from reduced acute illness through more universal preventative care, which should be quantifiable. I'm trying to figure where the rest of the savings come from.

quote:
But, as noted above, it's worth avoiding ticking people off right from the get-go.

For the life of me, I can't remember the last time you ticked me off. [Smile]

Posted by Mucus (Member # 9735) on :

Dag:

quote:

How utterly patronizing of you. You haven't led Pixiest anywhere, and she certainly doesn't need you to do so.

I'm not entirely sure if you mean being compared to a student is patronizing or just the correction itself.

If its the correction, well, I've seen posters commenting on people's spelling or grammar on this forum, and quite bluntly I might add.
I simply made a suggestion based on my appreciation of the fact that many previous posters had points based in hospital wait times, or WHO statistics, or any number of pieces of evidence. Posts of that sort seemed to be more constructive and I looked forward to more of the same. *shrug*

If its simply being compared to a student, well, I can't do much about the connotations that you apply onto that. Different people have different experiences and appreciation of academic experience.

quote:
She's not better served by going and doing the research to support someone else's position.

Someone else's position? I haven't even taken sides in this debate. You can read each of my posts in this thread to confirm it. In a very real sense, I don't care about the outcome, I'm not American and simply have been reading out of curiosity.
My "position" if any was simply that one can learn from other experiences, which does not seem to be inherently a controversial position.

AvidReader:

quote:

This thread has made me realize that I'm a scary patriot. When I saw Mucus asking why didn't we just see how Canada had dealt with UHC issues, my first thought was, "Why do I give a crap about Canada? I don't want to do it their way."

Eh. Its just Not Invented Here. Its not your fault, everyone suffers from it, as the link will aptly demonstrate. This quote is a bit ironic though.

quote:
While the etymology is perhaps apocryphal, the American National Institutes of Health (NIH) is said to either to be the direct inspiration for the term, as a play on its acronym or as an organization subject to this attitude.

pH:

quote:

It's great to say that the US should just do what Country X should do when it comes to gun control, except that Country X did it's gun control thing years ago. We're not frozen in time here.

Good thing in my very first post, I said

quote:
"How was the abortion debate handled in Canada... How is our experience different?" "

*shrug*

Posted by Dagonee (Member # 5818) on :

quote:
If its simply being compared to a student, well, I can't do much about the connotations that you apply onto that. Different people have different experiences and appreciation of academic experience.

No, it's the connotation that you need to treat her like you're her parent. Lest we forget the analogy at issue:

quote:
"Mom, how do I solve this math question?"

"I don't know, not my area of expertise. But maybe you should find a textbook on calculus and find out instead of working out from first principles what formula to use for integrals."

"What? You should have just given me the answer! How dare you ask me to do research instead of giving me a simple answer!"

quote:
Someone else's position? I haven't even taken sides in this debate. You can read each of my posts in this thread to confirm it. In a very real sense, I don't care about the outcome, I'm not American and simply have been reading out of curiosity.

Good. I didn't say you had taken a position. But the position you're asking her to research is not her own.

quote:
My "position" if any was simply that one can learn from other experiences, which does not seem to be inherently a controversial position.

That's not controversial. What's controversial is taking someone to task for not doing it when you can't be bothered to do it either. And, in the course of doing so, suggesting that you're doing her a favor by both chiding her and refusing to give information that it seems you possess.

Posted by pH (Member # 1350) on :

quote:
Originally posted by Lavalamp:

quote:
Originally posted by pH:
You know, no one ever answered Pix's question about controversial procedures (beyond this Canada vs. US abortion thing). And beyond that, what about simply unconventional procedures or methods of therapy? Who decides what off-label uses of what drugs are acceptable?

-pH
Why would making sure everyone has health insurance change any of those things. I didn't answer Pixiest's earlier post about this stuff because it just didn't strike me as particularly relevant to the solution that's being proposed, as far as I understand it.

If all we're doing is making the insurance cheaper by putting EVERYONE into the same pool, I'm not exactly sure how this changes anything except for small insurance carriers who may be suddenly exposed to increased competition in niche markets they formerly served.

If, as I suspect, the US system merely makes it so that every insurer offers a low rate for basic (minimum) coverage, I don't really anticipate the social upheaval that would come from government-control.

The big change here is that the insurance pool is larger for everyone, and most people (if not all) should see a lower premium as a result. IF what the insurers have been telling my SMALL company all these years is true, at any rate.

If there was a way for my company to join a larger pool and save money on policies, we'd do it. I don't see that happening without government intervention because there's no incentive for the insurers to pool our risks with anyone else's when they can just hit both smaller units at a higher rate. Insurance sales persons are cheap, so the cost of having a bunch more salespersons around to go bit by bit is just not enough of a cost to make it worth their while to save on that.

Look, the BIG lie in the current Health INSURANCE system is that the insurers tell us that employees in bigger companies aren't subsidized by the higher rates charged to the employees in smaller companies. They get better rates SOLELY because they have a bigger pool, of mostly younger employees all paying premiums but not necessarily using the services. What that is true, it is also true that the insurers lower their rates (relatively speaking) in order to get the business of the larger companies and so they don't make nearly as much profit from those folks as they do from an equivalent person (young/healthy) who happens to work for a small company.

They don't like to admit this, though, because the solution is patently obvious -- form larger pools and bludgeon the insurers into providing better rates to employees currently covered in the smaller pools.

What has forced their hand...I don't know. But something changed recently either in Congress or in the competitive arena of insurance to make people realize that things can't go on like they have for much longer. The insurance costs at small companies are crippling. Not just in terms of dollars spent on the policies either, but in terms of competitiveness and in terms of the amount of time the annual renewal of policies takes up. I won't go into specifics for my company, but I know that there's a lot of low-ball initial pricing going on, with 11th hour "underwriter bumps" when they think you'll be so tired of the whole thing that you'll sign just to have it over with.

On top of that, you can NEVER count on having the same coverage from one year to the next. The insurer from year A just seems not interested in keeping customers in year B. They raise rates, refuse to negotiate, and little companies have no leverage.

Now, contrast that with a system wherein everyone is in the same pool. Suddenly, there's no worries about who you work for. If you work for a giant mega-corp or a mom-and-pop, you'll still get the same rate. And why shouldn't you? What has the size of your company got to do with your personal health? (Okay, it does have a little to do with, but only in specific situations -- larger companies have better Safety programs generally, but we're talking lots of jobs that don't require that kind of thing).

So...
What I'm not really groking to is resistance forming the largest possible pools and thus getting the lowest possible rates.

If that's the basics of this solution, I'm happy.

If, on top of that, the government decides it can afford to subsidize the insurance of more people than it could before, and thus make sure that more people have health insurance coverage, I'm not just okay with it, I think we've done a good day's work.

I don't really see how this ends up creating a huge bureaucracy, gets us out of funding research, meddles with private industry, or personal choice. It's not like the government is the one offering the insurance. No checks will be written to the government.

It just seems like over 1/2 of the arguments against this proposal are about things that aren't being proposed.

As far as I can tell, absolutely NONE of this even comes close to addressing the actual question, which is quite relevant when you consider that there are a good deal of unconventional procedures and off-label drug uses on which many people already rely.

-pH

Posted by Mucus (Member # 9735) on :

quote:
Originally posted by Dagonee:
No, it's the connotation that you need to treat her like you're her parent. Lest we forget the analogy at issue:

Actually, if you might have noticed. That analogy was specifically applied as a response to *you*, not her. Her response, I specifically noted before, was a proper objection to whether the evidence was useful enough, not whether one should look at it at all.

quote:
Good. I didn't say you had taken a position. But the position you're asking her to research is not her own.

I'm still not sure what "position" you're referring to. To go back to the textbook analogy (if you don't find it too patronising). When one is referred to a math textbook, there may be an answer, or more likely there will be similar examples and case studies that will point the way to an answer. In this case, I just said "for example" the Alberta scenario, but I have no stake in it.
As I have said before, the evidence may lead to support her position, it may not. To go back to the textbook, I just know it may be useful if she's interested in it.

quote:
That's not controversial. What's controversial is taking someone to task for not doing it when you can't be bothered to do it either.

I cannot agree. Its not my point, its her point. It seems clear to me that if one brings up a point, one should have evidence to back it up.

It seems strange that I can only criticize her for not doing research if I have done the research in question. This would be a strange view if applied to say, reviewing academic papers. Imagine if a review committee had to have previously done all the research behind a paper in order to determine whether the paper had sufficient backing. It would somehow eliminate the point of doing the paper in the first place! Instead, its much more reasonable to assume that they only have enough knowledge to judge whether the paper had logically and sufficiently presented its evidence.

Posted by twinky (Member # 693) on :

quote:
Originally posted by pH:
And, as Dag said, if you really think we should consider how it worked in other countries, why not say something about it instead of expecting us to automatically jump to it?

Plenty has been said about it in the last three pages. I don't understand your complaint.

quote:
Originally posted by pH:
It's great to say that the US should just do what Country X should do when it comes to gun control...

Saying that Country X doesn't have Problem Y, while the U.S. does, isn't the same as saying the U.S. should do exactly what Country X does.

quote:
Originally posted by pH:
...except that Country X did it's gun control thing years ago. We're not frozen in time here.

I don't see anyone in this thread suggesting that you shouldn't attempt to learn from both the successes and mistakes of other countries.

Posted by Dagonee (Member # 5818) on :

quote:
Actually, if you might have noticed. That analogy was specifically applied as a response to *you*, not her.

More speciousness. Your response to me was a response to a statement about why your original response to Pixiest was not "useful" (the standard you seem to be applying here). In making that response, you specifically and explicitly stated that my comment was the equivalent of saying a student should be told the answers rather than pointed to a place to learn how to do a problem. To say that analogy did not equate Pixiest to the student is disingenuous in the extreme.

Further, the analogy was still a dishonest representation of what I said. You still haven't corrected that dishonesty. You still can decide you want to be honest here.

quote:
I'm still not sure what "position" you're referring to. To go back to the textbook analogy (if you don't find it too patronising). When one is referred to a math textbook, there may be an answer, or more likely there will be similar examples and case studies that will point the way to an answer. In this case, I just said "for example" the Alberta scenario, but I have no stake in it.
As I have said before, the evidence may lead to support her position, it may not. To go back to the textbook, I just know it may be useful if she's interested in it.

You didn't just say "You might want to check out what happened in Alberta." You also gave a little lecture about how useless her questions were. They weren't useless. The raised a very specific point, one that has yet to be addressed at all.

quote:
Its not my point, its her point. It seems clear to me that if one brings up a point, one should have evidence to back it up.

She asked - presumably the proponents - how this would be handled. She doesn't need to provide evidence that someone else handled it in a particular way.

quote:
It seems strange that I can only criticize her for not doing research if I have done the research in question. This would be a strange view if applied to say, reviewing academic papers. Imagine if a review committee had to have previously done all the research behind a paper in order to determine whether the paper had sufficient backing. It would somehow eliminate the point of doing the paper in the first place! Instead, its much more reasonable to assume that they only have enough knowledge to judge whether the paper had logically and sufficiently presented its evidence.

You're analogy is, once again, sadly misplaced. Pixiest isn't the author of the paper; she's the peer reviewer. The author is the proponent of the change to the health care system. As you said, "Imagine if a review committee had to have previously done all the research behind a paper in order to determine whether the paper had sufficient backing."

Why on earth are you trying to hold the review committee to that standard when you've admitted it's ridiculous to do so.

Posted by rjzeller (Member # 8536) on :

Comparing healthcare in the US with systems in other nations, such as the UK and Canada is fruitless and gets us nowhere. There are differences that go far beyond the healthcare system itself that impact the statistical outcomes one may witness.

One of the biggest problems in the US with healthcare is we're trying to maintain a private system, but strip all the motivators that make private systems work. Why? Becuase we have an entitlement mindset that ALL of us should have access to the SAME quantity and quality of care. Maybe we should, maybe we shouldn't, but we cannot apply one set of solutions to an environment that wasn't designed for them without a major overhaul in both structure and attitude.

The pool of medical talent in the US is highly limited, and some could argue this is an artificial limitation. The result, nevertheless, is higher than average incomes and costs. To become a doctor in the US takes great investments in time and money, and we limit how many people get accepted into the programs that would turn them into doctors.

Doctors make significantly higher salaries in the US than in canada (since every salary survey differs in the real dollar amounts, I'll leave it up to the generalized statment, but they all seem to confirm that US doctors make much higher salaries). And that doesn't even account for differences in taxation.

There are also controls affecting clinician behavior, such as tort/malpractice concerns, insurance limitations, differences in coding practices, availability of specialized care, patient demands, and so forth.

Pharmaceuticals are forced to sell for lower than they otherwise would in some countries due to regulations, so they charge higher where they can.

We have an insurance industry that is actually a maintenance plan, NOT an insurance plan. Our demands on health insurance are NOT the same as they are for auto, home, or life insurance.

We continually focus on quick, no-pain solutions to the healthcare dilemma in the US. And the reason is that we do NOT have a system, we have a mixture of the following:

Financing of health coverage
Different types of coverages
Provider reimbursment schemes
Different delivery systems
multiple ownerships and governance of care
Multiple regulatory environments

And why such a hodge-podge of coverage and costs?

Most consumers do not face any financial consequences for their healthcare choices, providers have wide economic and clinical autonomy, there is almost NO information about provider quality, healthcare information technology lags behind other industries, and the focus is on acute care--not management and prevention.

The result is a series of one-off solutions that simply do not work: certificate of need, Pay-or-play plans, purchasing coalitions, pay-for-performance, consumer-directed healthcare, and so on. While some of these showed short term drops in costs, there was always a rebound with higher-than-before costs.

Sharing of health information is arduous and costly, and privacy regulations make administration costs staggering (how often do you have to completely re-register when you move or start attending a new medical facility?).

We have a system that is overloaded with regulations, artificial restrictions on talent and avialability, lack of accountability and data on providers, extreemly high salaries, and exceptionally high administrative costs; yet at the same time, we expect everything for a $10 copay and access to the best of everything even if we don't need it. And thus we continually demadn the best when often second-best will do.

How do you tell one patient that they only need the $5000 pacemaker when their insurance will cover them for the $50,000 model just as well? Which do you think they're going to choose?

Which are YOU going to push on them, all things being equal, if your pay is influenced by the amount of services you bill?

Too many things have to change in order for the system to right itself IF we insist on making the costs to the consumer transparent. So long as the consumer is NOT the one paying the bill, the system remains broken unless you cut salaries and profit from the entire picture.

This is why a universalized plan will not work in the US, not unless you make some major changes across the entire spectrum of healthcare in this country. And if you do, be prepared for significant decreases in the development and funding for new drugs, practices, and treatments.

The less we pay directly, regardless of whether it's uncle Same or some newfangled HMO, the higher our costs will be, and the worse, not better, the problem will get.

Posted by ClaudiaTherese (Member # 923) on :

Well, rivka and katharina, it's great to know that you were reading. [Smile]

Posted by Mucus (Member # 9735) on :

Dagonee:

quote:

Your response to me was a response to a statement about why your original response to Pixiest was not "useful" (the standard you seem to be applying here). In making that response, you specifically and explicitly stated that my comment was the equivalent of saying a student should be told the answers rather than pointed to a place to learn how to do a problem. To say that analogy did not equate Pixiest to the student is disingenuous in the extreme.

I did not say that I did not equate her to a student. I said that the analogy was specifically directed at you. In the analogy, I specifically equated *you* to a student that lashes out at a parent for suggesting an alternative source of evidence. A curious student that examines the evidence is admirable, the latter is not.

In any case, this side-thread is getting long and we can both agree that neither of us will be convinced, let alone have this debate contribute to the issue of UHI.

Posted by Christine (Member # 8594) on :

quote:
This is why a universalized plan will not work in the US, not unless you make some major changes across the entire spectrum of healthcare in this country. And if you do, be prepared for significant decreases in the development and funding for new drugs, practices, and treatments.

I agree.

Posted by ClaudiaTherese (Member # 923) on :

quote:
Originally posted by [rjzeller]:
And if you do, be prepared for significant decreases in the development and funding for new drugs, practices, and treatments.

I think we'd be amazed at the outcomes if we successfully used the ones we already have.

----

Edited to add: Of note, much promising research is being done outside of the US, such as the development of the Edmonton Protocol for pancreas islet cell transplantation (removes the need for insulin therapy for diabetics). There is certainly promising research on tap in the US, but I'm not sure it is outcomes-driven as much as profit-driven. I'm wary of sinking money into doing new things just for the sake of them being new -- I want to see it justified in substantial expected outcomes.

[ February 13, 2007, 03:41 PM: Message edited by: ClaudiaTherese ]

Posted by ClaudiaTherese (Member # 923) on :

quote:
Originally posted by Dagonee:
I assume we get some from reduced acute illness through more universal preventative care, which should be quantifiable. I'm trying to figure where the rest of the savings come from.

I bet a good bit of it is through reduced chronic illness through more universal preventative care. Diabetes and hypertension are huge drains on morbidity and mortality, and they are pretty much asymptomatic for most of the course. [So if you aren't being screened and managed early, the endgame is exponentially worse. And when such a huge number of people are only being seen acutely through EDs, then you are going to have people showing up with the serious complications of late-stage disease: heart attacks, gangrene needing leg amputation, strokes, blindness, kidney failure, etc.]

This is quantifiable, though, and I should find the numbers. I have them somewhere. Work calls first, though.

quote:
For the life of me, I can't remember the last time you ticked me off.

Whew!

I respect you, so that's an important marker for me.

Posted by fugu13 (Member # 2859) on :

I think a lot of research done in the US is profit driven. I think that's why we have so much more research (including per capita) than other countries. I rather like that we have a system that allows it to be profitable for people to develop new medical techniques and technologies.

Posted by Dagonee (Member # 5818) on :

I misused acute - and I knew that when I typed it, and meant to change it. I should stick with my own jargon. [Smile]

Posted by Christine (Member # 8594) on :

CT -- just a nit: that quote you attributed to me was by rjzeller...I just agreed. [Smile]

Of course, speaking as someone with a (non life-threatening) condition that is currently untreatable, I have a vested interest in those new procedures, drugs, and treatments.

Posted by ClaudiaTherese (Member # 923) on :

quote:
Originally posted by fugu13:
I think a lot of research done in the US is profit driven. I think that's why we have so much more research (including per capita) than other countries. I rather like that we have a system that allows it to be profitable for people to develop new medical techniques and technologies.

I like new technologies, too -- I'm just wary of publically funding them unless they deliver significant M&M outcomes.*** To the extent that we avoid universal coverage in trade-off for more research, that's what we are doing.

***So, for example, there is likely to be a lot of money in yet another anti-seasonal-allergy medication, even if it is of minimal benefit. But do we really need another Claritin, especially when there are around 80,000 leg amputations from diabetes per year?

Sure, if it's all private enterprise, that's great. But given that "more research" is being cited as a reason to hold onto the system we have, I think that research is acknowledged as being indirectly subsidized. And it shouldn't be subsidized to line private pockets, especially without really good cause.

Posted by ClaudiaTherese (Member # 923) on :

quote:
Originally posted by Christine:
CT -- just a nit: that quote you attributed to me was by rjzeller...I just agreed.

My apologies! A very large nit, and well worth squashing.

quote:
Of course, speaking as someone with a (non life-threatening) condition that is currently untreatable, I have a vested interest in those new procedures, drugs, and treatments.

And I'm all for getting you that new research, but I wouldn't trade off public subsidy for it at the expense of more serious or life-threatening conditions. On the other hand, for all I know, your condition may well be one I would consider should be on that list. I don't know, as I don't know your details (and you shouldn't have to disclose them!).

But I do think there should be a list of some sort, you know? If there is public subsidy, even indirectly.

Posted by kmbboots (Member # 8576) on :

quote:
Originally posted by ClaudiaTherese:
Well, rivka and katharina, it's great to know that you were reading.

I'm reading, too. Mostly just to combat my withdrawal symptoms, though, (i miss you!) because I was already convinced.

Posted by Dagonee (Member # 5818) on :

CT, the idea that the lack of public health care amounts to a subsidy (even an indirect one) because a public system would alter research priorities speaks to a very deep theoretical problem I have with most government enterprise. It hints at the idea that the government establishes the baseline for human endeavor. This is chilling to me.

(And I know there are other, more direct subsidies for such research, including tax deductibility for employer-sponsored health plans. I'm not speaking to actual payments here.)

Posted by fugu13 (Member # 2859) on :

I think its entirely possible to preserve the incentives for research and move to a system that makes it reasonable for everyone to obtain good health insurance and good healthcare.

Actually, I think it can be done with remarkably little public funding of any kind (billions, certainly, but relatively few billions).

Provided insurance groups are made large enough and adequate funding is provided for people at low income ranges (in a way that does not disincentivize earning more money), and health insurance companies are allowed to competitively bid to provide insurance to the various groups, we'll continue to have strong health care research incentives. The only public money heading that way will be that providing health insurance to the needy, and that will only happen indirectly and mostly non-directably.

Posted by fugu13 (Member # 2859) on :

I should point out that the effective government subsidy of health care now is much higher than most calculations, because it includes the tax breaks to employers for paying (large) parts of employee insurance, disproportionately incentivizing healthcare compensation.

Posted by ClaudiaTherese (Member # 923) on :

quote:
Originally posted by Dagonee:
CT, the idea that the lack of public health care amounts to a subsidy (even an indirect one) because a public system would alter research priorities speaks to a very deep theoretical problem I have with most government enterprise. It hints at the idea that the government establishes the baseline for human endeavor. This is chilling to me.

(And I know there are other, more direct subsidies for such research, including tax deductibility for employer-sponsored health plans. I'm not speaking to actual payments here.)

I don't understand what you are saying, and I'm not sure we aren't talking past each other. Can you reword it?

(I'll be offline until tonight -- lunch break is over. Will chack back later when I am less distracted, though.)

Posted by Dagonee (Member # 5818) on :

quote:
Can you reword it?

Maybe.

Rather, I know I can reword it, but I don't know if I can make it more understandable.

A subsidy is generally considered to be monetary assistance given by the government to a private enterprise. Subsidies absolutely do not have to be actual payments. For example, government-granted monopoly is a subsidy if it results in the ability to charge higher prices. The essence of these kinds of subsidies is that the government somehow alters what would have happened absent government intervention and that this alteration leads to someone acquiring profit they otherwise would not have.

You describe the current system - which allows companies to profit from self-directed research in a way they would not under public health care - as a "subsidy." If I understand what you meant by reference to a list, the specific mechanism providing that subsidy is the lack of government input into which drugs are covered.

What particularly bothers me about this is that government inaction is seen as a subsidy. Now, I'm not saying that government inaction doesn't benefit someone financially - it almost always does. Nor am I saying that government inaction is always good or better.

I don't find anything problematic about acknowledging that our current policy choices regarding medical care have resulted in some people making out like bandits. But the idea that not being interfered with amounts to a subsidy - in effect a gift from the government - is what I find to be chilling.

Posted by Christine (Member # 8594) on :

CT: I'm not shy about disclosing my condition -- you would probably notice if we met in person, anyway. I am legally blind. That is to say that with best correction, the vision in my better eye is 20/200...what this means in practice is that I am currently inches away from a screen that has text blown up several times normal.

I would never presume to rank this on a list of conditions. I suppose it falls somewhere between heart disease and wart removal, but that's as specific as you'll get from me. [Smile]

I'm not thrilled with the idea of having the government rank it, either. I'll default to Dagonee on this point, though, since I'm really not sure how to put this -- it's more of a knee-jerk reaction at the moment. [Smile]

Posted by Counter Bean (Member # 10176) on :

I hope that it never happens in my lifetime, the cure for the health care system is universal insurance for doctors with caps on malpractice pay for lawyers. Half the cost of medicine would vanish overnight.

Posted by Lavalamp (Member # 4337) on :

pH:

I should've put a break in my post -- only the first few sentences were addressing the quotation from your earlier post.

As for off-label uses of medicines -- if you can get an insurance company to pay for it now, you'll probably be able to get an insurance company to pay for it later. Even if such things won't be covered under the kinds of basic coverage that everyone is likely to have, there are going to be LOTS of supplemental coverages out there -- often employer paid as a perk or a way to attract employees in hard-to-fill positions.

fugu--
What I don't really get is the logic behind saying that people who save now because they're in a big pool wouldn't continue to pay low rates (or even see an even lower rate) when they're part of an even bigger pool. Are you assuming that the larger pool will necessarily include a greater proportion of people of higher risk or proven ill-health? Or is this based on assuming that since the insurance system is going to pick up the acute care treatment tab for a bunch of folks who currently don't have insurance, that the overall outflow of money alone is going to drive up the "base" or lowest-possible rates.

As for regional or state-level efficiencies, the only thing I can see this being better for is regulation. State insurance regulators are often quite adept at forcing concessions from major insurers (if you want to sell auto insurance to our citizens, you darned well better offer home-owner's insurance -- that sort of thing). They are also fairly well experienced in going after carriers that pull various scams and or fail to meet regulatory requirements.

I don't actually see that a national pool would necessarily change that. Plenty of people work for multi-state companies. Their insurance is regulated in every state where employees take policies. The pool is based on the employees of the company, not where they are domiciled.

If anything, you might see some terrible inequalities in the system if you forced it to be state-wide pools. States with low populations, or those that have chosen to attract retirees and thus have a skewed age distribution, states that are tending to lose population (usually disproportionately losing working-age people), are going to be hit hard for no good reason, IMO. Why not let people live where they want and if you need to adjust for local factors, then when the policies come due, you adjust. State regulators can keep an eye on that sort of thing without requiring that the pool of all possible insureds be in their state. As long as one person in their state has insurance with company X, the existing state regulatory authority could have some control.

Anyway, I'm interested in trying to puzzle through this logic if you have a chance to answer.

Posted by Dagonee (Member # 5818) on :

quote:
the cure for the health care system is universal insurance for doctors with caps on malpractice pay for lawyers. Half the cost of medicine would vanish overnight.

That costs us $950 billion a year? Got a cite for that?

Posted by Will B (Member # 7931) on :

An alternative method would be to change the way we discourage malpractice.

There was a doctor in my hometown who ordered a penicillin shot for a patient at the ER, without seeing him first, without checking for allergies. The patient was allergic, and died. The doctor lost the malpractice suit, of course. Which meant that everyone's premiums went up, and he kept practicing.

In effect, when malpractice happens, it's other patients that pay -- both with money, and by being stuck with the same dangerous doctors.

Posted by Mrs.M (Member # 2943) on :

A couple of things:

Infant mortality statistics are extremely misleading. The US has very low infant mortality, comparable (if not lower) than other industrialized nations. The disparity in the statistics comes from what each country counts as a stillbirth and what they count as a miscarriage. Some European countries count every infant death before 40 weeks gestation as a miscarriage. Many (if not all) of those are counted as stillbirths in the US. Then you get into issues of when or if the the baby took its first breath and it goes from there. I was the one who linked to a Canadian study that confirmed the above (sorry, I didn't bookmark it and I don't have it in me to look it up right now). Additionally, there is the issue of fertility treatments - these create far more high-risk pregnancies, which can cause infant mortality rates to rise. This certainly is not due to poor health care.

I also want to point out that there are many US organizations dedicated to helping uninsured families. I know things are far from perfect, but I feel it's unfair not to acknowledge the work that is done to help out a large number of families. For example, here in Virginia we have FAMIS, which makes health care available to children whose families qualify. Aerin and I went to the VA State Legislature with the March of Dimes last week to lobby to get FAMIS eligibility raised from 175% to 200% (they're still in session, but we're fairly confident it'll be raised). This will put FAMIS on a funding level with WIC (another great organization that helps mothers and children).

Again, I realize that the US healthcare system needs improvement. Both my mother and my daughter have had severe health problems that cost huge amounts of money and needlessly complex navigation through insurance claims. We pay for our own coverage and you would not believe the cost. However, we're not just a bunch of monsters who are content to let people suffer and die.

Posted by Lyrhawn (Member # 7039) on :

quote:
Originally posted by Will B:
An alternative method would be to change the way we discourage malpractice.

There was a doctor in my hometown who ordered a penicillin shot for a patient at the ER, without seeing him first, without checking for allergies. The patient was allergic, and died. The doctor lost the malpractice suit, of course. Which meant that everyone's premiums went up, and he kept practicing.

In effect, when malpractice happens, it's other patients that pay -- both with money, and by being stuck with the same dangerous doctors.

I'm allergic to penicillin, and all the other illins, and I have to say that exact kind of thing spooks me severely.

Posted by pH (Member # 1350) on :

quote:
Originally posted by Lavalamp:
pH:

I should've put a break in my post -- only the first few sentences were addressing the quotation from your earlier post.

As for off-label uses of medicines -- if you can get an insurance company to pay for it now, you'll probably be able to get an insurance company to pay for it later. Even if such things won't be covered under the kinds of basic coverage that everyone is likely to have, there are going to be LOTS of supplemental coverages out there -- often employer paid as a perk or a way to attract employees in hard-to-fill positions.

So, if I'm reading you correctly, you're saying, "Don't worry about it if it's not covered by basic...you can always pay extra for it to be covered!" Yes or no? If yes, this is better than the current system why?

-pH

Posted by Lavalamp (Member # 4337) on :

pH, the cost of your basic coverage should be reduced. That saves you some money. If you choose to use that money to pay for supplementary coverage, then if you later need one of those off-label uses, you have a chance of being covered even though under today's system you wouldn't.

This proposal is remarkably simple and not all that far reaching in terms of reform. You'd still deal with the same insurers, the same health-care providers and the whole thing is run by private enterprise. Same as today.

It's just that it should be cheaper to get coverage for the basic stuff.

By basic, I'm thinking they mean a bare-bones health insurance that has moderate co-pays and covers most acute diseases and injuries, and a fair number of chronic conditions.

The only thing this proposal does differently is make it so the pool of people you're included in when they fix your rates is a lot larger than is currently done. Insurers for decades have explained the high prices by saying that costs rise in inverse proportion to the size of the insurance pool.

That's not the only cost component, of course (there are the actual costs of treatments paid for by the companies), but it is the one that makes things most inequitable and has no relationship to the health of the individual insured. For example, a healthy 25-year-old working for a 12 person company is going to pay much more for his insurance than if he worked for a large company. The reason given for THAT unfair differential is that by taking a job with a small company, he is stuck in a pool that (statistically) has higher health care cost per person than places with more employees...on average.

By putting everyone in the same pool, that 25-year-old should end up with the best possible rate (although fugu seems to believe this may not necessarily be true -- I'm hoping for more details there). In fact, everyone should end up with the best possible rate that their age/gender bracket could obtain.

The other thing that this simple proposal does is make it more affordable for unemployed, underemployed, and people who work for companies that don't offer a health insurance benefit to get insurance at affordable rates. Currently, if you try to get insurance as a "self-employed" individual, the rates are ruinous. You essentially form a pool of one from the insurer's perspective, although there are some companies that do offer this type of coverage among consultants and such who will build a pool from among all members in a certain category. The risk is spread across such a small pool that the costs are at the highest end of the scale.

The OTHER other thing this proposal would do is disentangle basic health care insurance coverage from employment. You could keep the same coverage when you change jobs. You can keep it if you decide to take a year off from work and travel the country. You could keep it if you are laid off and decide to free-lance. Having affordable insurance isn't contingent on finding an employer desperate enough for employees to offer this as a benefit.

This is not a panacea, though. Coverage will still cost money. People who suddenly find themselves without income are still going to have to figure out whether and how to pay their premium. If coverage lapses, you'll still have problems trying to pay any medical bills for services during that uncovered period.

Posted by fugu13 (Member # 2859) on :

Bob, the benefit isn't from being in a large group, its from being in a large group with a low expected payout (and to a lesser extent, a lower variance).

Additionally, given the vast numbers of baby boomers who would, if the current situation continues, be covered under Medicare as they aged, I am prepared to say the people at most large firms will become part of a pool with noticable higher average expected payouts if the entire nation is made one pool.

As for being hit hard for no good reason, my personal opinion is that, provided the system is structured so that health insurance is still affordable in order to avoid externalities, it only makes sense for people who are going to require more medical care to pay more. In fact, I think it is vitally important we preserve that characteristic as much as possible, because a large part of what makes markets have such better outcomes than other attempted solutions is the incentive to better one's self and one's situation.

Back to this best possible rate stuff. Lets imagine two groups of 25 year olds (males, even, just to simplify the situation), both groups statistically large (say, over 10k people). One group are coal miners, and one group are accountants. When you merge these groups, the cost of insurance for the coal miners will go down, and the cost of insurance for the accountants will go up. This is because the coal miners will have a far higher expected health cost than the accountants.

In fact, no matter how many people you add to the group, the insurance for people previously members of the group above a midpoint (approximately the average expected health cost) will be lowered, and the insurance for people below the midpoint will be increased, so long as the groups the people would otherwise be part of are statistically large.

Any group you present to me, if I can find a way to slice it up such that all slices are sufficiently large and the slices do not have the same average expected healthcare costs as the whole, then the insurance for the slices with lower average expected healthcare cost would be lower.

There's no way an insurance company can afford to charge people less than the average expected healthcare cost for a group (well, excepting if they overcharged for a while or had some really low health cost years which allowed them to invest significant sums, and they'd also have to do well in the investments -- usually the variance in health cost would prevent the accumulation of sufficient capital in this way to have lower costs); if they did, they'd lose money, and that isn't even counting the costs of administration.

Posted by Counter Bean (Member # 10176) on :

The direct cost is over 100 billion, plus the fact that the cost remains a barrier to entry for medical practitioners, an incentive to leave the business of medicine early and an incentive to leave certain areas of medicine that then go up in cost because only a handful of doctors are practicing (OBGYN for example) The cost of lost practitioners in the field is difficult to calculate, but a comparison to cost of care before the escallation of TORT cost is a place to start. The debt load on young surgeons and doctors, the cost in interest, it goes on and on. It is clear that the Lawyers have been engaged in a direct attack on our quality of life in order to shift wealth from the pool meant to sustain our health and well being to gild their personal nests.

If we as a Country believe that practicing medicine is a virtue we want to encourage, we should bear the premium cost with universal malpractice insurance and throttle frivolous lawsuits by not allowing lawyers to collect any of the damages. Take the insurance away from the insurance companies with profit motive and take the profit motive away from the lawyers, doctors are directly contributing to the public welfare, lets pull the leaches off them.

Report on Cost of Malpractice Insurance

[ February 14, 2007, 02:42 PM: Message edited by: Counter Bean ]

Posted by Dagonee (Member # 5818) on :

Where do you get the 100 billion from? According to the chart on page 15 of your link, medical malpractice tort cost only $20.9 in 2000.

Even if I accept your 100 billion number, you're still only about 13% of the way toward proving you can get rid of half the costs. And that would require that all medical tort costs are bad - which clearly they aren't. I haven't seen any evidence from you concerning what percentage of tort damages should not have been awarded.

I'm all for doing something about irrational tort awards, to the extent they exist. However, too many of the caps are limiting actual damages. If a medical error results in a need for lifelong care, then the award should cover that lifelong care. At least some of the caps that have been put in place do not.

Posted by aspectre (Member # 2222) on :

Just something to think about: Americans no longer the tallest peoples

Posted by Lavalamp (Member # 4337) on :

fugu,

I guess I'd want to look at how many people are already in insurance pools that include 10,000 healthy people in low-risk occupations before I concede this point.

I just don't think this is going to be nearly the problem you seem to think it is.

I'm insured in a group that includes about 10 people.

Most of the people I know are insured in groups that include a few hundred people.

I know there must be some people in pools of several thousand employees. And sure, I can at least imagine some pools that include only office workers who never travel or something along those lines. But I'm trying to think of a single company that has an insurance pool in the thousands where practically everyone is young, healthy and works in an office.

I buy your statistical reasoning. I just don't see where there are real world examples to match your hypothethical. And even if there are, what percentage of US workers with health insurance are in those situations?

If this new plan "harms" 1% of all US workers, heck, let's give them a subsidy too to take away their pain.

Posted by Counter Bean (Member # 10176) on :

Double the number of OBGYNs and you half the cost, you must look deeper then mere money and see the economic impact that results, it is the shortsightedness inherent in the profit incentive for the TORT system that gives rise to the second and third tier consequences.

Law itself needs to be simplified, all law should be in language that a sixth grade student can follow, those that make the law should not have ties to those that profit from its enforcement any more then insiders should be allowed to trade on their knowledge. Overlooking this has given rise to the most profitable swindle since women convinced men they do not like sex and are owed something for it.

The impact of this profession, so demanding that it creates a group who, unless exceptional are competent in their field and ignorant in every other, men and women with a level of functional competence so far below that of a typical savage it makes them unfit for survival in any world but the specialized one of their creation, yet they find themselves in leadership roles in a society that really needs leaders who are expert pragmatists, not experts in the silly game they create to employ each other.

Even if I accept your belief that some TORT is of benefit to society you cannot seriously suggest that some class of people should have aristocratic status and wealth for the occasional justice they manage to achieve. Justice is the duty and responsibility of every man, not to be delegated to a too specialized few.

The systematic persecution of doctors for the sin of being wealthy from their extraordinary contribution to society is one of the greatest injustices of all.

Posted by ElJay (Member # 6358) on :

I'm in a pool of several thousand people. I work for a company that employees around 50,000, but since we're spread across many states, I believe we are actually in several pools. But there's at least 6,000 in my state.

Most of us work in offices, although some climb telephone pools. But injuries sustained doing that are covered by workman's comp, not their health plan.

There are just as many old/overweight/smoking people here as there are in the rest of the population. There's no earthly reason I should get to pay less for insurance than people who work for Bob's company except for the fact that the insurance companies want my company's business more. Because they're taking the same risk by insuring 60 companies of 100 people as one company of 6000, so except for a slightly higher administrative cost, I don't get what the argument is. I don't buy that Bob's company pays more because it has significantly higher risk, I think it pays more because it has significantly less bargining power.

Posted by ElJay (Member # 6358) on :

And just to be clear what we're talking about here -- my monthly contribution is $120.43 for individual coverage for medical, dental, vision, short and long term disability, and basic life at one and a half times my annual salary. Medical alone would be $94, I pay about $13 each for the dental and short term, and the company covers the vision, long term, and life entirely. I have a $25 co-pay on office visits, $35 for specialists, up to an annual max that I don't really know because I don't go to the doctor all that often. I've never worried about or encountered something not being covered, and while I don't have a lot of comparative data, I believe I have what you would call very good coverage.

If someone who works for a small company or is self-insured wouldn't mind posting what you pay, I'd appreciate it.

Oh, also, I'm management. If I was a union employee at my company my monthly contribution for the medical would be $0, it's paid in full by the company. I'm not sure about the dental and short-term, but I wouldn't be surprised either way.

Posted by Dagonee (Member # 5818) on :

Is there any particular reason you're typing TORT over and over again, instead of tort?

Posted by fugu13 (Member # 2859) on :

ElJay: most of the differences in what insurance costs employees nowadays emerges from the bargaining process between employers and insurance companies. This both distorts the market, allowing insurance companies to charge more than they might otherwise, and means that parts of insurance payments are made by the private companies, making employee costs not directly comparable. The cost paid by the employer is still a benefit to the employee, though, and did the employer not pay it the employee's salary would be higher.

Furthermore, note how I keep specifying sufficiently large insurance pools. In smaller pools, the variance in costs from year to year is very high, meaning that to ensure those contracts are profitable the insurance company needs to charge more. This also means they make more profit off of those, because across all the different small companies the average is still the same as it would be for that group of people, but since each contract needs to make money and a much higher percentage of the contracts have higher costs than for groups with similar averages, insurance companies charge more. Its more a matter of statistics than leverage.

Once you're talking about a sufficiently large pool, though, the variance effect becomes sufficiently small the group can be compared directly to other large tools, even if there's a significant difference in actual sizes.

Btw, I'm curious how you know you have as many old/overweight/smoking people as there are in the rest of the population. For instance, I'd be surprised if nearly 8.5% of your employees were over 70 (the percentage in the population from the 2000 census is about 8.4%). It doesn't take a difference of very many people, particularly for the higher risk groups, to make a huge difference in the expected cost of health care -- five percent of the population accounts for about half of total health care expenditures ( http://www.ahrq.gov/research/ria19/expendria.htm ).

Bob: notice the statistic above. Five percent of the US population incurs nearly 50% of the health care costs. Obviously not all of those would be insured, but still. This means that nearly half the population is below the average health care expenditure in the US. Everyone currently a member of a large group which has a distribution on the left side of that incredibly lopsided distribution will likely have an increase in insurance costs, and I know you know enough statistics to know that's going to likely include a large number of people. As far as real world examples, that would require significant proprietary healthcare and insurance data, so its unsurprising I don't have any. However, given that insurance groups are currently frequently segregated by profession and location, and that profession and location can both have significant impact on expected health care costs, its very likely there are groups all over the distribution.

Posted by fugu13 (Member # 2859) on :

Oh, as far as pools where people are young, healthy, and work in an office, look into the big four accounting firms (and associated wannabes). Tens of thousands of employees, mostly shortly out of college and from middle class families with good family health insurance. About as low risk as you can get, minus the stress of being a big four accountant.

But it doesn't matter, much, the group only has to have a slightly higher percentage of healthy people have a significantly lower expected health cost.

For instance, imagine there's a company with 10k employees, 8000 of whom have an average expected health care cost of $1k, and 2000 of whom have an average expected health care cost of $4000. The average expected health care cost for a group covering that entire company would be $1600, so health insurance for that group would have to be more than that.

Now imagine a firm where 8000 of the employees have $1k average expected health cost, and 2000 employees have a $3k average expected health cost instead. Suddenly the average expected health care cost for the company becomes $1400, a savings of $200 a year. Obviously these are entirely concocted numbers, but they should help illustrate how a relatively small change in average expected health costs for even a small-ish subset of an overall group can result in meaningful differences in overall cost.

Posted by ElJay (Member # 6358) on :

fugu, I know that the employer pays a significant chunk of the insurance cost. . . and I believe they prefer it that way, instead of paying a higher salary, because they get a tax break for it. As I understand it, they still would under the proposed plan Bob listed, except the difference is that every company would be taxed the same percentage and that money would be used to subsidize insurance costs for everyone. Thus leveling the playing field between different sized companies and companies that currently do or don't provide benefits.

My listing of my costs should be disconnected from my first post, and was more because I'm interested in what the disparities actually are between someone like myself, who (I think) has a pretty good deal, and someone who isn't part of as large a barginning pool. I know that can't be a direct comparison without knowledge of exactly what percent the companies pay, but it can give an idea.

For demographics, I should have said as many old people as the rest of the working population. I'd also be surprised if 8.5% of our employees were over 70, but I'd also be surprised if a very high percentage of people over 70 are working at all. We do have several people over 60 that I'm aware of, and all of my employees are old enough to be my mother. For smokers and overweight, I know more smokers at work (by far) than I know in the rest of my life combined. Driving/walking by my building at any one time you'll see more people outside smoking than in front of any other building downtown of any size. (Indoor smoking in the workplace is illegal in my city, so I don't think it's just that other buildings have snoking lounges.) I'll count at lunch tomorrow, if you like. And 6 people in my office of 200 have undergone gastric bypass surgery in the last 2 years. So that's at least 3% morbidly obese. For just "overweight," I'm eyeballing it. [Razz]

Added: Forgot to mention, we also have a planning group working on the fact that a high percentage of our middle management staff is approaching retirement age and we don't have enough younger managers in the pipeline to replace them. That's another reason I think we have at least as many "older" employees as most other companies out there.

Posted by fugu13 (Member # 2859) on :

You might very well be part of an insurance group that would be getting a better deal by being merged with other groups [Smile]

Posted by ElJay (Member # 6358) on :

I just find that really hard to believe. For any sufficiently large company, as long as it's not an inherently hazardous profession such as the aforementioned coal workers, there are going to be people at varying levels of risk. Older people have more health problems, and so are probably more personally expensive. Younger people have more dependents, and so add costs that way. Most people work until their early 60s, and most people don't suddenly quit one job at 40 and find one at a different company that only hires people with 20 years of experience, so most offices are pretty well mixed.

My previous job was at an internet start up in the 90s, and yes, there were a lot of 20 year old kids doing the coding. There were also two retired professors doing editing, and several mid-50s people in HR and management who'd been brought in by the investors to make sure the company actually ran. I paid a lot more for insurance there, adjusted for inflation. It was also an office of about 60 people. In fact, my current insurance is the cheapest I've ever had. I can't speak for the entire company, but in my department we've got alcoholics, (we pay for treatment) battered wives, (we pay for counseling and therapy) people who are in and out of the hospital with chronic conditions, and people who are perfectly healthy. Just like anywhere else. There's no reason for it to be cheaper except for size.

To make a long story short, I think you're abstracting things too much. I'm sure that academically you're right, and for the hypothetical pools you're talking about everything works exactly as you say it does. I just think that applies to the actual demographics of the American workforce about as much as those guns v. butter graphs they draw on the first day of freshman economics apply to the national budget.

Posted by fugu13 (Member # 2859) on :

Its not a matter of not having varying levels of risk, its about the average levels of risk. Even if two companies have a wide variety of people with all sorts of different risks, they can have very different average risks, and very different average risks. It only takes a few high risk people (proportionally) to significantly distort average risk, particularly as high risk is often very high risk.

For instance, even a firm that hires remarkably similar people to another firm is going to be higher risk in a city with a large amount of air pollution and higher rates of automobile accidents compared to a city with healthy skies and good public transportation.

I think you're abstracting things too much by jumping from a lot of variation to similar averages [Smile]

Also, you don't seem to have grasped what I said earlier about small groups not being what I'm talking about. Anything under at least a few thousand is too small to be possible to talk about in terms of average risk.

Posted by Lavalamp (Member # 4337) on :

I'd also be surprised if whatever new system is envisioned doesn't take age into consideration when figuring the costs. I don't anticipate a flat-rate. One of the huge determiners of what individuals pay per month for health insurance is their age. At least I'm pretty sure I pay more than the 25 year olds in my own company.

If that's not the case, then fugu's example makes more sense to me, but basically, if we're all separated into demographic bands, then the 25 year olds in my company shouldn't be hit with a penalty for working in a company where the other employees are pushing (or looking back on) 50. And yet they are. And that's because the company has to make SURE they can profit on the policy they wrote to our pool.

fugu, I liked your explanation of why the insurers would have to charge more for each small pool policy they write -- to make sure that every policy is profitable.

You and ElJay both asserted that the bargaining power is what keeps rates lower for companies with larger insurance pools. I tell you have had had insurers flat deny this to be true -- that they set their rates purely on actuarial estimates and the larger pools don't really get a "break" through bargaining. They get it through being large so that the law of averages doesn't bite the insurer like it might with small pools. I never really understood what they were talking about until fugu's example -- they have to make every single policy profitable at the group level so that means a larger margin is built into the smaller pools because variance is high.

Thanks fugu!
(NOTE: I also think they are lying to me, though, because they can't possibly hang onto business from the huge companies if they don't offer competitive rates. I'm with ElJay on this aspect of it -- the people at small companies are absolutely subsidizing the cheaper rates offered to large companies. I don't believe the insurers want us to know how it works, but that's exactly what the bottom line is.)

Anyway, back to what you'd said about variance in pools. This also explains why the insurers have been so resistant to change over the years. Their profits are built on the backs of small groups.

Given that, they probably have also resisted pooling across all locations of large companies, so I wonder what we're talking about in terms of the upper limit pool sizes in the current environment.

I thought of the Big 4 accounting firms as one possible example of a large pool of mostly young healthy people (save stress of those jobs). I really couldn't come up with many other large pools of young, healthy people, though. Maybe brokerage houses? But are they in large enough pools? Perhaps engineering firms, but most of them are mid-sized companies. Software houses, I suppose.

But still...I'm thinking that not a large number of people are part of a really big pool composed of mostly young people.

But see...here's where the age example falls apart for me as an explanation of why a national pool would be "bad" for very many people. The year-to-year variance of that pool's health care performance would be about as small as we could get. So, that removes the penalty of small pools entirely.

Now, within that pool, since they adjust everyone for age and gender related risk, they really, truly should be giving each person the best possible rate for a person in their demographic.

The only thing that should make a 25 year-olds rate be worse under this scheme than the current employer-based system would be if there's a huge number of sick 25 year olds who will be added to the pool. I don't think that's the case.

Of course, if we aren't charged differently based on age and gender characteristics, my objection is moot. But I'm pretty sure I'm right on this one.

I don't pay the same rate as the 25 year olds in my company. I'm also not paying the same rate as my boss (who is older). At least I'm fairly sure I'm not.

If I'm wrong on that, then maybe we need to consider age/gender-band pools when we make up the national system.

Also, aren't the 70+ year-olds influence on the pool is sort of off the table if medicare/medicaid are still in operation. Hmm...not sure on that one.

Posted by ElJay (Member # 6358) on :

fugu, I know small groups aren't what you're talking about. Merging the current small groups into large groups is what I'm talking about. Because I think the business model of having to make every pool profitable instead of having to make the entire company profitable over all the pools they insure is basically an excuse to rip off smaller companies. My optimistic side wants to think that they're just doing it for larger profits, and not in fact to make the smaller companies subsidize the larger ones. But the only way I agree with you that some people's insurance costs will go up under the plan Bob outlined is if large companies are subsidized by small ones currently. Or if a company is currently paying more than 4% of a given person's wages for their health benefit and decides to only cover the required 4% after the change.

Posted by Dagonee (Member # 5818) on :

quote:
One of the huge determiners of what individuals pay per month for health insurance is their age. At least I'm pretty sure I pay more than the 25 year olds in my own company.

I'm very skeptical of this (speaking only to employer-provided group coverage). I think, at least for companies greater than 50 people, the ADEA prevents this. Not sure, but I've never seen an age-specific premium chart, both when i was selecting plans for my own company (which was 30 at most) or selecting plans as an employee.

I'm almost positive it's illegal to adjust premiums for gender.

Posted by dkw (Member # 3264) on :

Bob's company employs less than 30 people.

Posted by Dagonee (Member # 5818) on :

I meant I was skeptical of it being a huge determiner - even if people with less than 50 can discriminate like that, they're a small percentage of the number of insured people.

Posted by fugu13 (Member # 2859) on :

Many of the small groups would be benefitted, yes. However, there are significant numbers of employees in large groups as well.

Bob's quite right in that insurance estimates are fundamentally based on actuarial science, and expected cost is the most basic part of actuarial science, not some theoretical abstraction.

While I have no doubt bargaining goes into eventual insurance deals with companies, there can't be that much variation around the actuarial estimate. If the insurance company tried to charge too much, another insurance company would step in. If the insurance company didn't charge enough, they'd lose money.

Whether or not age ends up being a determiner, there are always groups of high risk people in any age group who can be easily grouped together. Part of my assertion is that, so long as good insurance that leads to good healthcare remains affordable, it is better if people with higher risk tend to be members of groups that pay more. It provides people with incentives to mitigate their risks, and also allows for more tailoring of the basic insurance policies if there are qualitative tendencies among the groups. I want insurance to be affordable for everyone, but I don't think everyone should be paying the same price for basic insurance.

Posted by ClaudiaTherese (Member # 923) on :

(Dagonee, I'll dig back in today. It'll be my first night home before 6:30 this week. [Smile]

)

Posted by Dagonee (Member # 5818) on :

I won't be offended if you don't have much to say - although I'd love to hear your thoughts. I've gone far afield into political theory, and a fairly esoteric portion of it at that.

Posted by ClaudiaTherese (Member # 923) on :

I have just been so swamped, and this is one of the areas I don't do by halves, you know? It requires and is worth so much more than an offhand comment, although not so much for voting on war movies. *grin

Thanks for understanding. Life will slow down for a brief bit today, thank goodness.