With the Presidential race heating up, and "Sicko" not
yet faded from consciousness, the subject of "Universal
Health Care" becomes fodder for discussion once more.
There are many viewpoints about the idea of health care and what
should be done about it, but perhaps one of the more interesting
ideas comes from simply parsing, "Universal Health
Care."
Let's drop back for a moment, and introduce an alternative:
"Go away and die."
That is simple and literal, if you can't afford health care,
you don't get it. But what that phrase really means is,
"Don't expect me to pay for your health care, but
don't make me feel guilty about it, either." In
other words, we want to feel like a Christian Nation - but
we'd rather keep our financial exposure within
"practical" limits. There may also be an element
of "lifestyle self-righteousness," though the term may
a bit harsh. (I'm a bit guilty of this too, I watch what I
eat, get exercise, deferred instant rewards in order to go to
college and get a good job, etc.)
So far as a society we have been unwilling to simply say,
"Go away and die," and some may feel that's good,
others may feel it's bad, but it is. But the upshot is
that it isn't very efficient at all. If we're not
going to establish "directly financially limited
lifetimes," then we should strive to improve the efficiency
of what we are doing. Today too many people stay away from
medical care until they're very sick, causing the costs to
rise.
Time to begin parsing. Start with "Health Care."
Isn't that "caring for health," as in day-to-day
wellbeing. Can't we separate "health care"
from "sickness and accident" care? Now add
"Universal" to the mix. There are certain
components of caring for wellbeing that are universal, every one
needs some, plus every man and woman has additional unique needs.
Every baby needs prenatal care and well-baby examinations,
immunizations, etc.
Every person needs dental cleanings and exams.
Every person should have a periodic physical.
Every person 50 and over should have periodic colonoscopies.
Every man over 40 should have periodic DRA and PSA tests.
Every woman should have periodic pap tests.
Every woman over 40 should have periodic mammograms.
(I'm sure this list isn't complete, but IMHO it's a
good start.)
These are "Universal", about as "Universal"
as "Health Care" can get. Nor do these items have
anything to do with "sickness and accident" care.
Now let's go back and examine the concept of
"insurance" for a moment. At its simplest,
"health insurance" means that I'm betting that
I'm going to get sick or have an accident, and my insurance
carrier is betting I'm not. My premium, balanced
against the anticipated cost of such care, establishes the odds
of our bet. Car and homeowners insurance are the same - We
bet that something bad is going to happen, our carriers bet that
it won't, and our premiums compared to their payout exposure
express the odds.
In this light, "insurance" is an entirely inappropriate
model for funding "Universal Health Care" as I parsed
it, above. That's because those "Universal Health
Care" items are needed - there are no odds about it, they
should happen. Burying them in an odds-based financial
model simply muddies the water - and all-too-often applies
pressure to make those "universal" medical needs get
skipped.
Yet in another way, they are linked. Because if this
"Universal Health Care" happens, people tend to be
healthier, and the odds improve for the insurance carrier.
Many insurance carriers therefore have better coverage for
"preventive maintenance" type health care - it's in
their best interest to avoid catastrophic payouts. However,
these "Universal" needs are still only taken care of
for those who are already insured. Those who are not tend
to get late - and more expensive, care.
A modest proposal:
One must realize that society can't turn on a dime.
Even in 2 Presidential terms we'll never dismantle the health
insurance industry and replace it with any sort of single-payer
system, it's just too disruptive and offends too many wealthy
and powerful people.
But perhaps what we can do is institute "Universal Health
Care" in the sense I parsed. Leave "Sickness and
Accident" coverage to the existing health insurance
industry, with the odds-based financial model that's
appropriate. But find some way to make "Universal
Health Care" universally available.
It's also an interesting start that doesn't require
dismantling industries or power structures. It gives us an
opportunity to better evaluate the health of the nation's
people, and assess a strategy for those who are today going
untreated until they show up at the Emergency Room.
I like it. In my world it is like the difference between having a computer repair technician and having a computer maintenance program. I am glad you humans like your colonoscopies, you can have them. As for me, just blow the dust out of my fans, and check for loose modules and I will be OK.
I like the idea of distinguishing preventative care from chronic/acute/urgent/emergent care. That's a good idea.
When it comes to that second bunch of stuff, though, a useful referenc efor you might be the State of Oregon's Prioritized List of 710 medical conditions whose treatments may be covered by the Oregon Health Plan, AKA Medicaid. (I say "may be" covered because coverage is budget-dependent; currently the plan covers conditions up to line 530 of the prioritized list.)
Anyway, there's some reference information on some kinds of preventative care at the end of the list too, if you're interested.
I thought I remembered the US "shutting down" Oregon on this "health care rationing plan" back in the 1990's. I liked it at the time, because if it's all a matter of finance, be explicit and honest about it, and don't hide the fact behind any weasel-words.
Nope. It was a difficult and lengthy process to get the necessary federal waivers to launch the program, but it did launch quote a few years ago. The resulting system is not without its flaws, of course, but I think it's a good model.
its not pay or die, more like pay or be finacially ruined for the rest of your life due to new bankruptsy laws
the government could dismantle the health insurance industry in a second by socializing health care.
I haven't been paying attention to all the chatter because I know any proposal will never survive the fillibuster but this 'single payer system' isn't a proposal for government provided health insurance is it? That's the wrong way to go about it.
If you look at the 'successful' socialist programs they all have one thing in common, the government has a monopoly on the service. Government would have to take over the running of the hospitals and the staff would have to be civil servants for this to have half a chance.
Might have more luck if advocates in the US used "Christian programs" as in the OP. That would be harder for the rightwingers to demonise.
I'm reading some Bible stories to my daughter at the moment. She finds parables like the Prodigal Son and the Workers in the Vineyard hard to accept, she's more in the "Go away and die" camp now. I'm hoping this attitude will mellow.
If you look at the 'successful' socialist programs they all have one thing in common, the government has a monopoly on the service.
I don't know if you'd consider the UK's NHS "successful" (I'd consider it better then nothing), but the government doesn't have a monopoly.
A) There is a market for private insurance and private hospitals (While the NHS takes care of my more mundane needs, I have BUPA cover in case anything serious ever happens to me - which means I should be treated sooner in better surroundings than if I relied on the NHS alone).
B) Even in the NHS system, it's mostly run by trusts (non-governmental, not for profit organizations). There are even some private organizations involved (the amount of NHS privatization is always a political hot potato). The staff are not considered civil servants (as they work for either a trust or a private company, not the government).
I don't know if you'd consider the UK's NHS "successful" (I'd consider it better then nothing), but the government doesn't have a monopoly.
people like yourself who knock the UK NHS frankly make me want to puke, yes, it has its occassional problems, always thanks entirely to either governmental interference or big pharma marketing or a combination of the two, but the UK NHS system alone makes the price of entry into the UK worth it.
I defy you to cite a single example (factual, not anecdotal daily mail rubbish) of someone in the UK, doesn't even have to be a citizen, denied health care.
You can't. because it doesn't happen, period.
Sure, you can whine daily mail style about postcode lotteries for drug therapies for long term illnesses, see my point above about interference, at the sharp end it makes little odds, there are some thinks medicine simply cannot cure, at any price, so palliatives are the order of the day.
A) There is a market for private insurance and private hospitals (While the NHS takes care of my more mundane needs, I have BUPA cover in case anything serious ever happens to me - which means I should be treated sooner in better surroundings than if I relied on the NHS alone).
If anything serious ever happens to you and you relied on BUPA resources ___ALONE___ you'll die, period, the NHS is the foundation upon which BUPA and others trade, much like claiming you are independent of the highways provided by the state because you walk or cycle everywhere.
BUPA is great marketing, but the analogy here is Royal Mail vs privatised mail and courier services, great if you and your recipient live in london, but they do not want to know about delivering a single page letter or cheque to someone who lives out in the sticks the next day for the same price as the local letter, and this "cherry picking" cripples the Royal Mail postal service, that and, same again, political interference.
"Triage", you ought to learn what it means.... BTW, good luck trying to get a kidney transplant out of BUPA, or free spectacles, or free dentures, or a free pacemaker, or free dialysis for the next 30 years, or specialist pediatric care, or severe burns care, or radiotherapy and chemotherapy...
BUPA is all about jumping the queue when you have the most minor triage class complaints, but without paying true private treatment costs, because BUPA is itself MASSIVELY subsidised by the NHS (name a single BUPA trained doctor, nurse, theatre orderly, etc)
B) Even in the NHS system, it's mostly run by trusts (non-governmental, not for profit organizations). There are even some private organizations involved (the amount of NHS privatization is always a political hot potato). The staff are not considered civil servants (as they work for either a trust or a private company, not the government).
Good comments from GF. In my experience, my friends and family, NHS care in recent years has never been less than excellent. From the absolutely mundane to life-threatening illness, I doubt that any private treatment would have been better or quicker. I don't think I know anyone who pays for private care (including people who could easily afford it) - some of my colleagues get it as part of an exec package.
Let me see. We get to see our GP either the day or next day when I ring up. A year ago I had a bit of a scare and was referred, tested, cleared within 4 weeks. This is the period you can expect where cancer is expected. The three occasions my kids have had to go to casualty, they've never waited, been treated by paeds specialists in a paed accident unit. They got about a dozen vaccines. Both their births were as good an experience as possible. And I pay nothing except my prescriptions, which cost me just under £7 each for two months (which is, by the way, a fixed price for all non-hospital prescribed medication - those are free).
Is my experience unique? Doubt it.
Is it socialism? Who cares.
We get to see our GP either the day or next day when I ring up.
I've had several GPs where it's been a case of getting an appointment a week later (which is a bit useless when you need a doctors certficate and are fine by the time you see the doctor). Several of my collegues doctors still are like that. My current GP is better - you get 2 chances a day to ring up and get an appointment (not that they make the phone number to get the appointment that public, and phoning one of the surgery's other numbers always ends up with a harsh rebuke - including the number that you used to ring for appointments). If you are lucky enough to get through, then you do at least have a chance of seeing the doctor same day (though they will not make appointments for another day - you phone up in the morning the appointment will be for that morning, you phone up in the afternoon, the appointment will be in the afternoon).
As for private treatment, I've had several instances in my family (for various things) where the NHS waiting times were around 6 months, the BUPA or WPA waiting times were a week or two. With all these things, your mileage may vary.
people like yourself who knock the UK NHS frankly make me want to puke, yes,
And people like yourself, who can't get to grips with the idea that the NHS has some fundamental flaws, and scream at any criticism of the NHS, makes me want to vomit. I'm glad we have the NHS, but it's not the be all and end all of medical care by any means.
I defy you to cite a single example (factual, not anecdotal daily mail rubbish) of someone in the UK, doesn't even have to be a citizen, denied health care.
Why bother, you'll just scream "DAILY MAIL IS EVIL", stick your fingers in your ears and not listen. Any answer will involve a case mentioned in the media, which the Daily Mail will have picked up on and then you can go and ignore it. Just because something is in the Daily Mail doesn't mean it's necessarily untrue.
If anything serious ever happens to you and you relied on BUPA resources ___ALONE___ you'll die, period, the NHS is the foundation upon which BUPA and others trade, much like claiming you are independent of the highways provided by the state because you walk or cycle everywhere.
Are you a troll or just a complete fuckwit (or both)? I never said having BUPA makes someone independent from the NHS, because that's not how private medical care works. You go to your NHS GP for all daily treatments. If the the NHS GP finds a serious problem, you then go to a BUPA specialist instead of an NHS specialist and get treatment in a BUPA hospital instead of an NHS hospital. And that BUPA specialist and that BUPA hospital will have a far shorter waiting list.
BUPA is great marketing, but the analogy here is Royal Mail vs privatised mail and courier services, great if you and your recipient live in london, but they do not want to know about delivering a single page letter or cheque to someone who lives out in the sticks the next day for the same price as the local letter, and this "cherry picking" cripples the Royal Mail postal service, that and, same again, political interference.
WTF are you on about?
"Triage", you ought to learn what it means.... BTW, good luck trying to get a kidney transplant out of BUPA, or free spectacles, or free dentures, or a free pacemaker, or free dialysis for the next 30 years, or specialist pediatric care, or severe burns care, or radiotherapy and chemotherapy...
I can't get free spectacles or dentures off the NHS, I can get radio and chemo therapy from BUPA. And nothing on the NHS is free - every tax payer pays for it.
BUPA is all about jumping the queue when you have the most minor triage class complaints, but without paying true private treatment costs, because BUPA is itself MASSIVELY subsidised by the NHS (name a single BUPA trained doctor, nurse, theatre orderly, etc)
It's not subsidised, it sits on top. And you will find private only medical professionals, who haven't had anything to do with the NHS (however, they won't be British).
insurance != gambling I thought I had an interesting perspective, and presented some arguments that brought me there. I'd like to hear your counter-arguments.
its not pay or die, more like pay or be finacially ruined IMHO it depends on your initial conditions. I'm fairly well off, so it would be financial ruin for me. For someone struggling to stay fed and sheltered, it may well be "pay or die".
the government could dismantle the health insurance industry in a second Fat chance. Any such actions would have to be voted on by politicians, politicians who need campaign contributions in order to keep their jobs. The hint of socializing health care over a decade ago completely changed the complexion of Congress. IMHO the real shame back then wasn't the change, it was that as a society we acted like brats, "Nyah Nyah, I'm not listening! Stuck our fingers in our ears and pouted." We had the opportunity for national debate, and we shut it down, claiming that the existing health care system was just fine. Within a decade US businesses were shedding US jobs left and right, offshoring, citing "cost of health care" as one of the significant reasons. We didn't have to socialize, but we should have had the debate, and we should have done SOMETHING!
My argument on this is simply about the inefficiency. At the moment, we're not telling people to "Go away and die!" but society is picking up the tab after it's expensive, because those people couldn't pay the tab when it was cheaper. It isn't always this way, but usually earlier diagnosis and care is cheaper and better - more cost effective. Then on the financial ruin side, is it better for the overall economy (There, trying to avoid that "society" word because it shares a root with "socialist.") to financially ruin people when something like cancer strikes? Don't forget, you're not just visiting financial ruin on that person, but on his/her children, and taking his/her non-essential contributions out of the local economy, etc.
on insurance and gambling: i'm interested to hear the counter-argument, too. it occurred to me a long time ago, and i've never really heard anyone argue against it (although most people have certainly never thought of it that way). i get more inclined to take the bet as i get older (less because of the "body falling apart" stuff, and more because i've seen more random disasters). i don't even see how your statement could be controversial.
on "pay or die" vs. "pay or be ruined": in the US, we do generally have enough support for emergency care that it's not really "pay or die" if people are willing to seek out help. it's more like "pay or be financially ruined, have a poor quality of life, never be truly healthy, and die younger than average."
on "the government could dismantle the insurance industry": he's right, depending on how you read "could". yes, if the government were to socialize health care, it would shake the insurance industry enough that it would look very different when the dust settles (although most of the big names like kaiser would still be around), and yes, it nominally has the power to do so. but you're also right in that there's no way that "could" (in practical terms) happen in the short term.
overall, i think your proposal is reasonable, but i'm not yet prepared to give up on just doing the whole job right. GB's model is very good; NHS provides a broad range of services to all who need/want them, both health and accident/emergency care, and there exists a quite healthy private insurance and hospital (even setting aside the already-noted private segments of NHS) industry.
perhaps i'm overly optimistic, but i believe we could get this within a decade, provided the next election or two go well. the recent activity in places like Oregon is very encouraging. moreover, it seems like we are finally having the debate. a decade or two late, but it does seem like it's much more active than it was, say, five years ago.
insurance != gambling I thought I had an interesting perspective, and presented some arguments that brought me there. I'd like to hear your counter-arguments.
For someone struggling to stay fed and sheltered, it may well be "pay or die".
Those are the people who qualify for the current government provided health care systems. If you're wondering why health care is so expensive look no further than government programs. They cap the costs that the hospitals can charge so they have to go looking for their profits elsewhere. Not only do we have to pay higher taxes to provide the poor with medical care but we also have to subsidize the low cost of their treatment through our medical insurance premiums.
The hint of socializing health care over a decade ago completely changed the complexion of Congress.
Highly doubtful there. More to do with the Republicans getting out and organizing. The excesses of 20 something years controlling the Congress were too much for the people so they voted for newer, better excesses to vote out later.
My argument on this is simply about the inefficiency. At the moment, we're not telling people to "Go away and die!" but society is picking up the tab after it's expensive, because those people couldn't pay the tab when it was cheaper.
Exact same argument used to get helmet laws passed. And airbag, seatbelt, 3rd taillight, etc...
You want to see some *real* change, go get the government meddling aimed at malpractice insurance. Maybe we can start by socializing that on our road to serfdom...
If you look at the 'successful' socialist programs they all have one thing in common, the government has a monopoly on the service.
I've been racking my brains, and I can't think of one country (in the developed non-totalitarian world) where this is true. Which ones did you have in mind?
Few of those Americans who use words like "Socialist", "Communist", "free market", "Democracy" have any idea what they are talking about.
I live in a country with socialized medicine and for my recent back troubles I went to a doctor recommended by the parent of one of my daughter's friends. That choice cost me 25 Euros and a 48 hour wait for an appointment. My doctor owns his own practice and see the patents he chooses. He's also a nice guy and we're glad to have added him to our social circle.
For my physical therapy I again had the same sort of choice and picked the one preferred by the state assurance body... mostly because it was on my daily bicycle route.
I've lived a long time in the US and I can honestly say that health care system is badly broken.
I've lived in other countries and seen a lot of interesting and moderately effective health care solutions. It's shame that so many solutions are apparently off limits because Americans have invented curse words that sound like "Socialist" but have nothing at all to do with Socialism or a civil society.
Wasn't really talking about health care but in general. Even though I apparently don't know how to use the word properly I would venture to say the interstate highway system is a 'socialist' program and is pretty successful. Aside from a few state created toll roads here and there the government has a monopoly on the creation and maintenance of roads. If you ignore the federal government's use of highway funds as a method to get states to bow to its wishes and don't view it as a way to redistribute wealth between the states then it could possibly be the one and only 'successful' socialist program the US has ever come up with.
"If you look at the 'successful' socialist programs they all have one thing in common, the government has a monopoly on the service."
With the qualifier "socialist" in there, and for sufficiently precise values of "socialist", you may be right.
However, as it applies to any of the seriously proposed ideas for universal health care in the US, it is a myth. Not even Dennis Kucinich, the most leftist Presidential candidate in many a year, has proposed anything of the kind. The ideas being floated are "Single Payer", not "Single Provider"; they're more "Medicaid for All" than they are "Kaiser Permanente for All".
Since you've fallen for that myth, let me pre-emptively knock down another big one: "Government-run healthcare payers are woefully inefficient."
Not true. One good way to measure te efficiency of a health care payer is to find the percentage of its total monetary inputs that is not spent on direct healthcare costs for its members. That percentage is for practical purposes a fairly direct measure of the payer's overhead. (Administrative expenses, shareholder profits, excessive claims denials, subscriber selection, what have you.)
When one finds this measurement for a variety of public and private healthcare payers, it turns out that private healthcare payers have a higher overhead than public, government-run payers. It's not a small amount of difference, either; private payers typically have three or more times the overhead of public payers:
"According to the World Health Organization, in the United States administrative expenses eat up about 15 percent of the money paid in premiums to private health insurance companies, but only 4 percent of the budgets of public insurance programs, which consist mainly of Medicare and Medicaid. The numbers for both public and private insurance are similar in other countries - but because we rely much more heavily than anyone else on private insurance, our total administrative costs are much higher."
There's plenty of evidence on this issue; one good starting place - and the source of the above quote - is here.
At least in california, medicare *also* regularly underpays health care providers to such a large extent that it is widely agreed to be one of the causes of the high price of private insurance. In other words, medicare is offloading some of its costs on the private insurers so you can't make such a simple-minded comparison of their costs and overheads.
The much touted WHO stats are garbagey for a lot of reasons and this is one of them.
It appears to be true that Medicaid reimbursements are lower, that they may actually be below the provider's cost in some cases, and that providers are somewhat obliged to charge private payers more to offset the difference or to eat the difference themselves.*
However, that has nothing to do with the relative efficiency of the payers.
If you have specific objections to the WHO stats, bring them forth. I'd love to hear them.
One that I've heard - which probably has some merit - is that a government payer usually gets its credit at better rates, and that sort of advantage would certainly show up in overhead rates for any payers borrowing money. Even if true, though, it doesn't detract from the worthiness of the overhead comparison as it affects healthcare payment efficiency. If it's an inherent advantage to government payers, then that's what it is... it'll still be an inherent advantage if the program is expanded.
[*: That's one of the reasons our clinic is unusual in the number of Medicad patients it serves; somewhere around 40-45% of our patient population is OHP. For the most part our clinic just eats the difference... which is one reason my salary is well below market rates.]
However, that has nothing to do with the relative efficiency of the payers.
Sorry, that doesn't follow. On the one hand you've got insurers who do a lot of work on chart review, and managed care. And the insurers do a lot of work to create and sustain relationships with practitioners. On the other you've got Medicare that seems to mostly just look at the bill and write a short check and which "sells" its product to providers mostly by fiat of law.
If you want a model of efficiency from the government there are parts of the VA system that you can look to. There you'll find some key structural factors that create that efficiency like physicians paid on salary (rather than by procedure) and a famously good system of on-line patient health records. Both of those are structural efficiencies that are gaining some attention and traction in the private systems.
So, yes, the WHO numbers really are bogus that way.
Another famous WHO bogosity is the tossing around of health-care expenditures as a percentage of GDB. Yet, these numbers don't control for procedure types or population demographics
Another WHO number is interesting in the way that universal care proponents quietly ignore it: patient satisfaction numbers, in which the U.S. is #1.
Another WHO number is also interesting in the way it gets quietly ignored: you want some of the best outcomes in the world, even compared to insured people in the U.S.? Just walk into an emergency room, uninsured, with an acute condition.
Another thing simply bogus about the WHO numbers is that they don't ask the question "to what extent does health care spending the U.S. subsidize care in the nations we are comparing to the US?" The US is a world leader in equipment and pharmaceutical innovation and this implicit subsidy should not be overlooked as a possible contributor to efficiencies in places that have price controls and that import more of their medical innovation.
One that I've heard - which probably has some merit - is that a government payer usually gets its credit at better rates, and that sort of advantage would certainly show up in overhead rates for any payers borrowing money. Even if true, though, it doesn't detract from the worthiness of the overhead comparison as it affects healthcare payment efficiency. If it's an inherent advantage to government payers, then that's what it is... it'll still be an inherent advantage if the program is expanded.
But it doesn't seem to be an inherent advantage. Medicare patients have poorer access to physcisians (except in places where the government holds a gun to the provider's head). Private insurance rates are higher because medicare underpays. Anyone can look "efficient" if they are paying with a gun in one hand and not-enough-money in the other -- and private insurance buyers are (in a round-about, wasteful way) making up the difference.
That is why, for example, in the "Governer's plan" - California's version of Massachusetts' personal mandate crap - a cornerstone of the plan is to raise medicare's payouts to more closely resemble private payouts. What does that tell you about your supposed "efficiency"?
Seriously, have you ever been to, say, the DMV, or the court house, or the local town hall business office, or.... In the very best of these places the civil servants there have many fine virtues of attentive professionalism. I'm sure tax payers are getting a good deal in some cases. But even the very best of those: efficient? Efficient as in optimizing a labor budget and aggressively responding to changing market conditions? Civil service bureacracies are, by design, pretty hostile to such efficiencies. It's just not what they're good at and it's not what they're supposed to be good at.
"On the one hand you've got insurers who do a lot of work on chart review, and managed care. And the insurers do a lot of work to create and sustain relationships with practitioners."
That's the overhead. Why are unlicensed, non-medical personnel reviewing these charts? Are they making health care decisions better, or just looking out for the payer's bottom line? It is precisely the lack of all this superfluous crap that makes public payers' overhead lower.
Anyway, you're apparently misunderstanding the specific and narrow way in which I am talking about one measurement of efficiency. There are of course many possible measurements of efficiency. Efficiency in providing customer satisfaction, efficiency in keeping scheduled appointment times, what have you... efficiency is a broad term. I'm not claiming public payers are efficient for all possible meanings of the word.
However, I defined above a particular thing I'm talking about, although I did it in words and not algebra. Let me be more specific:
Let R = Payer Revenue and PS = Health Service Expenditures. (PS is money paid to providers in exchange for services rendered.) Let the payer's overhead be OV = (R - PS)/R
An efficient payer has a very low value of OV.
So that's why I say that the subsidy a public payer admittedly receives from private payers has nothing to do with the payers' respective efficiency. It's hard to see how an overcharge or a subsidy could affect OV in a way that makes medicare look better. (In fact, if a private payer is being overcharged, you'd think it'd raise PS and therefore reduce its OV.)
As for your WHO references... okay. You might have some valid complaints there. But when I asked for criticisms of the WHO data, I guess I presumed you'd realize that I was only talking about the WHO data that I was referring to, on healthcare payer overhead. I'm not going to attempt to defend their whole body of work! :-)
I hope you will take the time to look up the main WHO report that everyone cites. It's widely available on-line, it's only a few 10 pages, and it's written for a broad audience.
The satisfaction numbers are "biased" as you describe: they refer to "satisfaction" among patients who have good access. If you compare people with good access in France or Germany or whatever to people with good access in the US, the one's in the US are distinctly more satisfied with how well the system treats them -- the personal experience of the system is better.
That matters to the political questions at hand: given so many uninsured in the U.S., should we seek solutions that break how the system works for people for whom it already works well? Or should we seek solutions that increase the number of people who can afford access?
It seems to me that in the blogosophere and the MSM, a lot of editorial support for radical "break everything and start over" solutions is driven purely by emotion and mudslinging. Oh, and pandering: the main argument pro single payer systems is basically that health care is a government-provided entitlement in a few countries, and they seem to do alright, so wouldn't you, the middle-class, like to live in world where you just never have to worry about medical bills? Yet, when you dig in and ask why care is cheap abroad (hint, US advances in technology) and how circumstances are different (hint, often better care in the US, very different population demographics, very different environments) then such simple-minded pandering as "it works for Canada" is all but irrelevant.
I wonder how the satisfaction numbers would line up if the U.S. figure counted those who can't afford care as entirely unsatisfied rather than selecting them out. After all, if you can't have care at all, you can't be satisfied at all.
For that matter, I'd like to know how satisfaction was determined in the first place. If it's an aftercare interview, I presume those who died didn't get counted as entirely unsatisfied either.
Preserving the high satisfaction value for those who can afford it could be as simple as not banning private practice.
"It works for ..." is more than simple minded pandering when the list is as long as it is. I find it hard to believe that the U.S. is so unique that there is no validity to "it works ..." for every country in Europe, Canada, Cuba, etc etc.
Not true. One good way to measure te efficiency of a health care payer is to find the percentage of its total monetary inputs that is not spent on direct healthcare costs for its members. That percentage is for practical purposes a fairly direct measure of the payer's overhead. (Administrative expenses, shareholder profits, excessive claims denials, subscriber selection, what have you.)
A private insurance provider makes a profit. Isn't that the whole purpose of business in a 'free' market. Like the story a while back where the insurance companies are somewhat pulling out of Florida because the caps on their profit margin isn't enough to make up for the risk.
I would also guess that there are hidden costs associated with the government programs since a lot of different agencies share services like payroll, health insurance, etc... Highly doubt that is calculated into the figures. Once someone retires out of the administration of Medicare they are transfered to the budget of the Office of Retired Bureaucrats and so Medicare washes their hands of this expense which someone like Kaiser can't do. See where I'm going with this?
From your link:
Dennis Kucinich is the only Presidential Candidate with a plan for a Universal Single Payer, NOT FOR PROFIT Healthcare system.
Bullshit. The profit is only removed from the insurance side of the equation which is why 14,000 health care providers support the plan. They still profit as in the old system they just don't have the risk associated with a non-paying public because the government guarantees their payment. True the government will cap what it will pay as in the current public assistance programs but this will only degrade the system. How does this plan propose to finance new, state of the art (read expensive) equipment with a 4% over direct healthcare costs margin to cover all other expenses? Can't do it without another government plan to finance the new equipment and another to build new hospitals and another to fix the old hospitals and pretty soon the government is running the whole system through a patchwork of legislation except for the running of the actual hospital and its staff which is still for profit.
This is why I stated the only successful 'socialist' programs are the ones where the government declares monopoly rights to provide the service and does away with the competition. Otherwise you are only subsidizing the profits of a certain portion of the population, in this case health care workers. Make them civil servants and you take advantage of economies of scale with regards to the administrative costs associated with their employment instead of having a thousand different retirement plans that are directly funded by the government anyway.
All these proposals offer half-ass solutions and the Europeans pipe in with "it works for us" but we're better than that. If you're going to do something that effects *every* citizen then at least have the common decency to do it right. The first time...
Of course. (Or at least, that's what the shareholders must hope for.) But that is also exactly the point: Why on earth should I want a for-profit middleman taking his profit from my healthcare dollars?
If you remove a for-profit middleman and replace him with a not-for-profit middleman of similar capability, then it stands to reason you'll be paying less for the service offered, doesn't it?
Now, you might claim that Medicaid can't possibly be efficient without the incentive of profit, but I can tell you that from my POV that's just not true. I think most people who have actually worked in the provider's billing portion of the US healthcare industry will tell you that when it comes to actually paying its bills, Oregon Medicaid is pretty decent. They don't pay much, but they don't argue so much either. Most of the time, they just pay, and promptly. Private insurance has a much higher bogus-rejection rate. (I was just working on a billing yesterday that we submitted in November of 2005 - and resubmitted every couple months since then - and the private payer is still arguing that they've never received it.... even though they paid other claims on the same electronic data transmission.) OHP may (or may not) pay more fraudulent claims because of this, but it's not pervasive enough to destroy in their overhead if so. (And yes, the WHO study included fraudulent and mistaken payments as overhead.)
"How does this plan propose to finance new, state of the art (read expensive) equipment with a 4% over direct healthcare costs margin to cover all other expenses?"
I'm not here to defend Kucinich's plan, but it does seem as if you have completely misunderstood it. Which equpment are you referring to, medical equipment? A Medicaid-for-all plan would not require any of that, because - as I said - it's a payer, not a provider. All they'd need for equipment would be some bigger datacenters for claims processing, plus the usual staff and office space.
"This is why I stated the only successful 'socialist' programs are the ones where the government declares monopoly rights to provide the service and does away with the competition."
I see. you're actually advocating such a system. Most people who say things like that oppose such a thing, so you caught me a bit off-guard. :-)
Anyway, no I don't agree. We don't need to do anything that radical to make a major and possibly sufficient improvement. Kaiser Permanente is a good example of a vertically-integrated HMO that could be seen as an example of a "socialist" healthcare system writ small. The VA is another example. While they don't totally suck, they are not exactly paragons of customer satisfaction either.
Parsing "Universal Health Care"
With the Presidential race heating up, and "Sicko" not yet faded from consciousness, the subject of "Universal Health Care" becomes fodder for discussion once more. There are many viewpoints about the idea of health care and what should be done about it, but perhaps one of the more interesting ideas comes from simply parsing, "Universal Health Care."
Let's drop back for a moment, and introduce an alternative: "Go away and die."
That is simple and literal, if you can't afford health care, you don't get it. But what that phrase really means is, "Don't expect me to pay for your health care, but don't make me feel guilty about it, either." In other words, we want to feel like a Christian Nation - but we'd rather keep our financial exposure within "practical" limits. There may also be an element of "lifestyle self-righteousness," though the term may a bit harsh. (I'm a bit guilty of this too, I watch what I eat, get exercise, deferred instant rewards in order to go to college and get a good job, etc.)
So far as a society we have been unwilling to simply say, "Go away and die," and some may feel that's good, others may feel it's bad, but it is. But the upshot is that it isn't very efficient at all. If we're not going to establish "directly financially limited lifetimes," then we should strive to improve the efficiency of what we are doing. Today too many people stay away from medical care until they're very sick, causing the costs to rise.
Time to begin parsing. Start with "Health Care." Isn't that "caring for health," as in day-to-day wellbeing. Can't we separate "health care" from "sickness and accident" care? Now add "Universal" to the mix. There are certain components of caring for wellbeing that are universal, every one needs some, plus every man and woman has additional unique needs.
Every baby needs prenatal care and well-baby examinations, immunizations, etc.
Every person needs dental cleanings and exams.
Every person should have a periodic physical.
Every person 50 and over should have periodic colonoscopies.
Every man over 40 should have periodic DRA and PSA tests.
Every woman should have periodic pap tests.
Every woman over 40 should have periodic mammograms.
(I'm sure this list isn't complete, but IMHO it's a good start.)
These are "Universal", about as "Universal" as "Health Care" can get. Nor do these items have anything to do with "sickness and accident" care.
Now let's go back and examine the concept of "insurance" for a moment. At its simplest, "health insurance" means that I'm betting that I'm going to get sick or have an accident, and my insurance carrier is betting I'm not. My premium, balanced against the anticipated cost of such care, establishes the odds of our bet. Car and homeowners insurance are the same - We bet that something bad is going to happen, our carriers bet that it won't, and our premiums compared to their payout exposure express the odds.
In this light, "insurance" is an entirely inappropriate model for funding "Universal Health Care" as I parsed it, above. That's because those "Universal Health Care" items are needed - there are no odds about it, they should happen. Burying them in an odds-based financial model simply muddies the water - and all-too-often applies pressure to make those "universal" medical needs get skipped.
Yet in another way, they are linked. Because if this "Universal Health Care" happens, people tend to be healthier, and the odds improve for the insurance carrier. Many insurance carriers therefore have better coverage for "preventive maintenance" type health care - it's in their best interest to avoid catastrophic payouts. However, these "Universal" needs are still only taken care of for those who are already insured. Those who are not tend to get late - and more expensive, care.
A modest proposal:
One must realize that society can't turn on a dime. Even in 2 Presidential terms we'll never dismantle the health insurance industry and replace it with any sort of single-payer system, it's just too disruptive and offends too many wealthy and powerful people.
But perhaps what we can do is institute "Universal Health Care" in the sense I parsed. Leave "Sickness and Accident" coverage to the existing health insurance industry, with the odds-based financial model that's appropriate. But find some way to make "Universal Health Care" universally available.
It's also an interesting start that doesn't require dismantling industries or power structures. It gives us an opportunity to better evaluate the health of the nation's people, and assess a strategy for those who are today going untreated until they show up at the Emergency Room.