Parsing "Universal Health Care"

hal9000_sn3

Thu Aug 09 21:49:43 -0700 2007

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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.

Parsing "Universal Health Care"

peacefinder

Thu Aug 09 22:22:36 -0700 2007

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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.

Parsing "Universal Health Care"

phred14

Fri Aug 10 05:30:56 -0700 2007

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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.

Parsing "Universal Health Care"

peacefinder

Fri Aug 10 08:19:58 -0700 2007

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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.

Parsing "Universal Health Care"

Uncle Entity

Thu Aug 09 23:57:29 -0700 2007

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The major flaws in your argument:

• insurance != gambling
• 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.

Parsing "Universal Health Care"

Alan

Fri Aug 10 00:31:31 -0700 2007

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... socialist programs ...

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.

Parsing "Universal Health Care"

maethorechannen

Fri Aug 10 04:41:48 -0700 2007

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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).

Parsing "Universal Health Care"

GuyFawkes

Fri Aug 10 10:08:06 -0700 2007

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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).

See my initial comment about interference.

Parsing "Universal Health Care"

Herrison

Fri Aug 10 11:59:22 -0700 2007

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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.

Parsing "Universal Health Care"

maethorechannen

Fri Aug 10 13:14:37 -0700 2007

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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.

Parsing "Universal Health Care"

maethorechannen

Fri Aug 10 13:00:13 -0700 2007

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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).

Parsing "Universal Health Care"

phred14

Fri Aug 10 05:25:11 -0700 2007

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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.

Parsing "Universal Health Care"

Anthony Sorace

Fri Aug 10 06:17:43 -0700 2007

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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.

Parsing "Universal Health Care"

Uncle Entity

Fri Aug 10 11:39:10 -0700 2007

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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.

Here's a previous discussion on the subject.

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...

Parsing "Universal Health Care"

Pseudonym

Fri Aug 10 06:34:48 -0700 2007

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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?

Parsing "Universal Health Care"

Bhima

Fri Aug 10 08:47:19 -0700 2007

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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.

Parsing "Universal Health Care"

Uncle Entity

Fri Aug 10 10:44:33 -0700 2007

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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.

Parsing "Universal Health Care"

peacefinder

Fri Aug 10 09:11:30 -0700 2007

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"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.

Parsing "Universal Health Care"

Thomas Lord

Fri Aug 10 10:22:33 -0700 2007

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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.

-t

Parsing "Universal Health Care"

peacefinder

Fri Aug 10 13:15:47 -0700 2007

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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.]

Parsing "Universal Health Care"

Thomas Lord

Fri Aug 10 15:24:16 -0700 2007

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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.

-t

Parsing "Universal Health Care"

peacefinder

Fri Aug 10 18:22:37 -0700 2007

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"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! :-)

Parsing "Universal Health Care"

Pseudonym

Sat Aug 11 04:42:53 -0700 2007

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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.

...which is likely to be based on a biassed sample, since those who can't afford to be patients are selected out.

Parsing "Universal Health Care"

Thomas Lord

Sat Aug 11 08:33:00 -0700 2007

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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.

-t

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pyro9

Sat Aug 11 13:29:07 -0700 2007

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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.

Parsing "Universal Health Care"

Uncle Entity

Fri Aug 10 12:32:12 -0700 2007

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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...

Parsing "Universal Health Care"

peacefinder

Fri Aug 10 13:50:03 -0700 2007

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"A private insurance provider makes a profit."

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"

Uncle Entity

Fri Aug 10 15:18:19 -0700 2007

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Why on earth should I want a for-profit middleman taking his profit from my healthcare dollars?

You aren't paying the middleman for health care, you are paying to mitigate the financial risks of a major health problem. If all these people get together and pool their risks then you have a system we call insurance, you are only financially responsible for the amount of your premiums, over time, instead of the full amount of the service. The middleman in this case is charging for their assuming the risk associated with this service.

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.

Yes medical equiptment. When this grand new plan comes into effect they will reduce costs by capping profits. The hospitals have set costs and anything over this can be used to invest in the future or pay shareholders. They will most likely cap profits right around the set cost level which would leave the hospital with no money to invest in new equiptment and so will slowly cause the quality of the health care system to erode.

To mitigate this problem will require the government to step in and finance the future instead of the hospital doing it themselves even though they are still a for-profit business.

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.

Not advocating as much as spelling out the difference. Anything less than full government monopoly is just a form of corporate welfare that takes from the many and concentrates that wealth into a certain industry. Socialism and profit motive are mutually exclusive.

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.

Kaiser is a non-profit entity I do believe. Why can't all these people calling for a non-profit insurance carrier simply move to an existing program, there is obviously a large enough demand they could probably take over a big chunk of the market with a little advertising. So why doesn't this happen if the non-profit middleman is such a good thing. Makes you wonder what the *true* motives are behind these proposals when there are existing non-government programs that are identical to the proposed plans.

Parsing "Universal Health Care"

Thomas Lord

Fri Aug 10 15:37:14 -0700 2007

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Just a note that a "nonprofit coroporation" like Kaiser is not an example of "socialist" healthcare.

An NPO must still balance it's books.   It still operates as a business -- just one that can't access the public or private equity markets to raise cash.

A socialist program is entirely different.   The government builds out offices and pools of labor and then it just runs.   If it costs too much, either it fails to provide service or it sucks tax revenue or government borrowing away from other things.  It lacks even the basic economic checks and balances of an NPO.   It can't "rightsize" or innovate without help from a legislature.    It's a whole bunch of pensioners-to-be "playing office".   

-t

Parsing "Universal Health Care"

maethorechannen

Fri Aug 10 04:29:07 -0700 2007

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Can't we separate "health care" from "sickness and accident" care?

No. Sickness and accidents are when people need the most expensive health care. Basic tests, shots, etc are fairly inexpensive - everybody needs them so you get economy of scale.

Most of what the NHS in the UK does is sickness and accident care - if anything, there is less emphasis on preventative measures as there is only so much funding available. There is actually a market in the UK for preventative measures, BUPA (one of the largets private medical insurance firms) runs a healthy business in  tests and screens that the NHS would never, ever pay for.

Even with Universal Health Care there is still a role for private insurance as, again taking the UK as an example, with Universal Health Care comes waiting lists. There is only so much resource available, and private insurance lets those with the means get out of the queue (and relieve pressure on the NHS at the same time).

Parsing "Universal Health Care"

mrjk

Fri Aug 10 07:57:17 -0700 2007

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"Can't we separate "health care" from "sickness and accident" care? No. Sickness and accidents are when people need the most expensive health care. Basic tests, shots, etc are fairly inexpensive - everybody needs them so you get economy of scale."

But that is the point - you've just supported his argument! Lets just take all the testing and stuff that people should get no matter what and fund it. It won't be that much money, as you say, and it won't be a full answer but if what all the experts say is correct, it will have a big effect on costs.

Parsing "Universal Health Care"

Beryllium Sphere(r)

Fri Aug 10 08:01:05 -0700 2007

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with Universal Health Care comes waiting lists. There is only so much resource available

This is what nobody likes to talk about. Every system must do some form of rationing. In the US it's done by having 45 million uninsured, in the UK by having waiting lists. Oregon experimented with providing basic care to everyone by denying some rare and expensive treatments.

I really like the idea of providing free preventive care. HMOs were supposed to move in this direction because they were supposed to have an incentive to help their members stay healthy. Is it possible, though, to keep it separate from sickness care? It's common for people to speak up during routine physicals and wreck the doctor's schedule with health complaints.

Parsing "Universal Health Care"

phred14

Fri Aug 10 08:45:45 -0700 2007

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Every system must do some form of rationing. I like the Oregon system because it's equal, open, and honest.

keep it separate from sickness care? I think it is. Modern health insurance has turned the modern medical clinic into billing wizards.  That's really what this is - a billing issue, making sure the right billing gets put into the right bucket.  More often than not, when a medical complaint comes up during a routine exam, the response is to schedule another appointment.  That makes the separation easy.

In a way, making preventive/maintenance care universal is kind of a watered-down Oregon plan, because it's a very small, very specific set of items which have become standard.  One side-effect that I didn't go into is the gathering of statistics.  We really don't have a very good estimate of the "health of the nation," and this wouldn't do it either.  But it would get us closer than we are today.  It would also help generate better numbers to feed into planning and decisions for future health policy.

Parsing "Universal Health Care"

GuyFawkes

Fri Aug 10 10:33:29 -0700 2007

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Every system must do some form of rationing. In the US it's done by having 45 million uninsured, in the UK by having waiting lists.

NO IT IS NOT, please learn what "Triage" means.

There is no waiting list for having a baby, a heart attack, a broken bone, etc etc etc.

There _is_ a waiting list for things like hip replacements, but often there are medical reasons for waiting, and interim treatments, eg you need your breathing sorted before you can safely undergo the general you need for your hip operation, or you have to wait for the suitable donor kidney.

The NHS also does a LOT of elective surgery, tummy tucks, breast augumentation, full dental clearance (which I had earlier this year) and for this non life threatening stuff you get to wait, sometimes days only.

The "rationing" that is going on is the person who wants a tattoo saying "Rose" removed for free because their new girlfriend is called "Jane" gets dealt with when there are no more serious cases on the books, the more trivial your complaint, the longer you wait, which is exactly as it should be.

WITHOUT EXCEPTION (and I know a lot of medical staff, the major regional hospital is a 2 minute walk from here) every "complaint" about NHS I have heard about reads quite differently when you talk to the actual staff involved, the abusive drunk who wasn't treated promptly enough, not because he was abusive or an asshole or his injuries were his own stupid fault, but because of a medical reason, eg contra indications between a drug and his blood alcohol level.

Reporting such things factually doesn't sell newspapers though....

Parsing "Universal Health Care"

maethorechannen

Fri Aug 10 13:21:05 -0700 2007

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There is no waiting list for having a baby, a heart attack, a broken bone, etc etc etc.

There _is_ a waiting list for things like hip replacements,

But the people who deliver babies, treat heart attacks and put bones in casts aren't the same as the ones who replace hips, treat cancer and do heart bypasses. It's not a triage system.

Parsing "Universal Health Care"

GuyFawkes

Fri Aug 10 14:57:54 -0700 2007

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they are actually, hospitals aren't staffed by consultant surgeons only

Parsing "Universal Health Care"

pyro9

Sat Aug 11 16:19:24 -0700 2007

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There is a waiting system in the U.S. as well, it's just distributed differently.

For non-emergencies, those with insurance and/or cash will wait from hours to a day or so, all else will wait FOREVER.
For emergencies, the uninsured are advised to go to the waiting room and wait until their condition becomes too serious to risk transport.

Any health care system will have complaints no matter how good it really is. It's only natural that most people do not react calmly to an injury requiring the hospital. In an agitated state, minutes seem like hours.

I can only home that socialized medicine can make treatment take priority over paperwork.

Parsing "Universal Health Care"

Uncle Entity

Sat Aug 11 22:57:25 -0700 2007

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I can only hope that socialized medicine can make treatment take priority over paperwork.

This is a bureaucracy you're talking about here...

I've been thinking about this and here seems like a good as place as any to put down my thoughts even though it only somewhat reflects on what you're saying.

We have this broken system where it is too expensive for middle class people with children to get insurance. Not middle class single people, my premiums are ~$100/month, but exclusively middle class families. There are programs to pick up the poor and the children of middle class families that make up to 200% over the poverty line.

So who exactly is going to benefit from universal coverage? I doubt my 'single payer' taxes are going to be less than the $25 a week that I pay now so I won't benefit. The rich don't care because they spend more than that for Evion for their dog. The poor and middle class kids are already covered under a 'single payer' program. By all accounts this seems to either be a push by the 'broken' health care industry to get everybody to subsidize their 'broken' system or just an attempt to put upper middle class families on welfare, those who make too much to qualify for the already existing middle class children's program.

Let's say this 'single payer' system gets enacted by some miracle. The overly expensive broken system is still the same as it was before they just have 45 million more patients to care for overnight. We already have a shortage of medical personnel so people that get good care today are going to get shitty care while those who get no care today are also going to get bad care but its 100% better than no care.

I guess this is where I ask, "what's in it for me?"

Parsing "Universal Health Care"

pyro9

Sun Aug 12 07:18:27 -0700 2007

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Yes, single middle class people DO often have insurance today, but it is a really messy  patchwork.


My comment on paperwork stems from an incident where I fell through a ceiling and had the side of my wrist cut open on the way down. I'm standing there dripping blood and half of my fingers don't work and the top priority for the hospital was to have me sign insurance verification papers. So much so that the nurse didn't even notice that I was not likely to hold the clipboard with one hand and sign with the other.

Just try showing up at a hospital in work clothes and you'll see the unwritten policy that everyone is the scum of the earth until proven insured. Before proof it's "just hold that shirt over it, you'll be OK" and after proof it's "let's get you a painkiller and clean that up".

None of that needs to be if the hospital can presume anyone who comes in is somehow covered.

While the proper tradition of western medical care is to have a long relationship with a GP and to have him/her recommend a specialist known to them when necessary, the modern work provided HMO practically forbids that. Plans change frequently, and each time the insured is expected to change doctors.

Meanwhile, if you're on an employee health plan and develop a chronic condition, any hope you had of becoming an  entrepreneur  is shot unless you win the lottery first. Insurance costs go up a LOT if you're not covered under a large group plan. Meanwhile, if you're downsized, you'r SOL. If your condition is one where with treatment you live a normal life and without you're not quite disabled, not really healthy, and die a decade earlier, you WILL be in the "pay up or die" category. I don't kow your circumstances, but a lot of the insured middle class are just one outsourcing away from that problem.


There are plenty of currently well insured people who are best advised NOT to have a simple screening done for conditions that are easily enough treated before they become symptomatic simply because a positive result would make them a sort of insurance pariah. Even a single "ill considered" visit to a specialist can make you a sort of pariah.

The last time my mom had to change plans, I needed to use some fairly hairy mathematical analysis to help her choose the optimal plan. Even with that, every time she needs a doctor the HMO starts splitting frog's hairs to redefine procedures into categories with higher copays and/or lower caps. By 'the HMO", I mean whichever one is involved at the time. All of them seem to be that way. Actually verifying the correctness of a billing is more complex than many people can manage. They end up just paying the stated amount without checking.

Part of the current brokenness is a result of HMOs applying pressure outward from themselves because they can't apply it systemically (and have no incentive to even try).  Actual  caregivers are  caught between HMOs that can shut a practice down just by scratching them off of the approved list and suppliers who don't have to care. Meanwhile, in order to cover liability issues from shotgun lawsuits, suppliers must charge several times as much as they would otherwise because there is no level of certification that can protect them from unwarranted lawsuits. If/when the government itself becomes the primary buyer, the incentives will be in place to correct that. That is a problem that can only be solved at the systemic level.

So if done right, what's in it for you is a less broken and less expensive system where profit margins don't trump medical concerns. It may well be that TODAY your single payer taxes won't be any less than your insurance payments, but TOMORROW when you're older and need more health care you might find things looking very different.

As you get older you might appreciate the better life expectancy enjoyed by citizens of countries who have socialized medicine.

If your parents are still living you might appreciate not having to one day rescue them from the choice between food and heat, or medicine. Depending on the winds of fortune you might find yourself cursing the "what's in it for me" attitude that helped make your continued employment in an uncertain economy literally a matter of (your) life or death.

It's also worth noting that medical problems very rarely get cheaper to take care of when ignored for a while and that people who ignore medical problems rarely become more economically productive as a result. A system that actively encourages or even forces people to ignore medical problems until they become much more expensive and serious enough to render them unproductive WILL suffer from lost productivity and higher costs. This comes at exactly the time when Americans are being asked to remain productive longer than ever to prop up the economy.

You may even avoid having "what's in it for me" echoing in your head as you treat a broken finger or toe with two shots of whiskey, a firm pull and a roll of masking tape.

So perhaps it's not currently "pay up or die", it's merely "pay up or die sooner". The older you get the more you must pay up to avoid dying sooner.

Parsing "Universal Health Care"

J.B. Nicholson-Owens

Sun Aug 12 18:46:29 -0700 2007

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More on the myth of waiting lists: Under the current American system, I'm already on waiting lists. I can't get appointments to see any health professional when I want without being in an emergency. So this scare talk about waiting lists (which are supposed to dissuade me from thinking a single-payer universal health care plan like HR676 isn't worth my support) strikes me as a lie. I find Dr. Steffi Woolhandler's (from PNHP) views on this topic to be far more persuasive.

I'm willing to make appointments 6-8 months ahead of time for medical care. In some instances, I'm scheduling months ahead of time already. But I'm doing it at a price I can't afford to pay without becoming a wage slave to some organization that can negotiate better health care prices than what I can negotiate on my own working for myself in my own consultancy business.

Waiting times

peacefinder

Fri Aug 10 09:50:18 -0700 2007

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"...with Universal Health Care comes waiting lists. There is only so much resource available"

And the US has good wait times now?

There's another myth down.

(By the way, I owe y'all some disclosure. I work in a non-medical capacity for a ~10-provider pediatrics clinic in Oregon. For a variety of reasons - none of which involve higher reimbursements, alas - our clinic has a higher proportion of OHP (Medicaid) patients than most similar clinics. I do not represent the clinic here in any official capacity, the opinions here are strictly my own.)

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President4242

Fri Aug 10 08:40:57 -0700 2007

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I like the idea, but I'd add three major bits to it:

1. Center for Disease Control Approved Epidemics- these should be covered to encourage quarantine of early cases to cut costs on potential later cases.
2. Vision coverage- it might be just because I'm very affected by this (best thing I ever did for my migraines was get perscription sunglasses) but it also affects other people- in the 5 years I didn't have vision coverage I had several close calls while driving when a migraine hit and suddenly all the cars and lanes were doubled for my vision.  I see that as a public danger that should be included in Universal Health Care.
3. Require rebates to healthy people- without this, the insurance companies will keep the high premiums as profit.

In other words- expand your preventative care to stuff that could affect other people if they come in contact with the original sick/accident victim.  And make sure that the insurence companies don't just take your universal health care program as a sign for more profit.

insurance v. gambling

Thomas Lord

Fri Aug 10 08:43:17 -0700 2007

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Insurance is not a lot like gambling (not in the sense given above), other than that both make heavy use of statistics for setting prices.    Here is why:

"Gambling" is a zero-sum game.    You start with a certain amount of money on the table, distributed among the players, and in essence you play until one player holds all the money.    In an egalitarian game like poker, players use a market to set the price of a chance at the pot.  In a parlor game like blackjack or craps, bet prices are essentially fixed by the house (and, hint, they're just a very, very slight bad deal).    There's no argument, in a straight game, about who gets what money after the cards are turned over.


"Insurance" is not zero sum, the the rules about who gets what money are more complicated:

Insurance is a form of investment fund.   Fund members (the insured) pool funds.  The insurer is a fund manager who invests those funds in the market.

In all forms of insurance, fund members give up simple rights to make withdrawls from the fund.   For example, in life insurance you can only withdraw funds by dying (or, in some cases, cashing out and leaving the fund entirely).   In health insurance, withdrawls are strictly needs based and fund members use a contract to define what counts as a "need".   Also key to health insurance:  you get no equity.   You can make needs-based withdrawls, including in excess of your theoretical shares, but if you never do make withdrawls, and then want to just leave the fund -- you're simply out all the money you've put in.

The restrictions on withdrawing money from a health insurance fund have a simple purpose:   given more control over the money, in theory, insurance fund managers can produce higher rates of return (fund growth) than if their assets were less restricted.    That is:  you may just be putting in a few hundred bucks per month into the fund, but your insurer's fund should be performing very well compared to other possible ways to invest those few hundred bucks.

The restrictions on payouts also means that health insurance is a kind of privatized system of medical service rationing.    People complain that socialized medicine is rationing.   True enough.   Private health insurance is also rationing: it's just that there's (theoretic) competition among rationing services.

So, two last points:

Health insurance is gambling, afterall, but only in the way that when you choose an insurer, you are betting on the skill of the fund manager to play the market well.   It's not so much placing a bet on your health, other than that you reasonably anticipate at some point that it will be convenient to make sudden withdrawls to pay for unanticipated health care needs.


Finally:  It is a little artificial to talk about "units" of health insurance.   For example, it is hard to compare a Blue Cross catastrophic plan to a Kaeser Permanente whole-care plan.   Still, if we posit some "unit", then in an efficient market the marginal price of sale and marginal cost of production of each unit should converge, right?

Certainly we don't face an efficient market here.    Nearly every insured person that I know has relatively little choice about insurance providers.   Entire regions are locked up by a few providers.   Many hospitals and doctors offices are dedicated to just one or a few insurers.   So, you live in Berkeley?  Work at the university?  (for example)  Then you are locked into a choice of a very small number of providers, only one of which has a strong presense.   And your choice of health care providers is locked in by your choice of insurer.   So, all up and down the market there's no price competition.

US health insurance isn't quite gambling --- but neither is it really a free market.  That, I suspect is the problem.

-t

insurance v. gambling

pyro9

Sat Aug 11 17:43:57 -0700 2007

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Part of tyhe problem is that some healthcare is never a free market and cannot be.

A functioning free market assumes that the consumer has time to make an informed choice between producers and most economists assume that the consumer may choose to do without. When faced with a serious injury, you will go where the ambulance takes you and owe whatever they demand. You may not even be conscious until it's all over.

Even non-emergency care distorts the market due to a partial ban on self treatment. I can choose to grow my own food, make my own clothes, or fix my own car.  I can not  prescribe antibiotics for myself even if I do know it's the correct treatment.  I cannot treat someone myself even if I know they will not otherwise get any medical care at all. The latter two probably prevent a lot of people from hurting or killing themselves but that does not eliminate the fact that it limits the freedom of the market.

The legal climate in the US contributes a lot to cost as well. Shotgun lawsuits where they sue the doctor, hospital, nurses, ambulance driver , his dog and his dog's fleas add up fast. Even something as simple as an electrical outlet for a hospital costs 3 times as much because of liability issues. 

Of course, that's a bit of a vicious circle. Extreme costs lead people to sue in a desperate attempt to not spend the rest of their lives paying off the bill and talking to collection agents who act as if they shouldn't have spent the money if they didn't have it.

universal health care is regressive

Thomas Lord

Fri Aug 10 09:01:03 -0700 2007

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Universal health care as recently implemented in Massachusetts and as proposed in California is an anti-labor, regressive, horrible idea.

Specifcally, the new idea of a "personal mandate" has been introduced: citizens will be required by law to have health insurance.   This is not "universal health care" -- this is "mandatory purchases from a small number of state-approved firms".

Of course these new laws include a "means test" -- if your income is sufficiently low by the standards of the legislature then the state will subsidize your mandatory purchase.    Perhaps that sounds kinda fair but please consider the high bureaucratic costs of implementing such a test.   Also please consider what happens if you are wind up, randomly, on the edge of that test:  having to turn down a raise at work because the loss of state subsidy would cost too much.

Here is a better idea:

We already have, in the federal tax system, a completely functional system for distributing "earned income tax credits".    That is, if you earn any money at all -- enough to file -- but your income is low enough -- then the fed's say "Ok, it's as if you already paid an additional $500 in income tax this year."   That amount is deducted from your tax bill.   If your bill was only $10, that means that you get a $490 refund.    In other words, this is a very simple and direct form of redistribution.

We also have, at the federal level, recognition of the concept of medical savings accounts.

Putting those together, as an alternative to universal care, we could construct an "earned income health savings credit" --  a kind of "free refund" for low income people that goes directly into a medical savings account.

That could help to create a truly free market for wellness care and acute care insurance: simply giving many of those in need some cash to go out and procure what they need.

As with the needs test problem in the Massachusetts law, an earned income health savings credit would put people "on the edge" of the credit in an awkward place.    Yet, there is a huge difference that makes the earned income credit saner:  there is no individual mandate.   For example, confronted with a chance for a raise, a worker might reason "Ok, I'll lose the health care benefit but I'll have more cash.   Penciling this out, it looks like I'll still be able to affort catastrophic insurance but I'll probably have to skimp on wellness care this year.   I'm young and healthy and eat right, so, let's do that -- hopefully another raise next year will bring me past where I was last year."    That isn't a crazy or inhumane kind of choice for people make -- better if nobody ever needs to but it's not so bad.   Under a "personal mandate" system, such choices aren't allowed.   Under an earned income health care credit, they are.

-t

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Julian Brookes

Sat Aug 11 05:12:53 -0700 2007

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Wouldn't one fix be simply to expand Medicare to cover the whole USA population? The original Medicare *was* implemented in relatively short time under President Johnson.