American by birth

[JR]

One of the best articles I've seen on the healthcare issue appears in this month's Atlantic magazine.

That's an excellent article. His recommendations a bit handwavy in terms of the actual money in play, but nonetheless are very intruiging.

Finally, ideas are being proposed. Unfortunately, the horse is out the gate and headed down the lane.

JR

[sparkeyjames]

Socialism is bad. (sarcasm)

Socialism is bad. (sarcasm)



This morning I was awoken by my alarm clock powered by electricity generated by the public power monopoly regulated by the U.S. Department of Energy.

I then took a shower in the clean water provided by a municipal water utility.

After that, I turned on the TV to one of the FCC-regulated broadcast channels to see what the National Weather Service of the National Oceanographic and Atmospheric Administration determined the weather was going to be like, using satellites designed, built, and launched by the National Aeronautics and Space Administration.

I watched this while eating my breakfast of U.S. Department of Agriculture-inspected food and taking the drugs which have been determined as safe by the U.S. Food and Drug Administration.

At the appropriate time, as regulated by the U.S. Congress and kept accurate by the National Institute of Standards and Technology and the U.S. Naval Observatory, I get into my National Highway Traffic Safety Administration-approved automobile and set out to work on the roads built by the local, state, and federal Departments of Transportation, possibly stopping to purchase additional fuel of a quality level determined by the Environmental Protection Agency, using legal tender issued by the Federal Reserve Bank.

On the way out the door I deposit any mail I have to be sent out via the U.S. Postal Service and drop the kids off at the public school.

After spending another day not being maimed or killed at work thanks to the
workplace regulations imposed by the Department of Labor and the Occupational Safety and Health administration, enjoying another two meals which again do not kill me because of the USDA, I drive my NHTSA approved car back home on the DOT roads, to my house which has not burned down in my absence because of the state and local building codes and Fire Marshal's inspection, and which has not been plundered of all its valuables thanks to the local police department.

And then I log on to the internet -- which was developed by the Defense
Advanced Research Projects Administration -- and post in online forums about how SOCIALISM in medicine is BAD because the government can't do anything right.

---------
Shamelessly stolen from some internet forum.

[jackellis]

I agree that everyone should have access to affordable health care. Even before all of the expensive technology and medications we have today, growing up I sometimes had to do without.

Medications and medical devices are expensive because the public demands perfection. A device that's "good enough" really isn't for most of us - otherwise minor changes to devices would not cost a king's ransom. At some point I'm probably going to have to take blood pressure and cholesterol medications and I'm going to ask for the old cheap stuff rather than the newer, more expensive stuff that does not appear to make a material difference.

Becoming a doctor is an expensive undertaking. My niece is $200k in debt for dental and orthodontia schools and will require years of good earnings to pay it off. My guess is that medical and dental schools deliberately limit enrollments in part to limit the supply of doctors and in part to ensure that only the best successfully run the gauntlet.

I have paid for my own health insurance on and off for the last 15 years or so. Although I can afford zero deductible, Cadillac coverage, I have opted for higher deductibles and lower premiums because it's insurance, not a subsidy. That means I need to be prepared to pay for routine physicals and some routine meds. However if I have a heart attack or am diagnosed with cancer, I expect the insurer to take care of me.

Perhaps one of the most thoughtful ideas in the draft bill was the notion of end-of-life counseling that would help people make important decisions about wrapping up their affairs. It was purely voluntary so I don't understand the fuss. Among other things, it might help people ensure that their assets and retirement money go to the right people rather than being turned back to a pension fund. I'm very, very disappointed that it's been taken out.

[JR]

Perhaps one of the most thoughtful ideas in the draft bill was the notion of end-of-life counseling that would help people make important decisions about wrapping up their affairs. ... I'm very, very disappointed that it's been taken out.

My mother died two years ago. Her affairs were in excellent order, having left a living will with DNR instructions. Even still, my sibllings and I had to make some very difficult decisions. Without a DNR it would have been a horrible mess. For instance, it's easy to understand that "Do Not Resuscitate" means that no tubes should be hooked up, providing life's sustenance, where otherwise the person would die. How about the ambulance trip to the hospital? Should the EMT do CPR? Give oxygen?

We would each be well advised to think this problem through very carefully and to communicate our views with children, neighbors, care givers, and especially the person with power of attorney. A doctor should be a part of that process, and he should get paid for the meeting.

It's very unfortunate that this fairly innocuous, but important, feature has contributed to so much confusion in the current discussion.

JR

[bruce hylton]

Socialism is bad. (sarcasm)



This morning I was awoken by my alarm clock powered by electricity generated by the public power monopoly regulated by the U.S. Department of Energy.

I then took a shower in the clean water provided by a municipal water utility.

After that, I turned on the TV to one of the FCC-regulated broadcast channels to see what the National Weather Service of the National Oceanographic and Atmospheric Administration determined the weather was going to be like, using satellites designed, built, and launched by the National Aeronautics and Space Administration.

I watched this while eating my breakfast of U.S. Department of Agriculture-inspected food and taking the drugs which have been determined as safe by the U.S. Food and Drug Administration.

At the appropriate time, as regulated by the U.S. Congress and kept accurate by the National Institute of Standards and Technology and the U.S. Naval Observatory, I get into my National Highway Traffic Safety Administration-approved automobile and set out to work on the roads built by the local, state, and federal Departments of Transportation, possibly stopping to purchase additional fuel of a quality level determined by the Environmental Protection Agency, using legal tender issued by the Federal Reserve Bank.

On the way out the door I deposit any mail I have to be sent out via the U.S. Postal Service and drop the kids off at the public school.

After spending another day not being maimed or killed at work thanks to the
workplace regulations imposed by the Department of Labor and the Occupational Safety and Health administration, enjoying another two meals which again do not kill me because of the USDA, I drive my NHTSA approved car back home on the DOT roads, to my house which has not burned down in my absence because of the state and local building codes and Fire Marshal's inspection, and which has not been plundered of all its valuables thanks to the local police department.

And then I log on to the internet -- which was developed by the Defense
Advanced Research Projects Administration -- and post in online forums about how SOCIALISM in medicine is BAD because the government can't do anything right.

---------
Shamelessly stolen from some internet forum.

Again; if it is good enough for congress, it is good enough for me.

[TB Roye]

If you want to know how good the Government Health plan will work just look at AMTRAK and USPS and also Fannie Mae and Freedie Mac.

Tom

[Slik Geek]

There is a complete disconnect between health-care and cost-effectivness considerations. Think about this- if you suddenly discovered a treatment that was very close to equal in effectivness to what is currently done, but costs 1/3 as much, why would anyone use or choose it? In healthcare there is an inherent bias to develop expensive treatments because there is no reward to develop cheap ones that do the same thing, and because expensive treatments will be paid for by people other than those making the purchase decision.

Hence the reason why we must avoid healthcare proposals that don't share cost with the patient. Otherwise, patients have no incentive to seek cost-effective treatment.

Less expensive treatments are in fact developed and implemented because there is an economic advantage to the provider. If you can provide similar treatment at a cost 1/3 of the existing procedure, but charge 1/2 the price, you make more profit and entities that are competing for business have to seek out those therapies. (Private insurers have done this, and hopefully our government too). For example, surgical procedures have been developed that reduce the hospital stay significantly, reducing the overall cost of surgery.

...to drive our system to a straight cash-for-service model that would give individuals an incentive to demand cost-effective care, since they are paying for it.

Very low deductible and low co-pay insurance programs take away the patient's incentive to demand cost-effective care. If the prescription cost is $5 for the generic and $10 for the much more expensive, new patent-protected drug, many patients will spend the extra $5 without a second thought. Now if the coverage was such that the patient paid 30% of the drug's cost, that $18 generic at $5.40 out-of-pocket suddenly is much more attractive than the $36 out-of-pocket for the $120 brand new drug.

According to the United States Government, National Health Expenditures as a percentage of Gross Domestic Product has grown as follows:
1960 5.2%
1970 7.2% (38.5% increase over 1960)
1980 9.1% (26.4% increase over 1970)
1990 12.3% (35.2% increase over 1980)
2000 13.8% (12.2% increase over 1990)
2007 16.2%

http://www.cms.hhs.gov/NationalHealthExpendData/downloads/tables.pdf

National Health Expenditures in raw dollars per capita has grown as follows:
1960 $148
1970 $356
1980 $1,100
1990 $2,814
2000 $4,789
2007 $7,421

Missing from much of the national debate has been insightful analysis into the contributors to the cost increases (other than inflation for the dollar amount increase). How much has the subsidy of health insurance contributed? Availability of more technologies, medications?

Note that the biggest decade increase (on a % of GDP) was from 1960 to 1970. In 1966, Medicare and Medicaid were started, suggesting that insurance programs, public and private, may be a significant contributor to cost increases, as the Gator suggests.

... the most efficient way to administer it would be through a single-payer state run system. The reason is that those paying for the treatments (single payer) has the incentive to demand that cost-effective treatments be developed and implemented.

Yeah, just like with military procurement. (sarcasm). I'm shocked that people even suggest this with a straight face. Private companies that are inefficient either die off or shape up. Government operations that are inefficient generally just demand more taxes to cover their expenses and the inefficiencies remain.

The problem with government run "anything" is that the people making those decisions aren't spending their own money, so what do they care if it costs more, especially if there is a sweet deal on the side for them. (And there often is). Cost efficiency happens when people have their "own skin in the game".

[cwithboat]

[QUOTE
Private companies that are inefficient either die off or shape up.
[/QUOTE]
Quite true. Except that efficiency here means return on stock holders investment, it has nothing to do with the health of individuals or the nation.
Remove the subsidies these companies get from the government and we will see how "efficient" they are regardless of the measure of efficiency.

[Gator95]

"The second solution is the opposite- if we decide that healthcare is not like other services that those who can afford it get more or better, then the most efficient way to administer it would be through a single-payer state run system."

I totally disagree with this statement IF the single-payer is the government. I'm on a government run insurance program (medicare ) and if medicare qualifies as efficent, I'd hate to see inefficent.

The admin and overhead cost for Medicare is lower than private insurance. Not saying it is perfect or that waste isn't there- only that the waste is endemic to any system where the purchase decision is made by someone who doesn't feel the costs.

On the general topic of 'Govenrment Run' vs. 'Privately Run', the main reason that we think private companies are more efficient is that the ones that aren't efficient go out of business. For things where failure is not an option, 'Govenment Run' works better IMHO.

Again, I am NOT saying big govenment is a paragon of perfect efficiency. I am saying that I think that inefficency is widespread in any large organization, government or private and is an inherent tradeoff for the benefits that come with scale. I think most of us who work for or have worked for a large Fortune 500 company can attest to that. Most of what you see in 'Dilbert' isn't too far off the mark. The last example I experienced was the 'end of June rush' to purchase a bunch of crap to use leftover budget at the end of the Fiscal year so our department doesn't get its budget cut the next year.

To be clear, I think that having a single-payer (public or private) still keeps the marketplace distortion of consumers not having an incentive to be price-sensitive in place. This is not good. However, if you are going to keep the flawed concept of a single payer then my opinion is that this should be a public entity, not a private one. I've worked both public and private sector, and honestly think for something that can't be let to fail we're better off public.

This is not political- I think my opinions are not universally shared by either party. I also think a public single-payer system, while better than what we have now, is not the answer to the core question of how we control costs and improve outcome quality. The Atlantic article is the best concise summary of the core problem and a SWAG at a solution that I've seen yet.

Glad we can have a rational discussion as mature adults, even if we have differences in opinion.

[jackellis]

I think Gator is on to something. Incentives matter a lot. Or, as California State Assemblyman Rod Wright is fond of saying, "Follow the Benjamins".

When I have purchased "insurance" with my own money, I have elected high deductible policies. I think pretty hard before going to the doctor other than for routine physicals (every 2 years) and certain screenings (the dreaded colonoscopy). I have the proper incentive to use health care wisely, but if I suffer a catastrophic illness, I wont face financial ruin. And if you must know, like Loring I'm an engineer

Access to affordable essential medical care should be a "right", but unlimited access to medical care should not. If baby aspirin is effective, then anyone who wants the more expensive drugs advertised on TV should be prepared to either pay for them out-of-pocket or buy a more expensive policy that covers such things. I think the same needs to hold true for elective procedures that may enhance quality of life but are not essential. For example (purely hypothetical), should a basic insurance policy be required to pay for an expensive cochlear implant that is almost invisible rather than a hearing aid that is plainly obvious? I think not. Should individuals be able to buy a more expensive policy that covers such things. Certainly.

I also second Gator's thoughts on the efficiency of large organizations. I've seen laggards in private industry and brilliant, dedicated people in public service. Whether government runs a parallel insurance scheme or not is only one factor of many that will affect the efficiency and cost of health care delivery.

[Dutchman46]

Health care.

While you are talking about health care. The CEO, have gotten more of a paycheck that any one can make in a month. I am 63, am was disabled 8 years ago. I didn't think health was that bad, until i couldn't work. I had to start paying cobra, (400.00 a month) While waiting to get disability. My boss didn't pay while i waited. Within a half of a year, the cobra started going up. I was paying 1,`200 dollars a month, and paying about 400. a month for my wife. I needed an attorney to take the case for disability, and paid 20 % of what i got for back pay from when i couldn't work. When all was done, Every thing that i saved for retirement was gone. My settlement for not being able to work. was $12.oo a week. My deductibles were about $35.00 for doctor, $100.00 for every trip to hospital, and $25.00 for each prescription.. The president of the company that year, got over 20,000,000 plus stiffens.I had damaged the nerves in my back, got a blood clot, that the doctors didn't catch. Then i got a heart virus, which leaves me running out of breath, just trying to get out of my chair. People say that they don't want government involved in any way. They don't know what they are talking about. If i had a government health care plan, I would have been taken better care of, and might have some money left, I have it much better on disability now,but because of private health care, I suffered greatly, because the doctors got little, and i paid a lot of my bills in bills from ins. Think about it. I will take gov health care any time.

[jackellis]

More on this topic.

[Slik Geek]

The admin and overhead cost for Medicare is lower than private insurance.

I'm skeptical. Studies often have inaccurate conclusions because the researchers either ignorantly or purposefully overlook certain aspects.

Medicare's outlay per person covered is significantly higher, easily more than double that of private insurers. For example, suppose that Medicare outlays were just double the private insurer outlays. If both entities spend the same overhead per covered individual, Medicare will appear to be twice as efficient with respect to overhead because they delivered twice the healthcare expenditures for every dollar spent on overhead. Even though they aren't any more efficient, they would appear to be more efficient.

Plus there are additional costs for Medicare that often aren't accounted for in the studies because other parts of government handle them, such as oversight/auditing, citizen education, revenue collection. Those costs are included in the private insurer calculations.

For things where failure is not an option, 'Govenment Run' works better IMHO.

I've worked both public and private sector, and honestly think for something that can't be let to fail we're better off public.

Having "beat my head against the wall" fighting government agencies that were not doing their job, and were absolutely incapable of handling my legitimate claims in a competent fashion, I'm horrified with trusting my healthcare in government hands.

The primary reason why I don't want the government to run the healthcare system is that under this type of system, you'll have no real advocate to help you. Under a private insurer system, you at least have government regulators to to turn to that are independent.

People say that they don't want government involved in any way. They don't know what they are talking about. If i had a government health care plan, I would have been taken better care of.

With all due respect, that isn't necessarily true. You don't KNOW that. You might have waited longer, or perhaps received a lower level of care.

I spent a number of weeks working near Montreal last fall. I talked with the people there about the government run healthcare system in Quebec. I visited a hospital, read the news papers almost daily. (This was just a curiosity at the time as we weren't in the situation we are now). I also spent an afternoon with four nurses from a major hospital in Montreal learning more about their system.

I talked with about 10 of the people I was working with over lunch regarding healthcare in Quebec. One quipped, "The only way to see a doctor quickly in Quebec is to die, the Coroner will see you the same day." Another told me privately how his gout attacks were frustrating because of how long it took to get treatment. He now pays OUT OF HIS OWN POCKET to see a private doctor so he can get treatment the same day, even though he has already paid for healthcare via his taxes. (This may actually be illegal in Quebec). That was the first day I was there, where I first experienced their 12.5% sales tax.

Nearly every day in the newspaper was an article about the crises in the public health system. A shortage of doctors (budget constraints) meant that a million citizens in Quebec didn't have a doctor available to them. Nurses are in short supply, even with Quebec's aggressive immigration efforts that have brought in numerous foreign nationals (they are more willing to accept the anemic nursing wages). (Perhaps this explains much of the lower health costs).

I became sick and needed a medication during my work there. I went to a private pharmacy and couldn't find the particular drug. Consulting with the pharmacist, I discovered that the medication is not available in Canada, even though it is freely available over the counter here in the U.S.

The bottom line to remember is the economics of healthcare applies to any option, public or private. Just because it is government run doesn't mean that it is free. Government run means you are compelled to pay for it, and you have no higher authority to appeal with for assistance if you feel poorly treated. Furthermore, alternate options that you can freely pursue now may become illegal or simply unavailable.

[Dutchman46]

I can tell you one thing for sure. I get some meds from Canada because it would put me over the top of my allowance. When i asked my doctor for a script, He could not figure me out. I showed him what that same medicine
would cost me over there, and he was floored. My portion of pay out from my pocket to order in the US was less than what the meds cost me in total from Canada. Many like myself, take advantage of that fact,even though it hurts their stock, is because it is much cheaper.

[cwithboat]

All of this stuff I hear about Canadian health care is anecdotal. When I walked into a local clinic in Naniamo and complained of chest pain, I saw a doctor within five minutes and was in a hospital bed within a half an hour talking to a cardiologist and I did not even qualify for Canadian health care.

Most of this thread has been arguments for and against single payer government run health care, which is not up for consideration by the 545 people in control. What is under discussion is a public option providing competition to the insurance companies, which scares them to H and gone.