Health Care Reform in the US

[jeff]

Originally Posted by Inquartata

So, on the basis of what historical evidence should we accept the thesis that government is better at running incredibly complicated systems better and more cheaply than the market?

For starters, the problem description is not apt. The problem is incredibly complex, but the government doesn't have to "run" the whole thing, unless a single payer + single provider NHS system came into effect. That would be much simpler and less expensive (as shown by the other nations that use such an option), but I don't think that's the answer you were looking for. Though I do enjoy the trusting faith that markets are always better and cheaper than government services.

For evidence of your question: if the public option comes into existence, then government just has to be an insurer, not a provider. Which it already is with Medicare - and since you ask, that's bigger and more complicated than any private HMO and runs more cheaply than the private providers. I've posted figures to demonstrate that previously, but happily you don't have to "trust me" on this: look at today's NYT business section where a professor of economics states this as a simple fact. So, QED, government can be less expensive running a complicated process than "market". There's your historical evidence.

Your general question is also misplaced. We don't have the luxury of rerunning events to see whether private or public would be better quality and lower cost under identical circumstances. What we do have is a track record of government running efforts that are infinitely more complicated than private enterprise could ever manage: the Manhattan project. World War II. NASA. Stuff like that.

Markets arise where there is an opportunity to make a profit. I find odd the assumption that the only services a society should have are those in which somebody has figured out how to run a profit at it, regardless of what needs exist - and if nobody figures out how to profit at an activity, then too bad. Two completely separate concepts bound together for no particularly good reason. That pretty much rules out providing services for the poor, since by definition they don't have the wherewithal to pay for them.

Originally Posted by Inquartata

But see, it hasn't been demonstrated that it's anything like a systemic thing, as opposed to an occasional failure in a particular office or manager or what have you.[

This whole issue turns on the assumption that abuse is a widespread and regularized business practice. And that is just assumed, not proven.

I disagree with you on this. There has been plenty of evidence to show that this is widespread, much of which has been presented here. It is in fact widespread and regularized. That's a fact.

Not that it's probative, but here's an anecdote: I know a doctor in NJ who had a patient say bluntly "I'm a Vice President at Blue Cross of NJ, and my job is to deny care". Feh, I worked at that company many years ago.

Really, the evidence is all around you. It is in fact a widespread practice for HMOs to deny contracted care, to dump patients when they get expensive (or might become expensive), to cherry pick the healthiest. I don't say "trust me" (though I think you should!) but this is something you could research as well.

Trust me.

Originally Posted by Inquartata

And that's just what has given us The Tedious State...

Eh, there's plenty of ways remaining for people to have excitement. I think it helpful for their to be redress to help individuals in the uneven struggle with mighty corporations. Oh, but they're always benign, right?

Originally Posted by Inquartata

Just so!

Back full circle to my erstwhile student and his aversion to knowing whence milk really came.

He is so screwed if he ever goes back in time... Or if society melts down completely...

Originally Posted by Inquartata

*Place stock Ambrose Bierce definition of marriage here.*

Hm, I don't think his rather jaundiced view of marriage is the one to place bets on!

[jeff]

Originally Posted by Inquartata

Aren't you the guy who argues that high percentages of income and wealth accruing to the small numbers of "rich people" is "inefficient" per se for society?

Nope, not me. I like meritocracy just fine, thank you very much. What I argue is that tax policy to help "them that has" to get more is unjust.

Originally Posted by Inquartata

Or even in the perfectly normal economic sense that the higher its cost the less likely he is to do so... or to put it another way, the higher the price, the lower his quantity demanded.

If you want to argue that the cost of entry for a doc (or anyone else) to open a line of business they aren't already in should be reduced to 0, then go for it.

But that has nothing to do with what I'm talking about: which is that doctors have no reason to avoid costly procedures that raise the cost of healthcare because they in fact do not have to pay for them (they "incur no cost"). That's the salient point I've been making since I introduced this topic, and unless I misremember, you haven't addressed the point I'm making! Not that yours hasn't been fun, but it's not responsive to this issue I raised.

Originally Posted by Inquartata

Good grief, I never thought that I would exhaust you!

Yeah, especially when I had some deadlines to meet.

Originally Posted by Inquartata

Wait, you said that they were not sensitive to cost; but now they would like to seek lower costs if only the law permitted them to do so?

Choose a side, man!

Er, no. You are misconstruing this. The laws I referred to (I'm sure you had heard of them prior to my mention in this thread, right? ) prevent practitioners from raising costs to everyone by self-referring an arbitrary mount of work to themselves. Like going to the auto shop and saying "MY car is making funny noises. Do I need a tune-up, oil change, master cylinder?" Well of course you do, come on in!

And before you say it's that gosh-darn gummint messing things up, be advised that HMOs have similar policies for providers who self refer.

Originally Posted by Inquartata

I'm saying that if he has to hire office staff and have filing systems and so on there must be some substantial cost to all of the little administrative stuff he has them do in the course of daily business. They are his employees, and just because he has them handle some things doesn't mean that those things are therefore without cost to him. And as I'm sure you are quite aware, "insignificant costs" when added up have a way of becoming substantial in the aggregate...

I understand that, very well in fact, but what you are doing is imagining that writing a prescription for a patient to get an MRI somehow adds to those administrative efforts in an extent that is all meaningful. No, it doesn't. No extra bill is written. The patient's chart is already opened because a consultation is performed. The doc writes notes into the chart reflecting the status of the consult. He or she adds one lousy sentence saying "sent Mr. Gomer off to get an MRI". The MRI - if approved by the HMO - costs a few thousand bucks. The radiologist faxes the result to the doc who ordered it. Somebody in the office takes the fax and puts it in the doc's in-box. Doctor reads it and files it away. Total cost of effort: a few minutes at most. Peanuts.

If you want to focus on what really kills staff time for doctor's staff, it's arguing with the HMO to pay for services already rendered, or to argue with HMO staff that a procedure is in fact needed and covered. That's what takes hours and hours of time and expenditure of money. Or loss of money, when the HMO refuses to pay (what's your leverage if the service is already rendered?) or say "settle for 50% on the dollar or we'll fight you for months" . Th time it takes to process a script is completely inconsequential by comparison to what actually is an issue.

Besides this, you've dropped the other example I gave - the first one, I think - in which doctors often use expensive non-reusable kit for no particular reason when a cheaper alternative was equally good. No extra paperwork, no nothing. Just that the doctor simply does not pay the 10x higher cost of the device. For him, it's totally of no consequence what it costs.

Originally Posted by Inquartata

I'm not so sure. Uncle Miltie is still too convincing.

Well, I know you at least tried to put a smiley there, but frankly, Uncle Miltie doesn't convince me at all. I think he was completely and tragically wrong in this area. When he got sick - did he have a doctor with an MD take care of him or did he take his chances with whoever walked in and said he was competent to do the job? At his university post, did he let anyone on staff who didn't already have a PhD? What was his take on drivers licenses - was that statist intervention too? Or was his animus against proving some level of competence (before being permitted to prescribe narcotics? before being permitted to cut living tissue) only directed at medicine!

On that note - I'm not sympathetic to the "mandatory insurance reduces my freedom" bit either. It's too Braveheart... Almost everybody who thinks they're invincible and refuses to get insurance will some day wind up in the ER and expect to be cared for at the expense of everybody else.

[Gav]

Originally Posted by Inquartata

"Everything"? Really? There are NO exclusions? NO kind of treatment for which it won't pay? I find it difficult to believe that it will cover faith healing or vodon rituals, for example. Or a heart transplant when you're 90.

You are being an ass.

Private health care in the UK will cover just about anything you want it to cover - so long as you are willing to pay for it.

And yeah that does inclide whichever stupid rituals you want. You just have to ask the right people. Money talks. You might not get general health insurance to cover it but you can pay for it. No one is going to stop you paying for whatever absurditities.

[I_luv_saber]

Sorry if this has been repeated, but I read in the paper today that Obama may be willing to drop the government option in favor of a co-op, in the interest of compromise.

Thoughts? (both on his compromising and the plan itself)

[jeff]

I've already said that I don't require a public system if the private one can be made to cover everyone, not gouge, cherry-pick, or dump the ones that might cost them money. I'd also like to see tort reform and an emphasis on preventive care that moves us a way from the procedure-oriented fee-for-service system we have (that does more to try to patch up health problems than prevent them from occurring in the first place.

I do think a public option is a good idea. As dcmdale said, 45% of the country is already in a government plan, and many of the rest are in tax-exempt (eg: subsidized) employer-provided plans. So co-ops, public option, and direct subsidies are all different ways that might have similar effect. See the poll results for this thread - that's pretty revealing: "reduce waste" is something anyone can agree to, and "expand Medicare to cover more people" is the other big vote winner. Seems like a public option is popular with board members. But since politics is all about "what is possible", I can see Obama dropping the public option if it's an obstacle to getting acceptance.

For a look at a country with a good public system see this article from yesterday's NYT magazine: http://www.nytimes.com/2009/08/16/ma...l?ref=magazine American couple in France (therefore not covered for free), husband gets sick and goes to hospital. Long story short:

At 2 a.m., when we were discharged, I offered my MasterCard to the surly gatekeeper. He said they would send us a bill. The doctor apologized for having to bill us, but we were not citizens, after all. Six months later, the bill arrived. For X-rays, an EKG, 10 hours in the emergency room, a doctor, a cardiologist, technicians, nurses, drugs and even the surly gatekeeper, we were required to pay $220. I might put up with a lot of ugly bureaucrats for that.

[prototoast]

Originally Posted by jeff

For a look at a country with a good public system see this article from yesterday's NYT magazine: http://www.nytimes.com/2009/08/16/ma...l?ref=magazine American couple in France (therefore not covered for free), husband gets sick and goes to hospital. Long story short:

At 2 a.m., when we were discharged, I offered my MasterCard to the surly gatekeeper. He said they would send us a bill. The doctor apologized for having to bill us, but we were not citizens, after all. Six months later, the bill arrived. For X-rays, an EKG, 10 hours in the emergency room, a doctor, a cardiologist, technicians, nurses, drugs and even the surly gatekeeper, we were required to pay $220. I might put up with a lot of ugly bureaucrats for that.

Keep in mind that in many other countries (I'm not positive on how it works in France) public education pays for some or all of medical students' expenses. This subsidizes public healthcare but for accounting purposes counts as an educational expense. Doctors make less money when they don't have to bankroll themselves through medical school.

[jeff]

OTOH, they don't pay $100,000 in malpractice, either. Nor do they have to worry about collecting from their patients or HMOs. Total adjusted compensation is a complicated topic.

[Gav]

Originally Posted by prototoast

Keep in mind that in many other countries (I'm not positive on how it works in France) public education pays for some or all of medical students' expenses. This subsidizes public healthcare but for accounting purposes counts as an educational expense. Doctors make less money when they don't have to bankroll themselves through medical school.

Would you say that a potential £100k a year wasn't very much money?

Doctor renumeration rates are decided in a complicated way over here but essentially - once they've been through their initial training (after their degree) they get good wages.

EDIT: additionally over here in the UK many students have to pay some sort of fee these days. It's a controversial topic.

[jeff]

Since their was speculation on where money is spent in Medicare or for end-of-life care in general, I thought I'd bring in the actual data.

From today's NYT Science section: An article in the New England Journal of Medicine published figures that 30% of Medicare dollars are spent during the last year of life, and half of that during the last 60 days. Much of that is spent on extremely expensive interventions that not only do not change final prognoses or improve quality of life, but actually increase patient suffering. A comatose patient on a ventilator with tubes sticking out from every orifice, with repeated blood draws, bed sores, high rates of infection, is not having a good end of life. I wouldn't wish it on anyone.

You can keep a heart beating for a very long time with today's technology. It's not clear to me that it represents "life" in anyway one would want to recognize it. While I'm on this topic: the dishonest claims by Sarah Palin, echoed by other Republicans and by the hyena radio jocks about "death panels" were a distortion of a Republican's (!) proposal to pay for end-of-life counseling sessions, not to provide death panels.

So, let's not continue the idle speculation that Medicare spends lots of money because it gives old folks a way to get out of the house and socialize at the doctor's office. That's not where the money is spent, and that money is not well spent. Sometimes "more" is not better.

[Bayou Bum]

Originally Posted by jeff

From today's NYT Science section: An article in the New England Journal of Medicine published figures that 30% of Medicare dollars are spent during the last year of life, and half of that during the last 60 days. Much of that is spent on extremely expensive interventions that not only do not change final prognoses or improve quality of life, but actually increase patient suffering. A comatose patient on a ventilator with tubes sticking out from every orifice, with repeated blood draws, bed sores, high rates of infection, is not having a good end of life. I wouldn't wish it on anyone.

So, who gets to make those decisions? The patient, family, doctor, insurance company, government panel? Shouldn't it be up to the patient or patient's family. This is the problem with government paid health care, who decides what treatment a patient can try to obtain?

What about prisoners on death row or with life sentences? Do you spend hundreds of thousands to keep a death row inmate alive just to kill him later? If not, don't we have an obligation to provide health care to all inmates.

What about the millions of illegal immigrants in this country? Will everyone be covered regardless of legal status or nationality?

I found it hard to believe that the majority of people actually trusted their health care with the same government that has given us so many unsuccessful agencies, such as FEMA, Department of Education, Medicare, Social Security, etc. Just as all of the welfare programs have not improved poverty in the united States, government run health care is not going to improve the health of people. I'm glad to find out that the majority still oppose government control of their lives.

[jeff]

It should be by the patient, if not incapacitated, and by family and/or other individuals designated by the patient, in conjunction with consultation with medical professionals so they understand the options available, their consequences, and what is realistically achievable. I've said that for a long time - in case you hadn't noticed - and have several times recommended on f.net that people set up a living will, medical proxy, and power of attorney so their wishes are known. That's whether it be DNR or "extend me as long as possible".

You are completely wrong if you try to say that this is risk we have to worry about if there is a government public option. That's completely nutty. Don't you realize that medical care for the elderly is funded by Medicare, which is (duh!) a government program. You say This is the problem with government paid health care, who decides what treatment a patient can try to obtain? Well, that shows you completely don't know what the heck you are talking about, because it is a government paid health care that today pays to keep comatose elderly people on a vent. Didn't I just lead in with a statement how this is where the Medicare money gets spent, and don't you know that it's a government program? Damn, you're clueless.

Failed programs like Medicare and Social Security? You're out of your mind. Those are incredibly successful programs - as witnessed by the panicky elders worried that the government might try to modify them. Not to mention the morons in the town halls worried that the government might get between them and their Medicare. Duh - it's the government that runs Medicare.

The problem is with dishonest creeps like Sarah Palin and her dittoheads. She claimed that there would be "death panels" controlling whether Granny would stay alive, but the truth was that there was a proposal by a Republican that end of life counseling (the stuff I mention in the first paragraph) would be covered by insurance. Not only that, but the liar, quitter, ex-Governor herself made almost the exact same proposal herself a few years ago.

[prototoast]

Originally Posted by jeff

Failed programs like Medicare and Social Security? You're out of your mind. Those are incredibly successful programs - as witnessed by the panicky elders worried that the government might try to modify them. Not to mention the morons in the town halls worried that the government might get between them and their Medicare. Duh - it's the government that runs Medicare.

By that logic, heroin and crack are successful drugs.

Seriously though, old people are selfish. They want us to pay for their ****, and they know that they'll be dead by the time the debt has to be collected. Old people don't like these programs because of some deep understanding of the benefit to society as a whole, they like it because it's free money.

[thereom4]

Originally Posted by jeff

The problem is with dishonest creeps like Sarah Palin and her dittoheads. She claimed that there would be "death panels" controlling whether Granny would stay alive, but the truth was that there was a proposal by a Republican that end of life counseling (the stuff I mention in the first paragraph) would be covered by insurance. Not only that, but the liar, quitter, ex-Governor herself made almost the exact same proposal herself a few years ago.

This is what absolutely kills be about this debate. People who know better continue to spread falsehoods about the plan, just to scare people who don't know any better. Then they get on T.V. and terms like "death panels" get thrown around and people believe it. Are you truly serving the needs of the people you were elected to serve when you know the truth yet spread lies? They serve themselves. It's a shame. Political gangs suck. The end.

[Bayou Bum]

Originally Posted by jeff

Failed programs like Medicare and Social Security? You're out of your mind. Those are incredibly successful programs - as witnessed by the panicky elders worried that the government might try to modify them. Not to mention the morons in the town halls worried that the government might get between them and their Medicare. Duh - it's the government that runs Medicare.

Get your facts straight. You base the success of Medicare and Social Security on the fact that the people who get their monthly check from the government don't want it to go away. Never mind the fact that both have cost the country billions more than ever promised and both are bankrupting the government. Initially, Social Security was promised to NEVER cost more than 3% of your wages. Now, it is at 6.2% and still can't keep up and accounts for the single largest expenditure in the federal budget, over 20%. Medicare is also over 20%. Our government is just a large wealth distribution program.

If SS and Medicare are so successful, then why are 47 million (by liberal estimates) still without healthcare and why do we still have over 12% living below the poverty level? We were promised these programs would end poverty in the US. Now they cost billions more than ever projected and have done nothing but cause dependence on the government. How will health care be any different?

And for the record, the elderly are upset with Obama taking away medicare advantage, not medicare. Once the government gives, how dare the government take away.

Typical liberal response to the facts, name calling. The sad truth is that liberals cannot debate on the facts so they have to resort to emotions such as fairness and lack of opportunity. Once confronted with the actual facts, the last desperate stand is name calling. Just proof to me that you realize you don't have an argument on the facts.

[thereom4]

Originally Posted by Bayou Bum

And for the record, the elderly are upset with Obama taking away medicare advantage, not medicare. Once the government gives, how dare the government take away.

Just proof to me that you realize you don't have an argument on the facts.

When you have the time, can you provide the facts regarding the emboldned words? Please. That's if you're not busy spreading falsehood elsewhere. Take your time.

[lindajdunn]

http://www.chicagotribune.com/news/c...0,667936.story

The program pays insurance companies a hefty premium above traditional Medicare reimbursements for enrolling senior citizens in managed care. But whether the higher payments are worth the cost is a matter of dispute.

Obama and many congressional Democrats see Advantage as a wasteful bonanza averaging about $17 billion a year for the companies, which critics say provide few benefits beyond regular Medicare.

====

I note that I'm co-guardian for an elderly mother in an ALF who has dementia. I pay attention to these things. IMHO, Medicare Advantage benefits private companies more than it benefits the elderly.

[thereom4]

Originally Posted by lindajdunn

http://www.chicagotribune.com/news/c...0,667936.story

The program pays insurance companies a hefty premium above traditional Medicare reimbursements for enrolling senior citizens in managed care. But whether the higher payments are worth the cost is a matter of dispute.

Obama and many congressional Democrats see Advantage as a wasteful bonanza averaging about $17 billion a year for the companies, which critics say provide few benefits beyond regular Medicare.

====

I note that I'm co-guardian for an elderly mother in an ALF who has dementia. I pay attention to these things. IMHO, Medicare Advantage benefits private companies more than it benefits the elderly.

Thank you for this. I'm reading it now.

[jeff]

So many foolish things, it's hard to know where to start. I'm waiting for a flight so I'll take a few minutes. Not that it will puncture your invincible ignorance.

Originally Posted by Bayou Bum

Get your facts straight. You base the success of Medicare and Social Security on the fact that the people who get their monthly check from the government don't want it to go away.

Yeah, there's that democracy thing getting in the way. And their kids don't want it to go away either and have to support their parents. Get your facts straight - this is a hot button issue the Republcans are now trying to exploit.

Originally Posted by Bayou Bum

Never mind the fact that both have cost the country billions more than ever promised and both are bankrupting the government. Initially, Social Security was promised to NEVER cost more than 3% of your wages. Now, it is at 6.2% and still can't keep up and accounts for the single largest expenditure in the federal budget, over 20%. Medicare is also over 20%. Our government is just a large wealth distribution program.

Take a look at the life expectancies when those programs started and what they are now, and advances in technology when previously you just sent somebody home to die, now you can patch 'em up and keep 'em going much longer.

So, here's Bayou Bum - the one person actually calling for death panels!

Originally Posted by Bayou Bum

If SS and Medicare are so successful, then why are 47 million (by liberal estimates) still without healthcare and why do we still have over 12% living below the poverty level? We were promised these programs would end poverty in the US. Now they cost billions more than ever projected and have done nothing but cause dependence on the government. How will health care be any different?

Gosh, that is so stupid. You do realize that in SS you get your own money back after having contributed to it? People like Inq have argued that it's a bad deal because because you could have invested the money on your own and done better. I don't agree for a number of reasons, but at least it's an argument that can be made by people with 3 digit IQs. SS is not the be all and end all for ending poverty, and never was. You just don't know what it means.

And for Medicare, it only kicks in if you're over 65 or have one of a small number of disabilities, so it could never have been universal healthcare.

You simply don't understand what these programs do.

Originally Posted by Bayou Bum

And for the record, the elderly are upset with Obama taking away medicare advantage, not medicare. Once the government gives, how dare the government take away.

That's nonsense. You don't understand what "medicare advantage" is either. Go get some proof of this, like others have said. "Medicare Advantage" was a Bush giveaway to insurance corporations that costs more than regular Medicare while reducing choice.

Originally Posted by Bayou Bum

Typical liberal response to the facts, name calling. The sad truth is that liberals cannot debate on the facts so they have to resort to emotions such as fairness and lack of opportunity. Once confronted with the actual facts, the last desperate stand is name calling. Just proof to me that you realize you don't have an argument on the facts.

Bayou Bum complaining about name calling? That's rich. You have an awfully thin skin for somebody who slanders everybody who disagrees with you. I'm just calling it the way it is - you don't understand the facts of the situation, can't back up any of your statements.

You claimed This is the problem with government paid health care, who decides what treatment a patient can try to obtain? when you were obviously ignorant that it's Medicare paying for the treatment patients are getting and doesn't decide it. That was total BS and I called you on it.

[Bayou Bum]

Originally Posted by thereom4

Thank you for this. I'm reading it now.

Let me know if you need help with the big words

[thereom4]

Originally Posted by Bayou Bum

Let me know if you need help with the big words

Awwww, what a sweet gesture. Really. You're willing to share your Hooked on Phonics with me. Thanks. Really.