HC Reform - how to go about it

[PeterGustafsson]

Hi!


The now-running Health Care Reform thread is getting old now - it has long since entered the stage in which posters nitpick each other, now new big ideas as put forward, and a small number of posters are responsible for the great majority of recent posts. (Maybe someone could design an AI system for identifying threads that are stale, and mark them as such.)

This is risky, but I would like to try to breathe some life into the subject.

The topic for this thread is:
How should a politician (or other policy-influencing person) go about to change the current US. health care system to something more akin to Canada/Europe?
In this context, such a system would share the following characteristics:
1. HC providers only get an insignificant proportion of their reimbursement from for-profit insurance companies.
2. At least 95% of the population are in the situation that they can get medical care - other than ER - without having to pay all costs upfront.
3. The sole role of for-profit insurance companies - in HC - is to make it possible for those people who want to be able to get care without any waiting time whatsoever, without having to pay up front.

The topic for this thread is NOT:
1. Whether a HC reform with the end result as outlined above is desirable. If you do not agree with that basic premise, you are more than welcome to start your own thread in which that nondesirability is a given.
2. To prove that a HC reform with the end result as outlined above is impossible, since the insurance companies are too powerful. For the sake of the argument, it is assumed that the current administration (or a following one!) has the guts to take one those companies, and actually manages to score a major breakthrough.

(Let us see how long all posters can stay on topic. I have my doubts in some cases.)

Anyway, here is my stab at it:
It has been stated that a single-payer system would be a complete non-starter in USA on a national scale, but does that have to be for every state? Assume that BO says something like this:

"Fellow americans, the health case system of our nation needs to be done right. In order to get it right nationally, but the risks of any inadvertent mistake - if the system is rolled out nationally - are just too big. Therefore, I and the congress are preparing a bill in which many different systems are tried out for a few years in different states. The system which proves to be best, according to several objective criteria, will then be used for the whole nation. Indoing so, all good ideas from both sides of the aisle will be put to good use."

This pushes several buttons - bipartisanship, rule of knowledge vs rule of unbending ideology, allowing blue dogs a graceful appearance, etc.

Then, in the 1534 pages of the bill is hidden a paragraph which authorises the president to use executive order in deciding which system goes to which state. BO uses those powers in a shrewd way: he assigns systems which are supported by blue dogs and moderate GOPs to many blue states. To the people in those states, this will not be much of a difference. However, he assigns single-payer systems to electorally vulnerable GOP senators which are in the more conservative half of their party.

Those senators will of course scream to high heavens, but they do so already - no difference. Then the exceutive branch steers competent people to those single-payer systems. ( The effecet is enhanced if incompetent bureaucrats are steered to red states which have been assigned a MC system similar to the current one.) If all goes well, those systems will make a lot of voters happy. Antipathy to SPS among voters (not politicians or lobbyists) will be significantly weakened. If the SPS are managed well, the voters in those states will not want to go back to the current mess, and the GOP senators will be put in a bind. Internal warfare in the GOP should increase, while increasing chances for a senate with 60+ dem members. If done right, one can start changing to SPS in more states and achieve win by defeat in detail.

Won´t work in California though, they will have to change their laws on voting for taxation increases first.


Have a nice time!

Peter Gustafsson

[I_luv_saber]

The topic for this thread is NOT:
1. Whether a HC reform with the end result as outlined above is desirable. If you do not agree with that basic premise, you are more than welcome to start your own thread in which that nondesirability is a given.

Peter, I think you will not get much success in staying on topic, because you are basically asking many, many participants to simply play Devil's Advocate and to argue how to implement a system they don't agree with. This will lead to one (or both) of two things:

• Unavoidable thread drift and/or

• One-sided arguments

I, for one, will not participate arguing in favor of a premise I don't agree with. Which is fine, I'm just saying you'll get limited participation on the topic, I think.

That said, in the interest of staying on topic, I'll simply stay out of it (unless it drifts to something it isn't anymore anyway...) while it's on topic.

[lindajdunn]

The obvious solution is to announce that the government will be going to a single payer system with the government as the single payer and that they will be OUTSOURCING care to existing, established companies. Those companies and their lobbyists that expect to profit from the change will then buy advertising, organize astroturf efforts, and otherwise work to insure that (1) the change goes through and (2) their company or the company they represent gets a significant portion of the pie.

Playing Devil's Advocate but also noting that this is the way the system works in the US. We have a highly complex bribery system which we deny is bribery by calling it lobbying.

[keith]

1. Whether a HC reform with the end result as outlined above is desirable. If you do not agree with that basic premise, you are more than welcome to start your own thread in which that nondesirability is a given.

The problem is that this is the problem.

You can quote statistics such as this;

World Health Organisation rankings place Britain's healthcare as 18th with the US is in 37th place. Japan is No.1.

... but the basic problem is that if you have health insurance the current system is pretty good.

As long as this perception holds the general response to any proposal is that it will damage care for those with insurance. Really the problem is that while Jack thinks he's fine he really isn't.

So, for your consideration;

Physician compensation reform.
Tighten up the FDA process to require that drugs show benefit over existing treatment.
Shift the cost of health care to employee pay slips (as per 401k contributions).
Remove tax exemption for employer provided health plans.
Cap medicare/aid at a fixed % of GDP. After all the arguement is that the US can't afford it.
Remove any legal requirements for Emergency rooms to provide anything other than palliative care in the absence of proof of insurance.


All of these are, of course, terrible ideas

[Bayou Bum]

Probably the best way of making this happen is for Obama to declare he was the duly chosen leader and in the interest of the public good/want he is going to seize control of the health care and insurance industries. Any Senator or Congressman who opposes him will be branded a racist and kicked out of Congress for treason. Anyone who protests will be charged with hate crimes and the police state will squash all opposition in the media. I don't see where it is that difficult, after all, the only opposition to his plan currently is a few disgruntled government hating racist that are opposing Obama's plan only to discredit him personally.

[Sins of the Fleche]

Personally, I think that if the government worked on a bill that focused more on providing a government-provided health insurance to compete with HMO policies, I think the American public would heartily support it. I think it's the poorly worded "right to die" and "end-of-life consulting" portions that have people on edge.

So like all things, I'ld say if the bill focused more on the economics of the situation and less on the actual health provision and healthcare management between the physician and patient, it'ld have a much easier time when it comes to putting it to vote.

[Inquartata]

To Keith's list I would add: Get rid of malpractice suits altogether in favor of having claims settled from a pool of funds collected like malpractice insurance premiums are now. The decision about whether or not malpractice in fact occurred would be made not by lawyers but by panels of medical professionals. The penalty for an accused physician found guilty of malpractice would not be higher insurance premiums and go forth and do it again, but loss of his license to practice.

How to make the US system more like Canada's? Have Canada invade and conquer us, then extend their system thither.

Otherwise I agree with I Luv Sabre, why would anyone agree to the OP's terms if he didn't want that sort of system here? Sort of like "Tell me how to beat you when we fence"...

[Hauptman]

To Keith's list I would add: Get rid of malpractice suits altogether in favor of having claims settled from a pool of funds collected like malpractice insurance premiums are now. The decision about whether or not malpractice in fact occurred would be made not by lawyers but by panels of medical professionals. The penalty for an accused physician found guilty of malpractice would not be higher insurance premiums and go forth and do it again, but loss of his license to practice.

How to make the US system more like Canada's? Have Canada invade and conquer us, then extend their system thither.

Otherwise I agree with I Luv Sabre, why would anyone agree to the OP's terms if he didn't want that sort of system here? Sort of like "Tell me how to beat you when we fence"...

Doctors lose their license after a malpractice suit? Really? How often does that happen? Medical boards don't publicly do anything that I'm aware of unless the malpractice is seriously over-the-top negligence and repeated over a long period of time.

And even then the loser will just blame his poor behavior on alcohol or, even better, on the prescription drugs he's been abusing. Then it's off to Club Med rehab, and back to work. Am I cynical? Why do you ask?

Letting industries self-regulate is a great idea... rigghhhtt.... and I have bridge in Brooklyn I'd love to sell you.

I do like your idea of a sort-of non-profit malpractice insurance fund, though. If it became clear that most doctors were supporting the serial malpractice of a few other doctors, your self-regulation might actually have a shot.

[Capt. Slo-mo]

Anyone who protests will be charged with hate crimes and the police state will squash all opposition in the media.

Were you actually paying attention at any time in the last 8 years?

Warrantless wiretaps, NSA domestic surveillance, tanks in the streets of Lackawanna ringing any bells?

How many "police state" protestations did you lodge back then?

[Hauptman]

Were you actually paying attention at any time in the last 8 years?

Warrantless wiretaps, NSA domestic surveillance, tanks in the streets of Lackawanna ringing any bells?

How many "police state" protestations did you lodge back then?

Not mention that if there is any censoring going on then Fox News seems quite immune to it. And I have yet to see any protesters being dragged away or prohibited from any of the town hall meetings... that seem to be getting televised on the "liberal" media.

Yeah, they're really doing a great job stifling dissent. lol

[Inquartata]

Doctors lose their license after a malpractice suit? Really? How often does that happen?

Not very often, alas. But my post was a suggestion, not a statement of how things work at present...

You're right, there would have to be some sort of oversight to ensure that the medical examiners did not sweep things under the rug in the interest of protecting the profession. But their job, as I envision it, would be restricted to determining whether actionable incompetence had in fact occurred. Once they had done so both the compensatory awards and the license revocations would be out of their hands,

[lindajdunn]

To Keith's list I would add: Get rid of malpractice suits altogether in favor of having claims settled from a pool of funds collected like malpractice insurance premiums are now. The decision about whether or not malpractice in fact occurred would be made not by lawyers but by panels of medical professionals. The penalty for an accused physician found guilty of malpractice would not be higher insurance premiums and go forth and do it again, but loss of his license to practice.

My son has a scar from his little toe to his ankle and from his ankle to his knee, the result of a little oopsie that took place in a hospital. We were told that had the oopsie continued for another hour, he probably would have lost his leg. As it is, he merely underwent 18 surgeries over a month (hospitalized the entire time) and then one last one about 6 months later. I have some lovely pictures.

As someone who has actually gone through the legal process in a state that went to a board that had to be satisfied before one could file a lawsuit, I note that attorneys generally profit more from the lawsuits than do plaintiffs.

IMHO, having an independent panel which vets claims goes a long way towards eliminating fivilous lawsuits. However, this change in my state did NOT result in a corresponding drop in malpractice insurance costs. IMHO, I blame this on the simple fact that insurance companies will charge whatever the client will pay and since there's insufficient competition in this market, maybe this is one area that should have government oversight.

I also note that losing one's license is not (imho) the best response. In my son's case, the doctor was not at fault and there were enough medical people involved to result in much finger-pointing.

[prototoast]

It's completely trivial to design a system that fits your criteria. Anyone can walk into any doctor's office to receive whatever treatment they want and the bill gets send to the federal government who pays it.

That's all you're asking for. Why bother making it complicated with any bells and whistles. Get whatever you want, send the bill to uncle sam. It's retarded for the government to pay for an insurance company, just pay all of the medical costs a la carte.

[Hauptman]

It's completely trivial to design a system that fits your criteria. Anyone can walk into any doctor's office to receive whatever treatment they want and the bill gets send to the federal government who pays it.

That's all you're asking for. Why bother making it complicated with any bells and whistles. Get whatever you want, send the bill to uncle sam. It's retarded for the government to pay for an insurance company, just pay all of the medical costs a la carte.

I'm really not sure if you were being serious or sarcastic.

If you're questioning the added value of gov't paying insurance companies to administer a plan then I agree with you. It makes more sense for the gov't to just do it directly and cut out the profit margins of the middleman.

[Inquartata]

In my son's case, the doctor was not at fault and there were enough medical people involved to result in much finger-pointing.

And that is what my envisioned medical examiner's panels would be there to determine. I suspect they could do a better job of it than lawyers and judges can. If they determine that a doctor, PA or LPN in fact screwed up and harmed a patient, the penalties would thereafter be automatic. If they did not so determine, then---not...

IMO taking attorneys out of just about any process can only improve matters.

But I'm afraid this thread-drift is likely to make Peter pretty testy, so I'll stop now.

[jeff]

Not very often, alas. But my post was a suggestion, not a statement of how things work at present...

You're right, there would have to be some sort of oversight to ensure that the medical examiners did not sweep things under the rug in the interest of protecting the profession. But their job, as I envision it, would be restricted to determining whether actionable incompetence had in fact occurred. Once they had done so both the compensatory awards and the license revocations would be out of their hands,

Absolutely right. Not very often indeed. Somebody has to screw up royally - and it usually is something like blatant drug abuse - to lose their license to practice medicine. Then they can go to another state and start over again, even if they left a trail of bodies behind. You would think that this would be checked for in advance, but it's not the case because we don't have a nationwide registry. Nor do we have a nationwide license, which would put an end to at least the ability to start over by crossing the state line.

If you asked me, licensing would be tightened up a lot more - and the individuals involved would themselves be professionals in the field. (If a ref screws up at a NAC, to they relieve him/her of duty based on what a lawyer says or based on the knowledge held by senior refs?)

More likely that somebody whew screws up badly they'll be unable to get malpractice coverage - but that only kicks in after there's been lots of damage done, and medmal lawsuits won by plaintiffs. That could take a long time to get a bad actor (or somebody who went bad) out of the field.

[prototoast]

Otherwise I agree with I Luv Sabre, why would anyone agree to the OP's terms if he didn't want that sort of system here? Sort of like "Tell me how to beat you when we fence"...

Once you start describing the system he desires, it becomes obvious just how preposterous it would be.

[DonnaP]

Sorry to drift but I have to respond to some of the comments towards malpractice issues.....

Just to have you all look at it from the other side - it is expensive, time consuming and emotionally draining to have done the very best you can to help someone, only for that person to sue you because they don't like the outcome - aka, they're not perfect. People have the right to sue, even if they don't have grounds. It is still a long and messy process, and sometimes, the suits are frivolous and just about people looking for a way to make money off the rich doctor. Medicine is not a "perfect" thing. Most practitioners don't go to work everyday to make any of you worse, we all work hard to make every patient better every day - really!!

Yes there are bad doctors, nurses, etc., but there are also bad patients. Like the ones who keep coming back with "injury" after "injury" that they need pain meds for, or the ones who are just trying to stay out of work because they hate their jobs. Why do doctors prescribe so many "unecessary" tests you ask?? Because they have to cover their a**es and prove they did everything they could, checked every possible thing, because if they didn't, you bet those lawyers will be on the phone.

I'm sure you all agree that it is reasonable for doctors to be paying $25,000 a year for malpractice, how about $50,000, how about $100,000 or more per year in malpractice insurance. Do you think that's reasonable? Depending on specialty, your doctor, surgeon, OB/GYN who shows up at 2:00 in the morning to put you together after your car accident, deliver your baby, or take care of your mother who had a stroke, may be paying 6 figures per year in malpractice insurance alone. In 2007, one of three malpractice carriers in CT tried to increase their rates by 89%!! Where is the reform for this part of the healthcare sector?

Several independent studies have shown that malpractice rate increases have nothing to do with claims made or settlements paid out, but rather are tied to the ebb and flow of the economy - meaning if the carrier needs cash flow - they increase rates.

Everyone is focused solely on access to healthcare and having insurance - if there aren't enough providers willing to work in the system, it won't matter who has insurance anyway.

[jeff]

Absolutely. While there are bad docs out there, there's also patients with out-of-whack expectations and a belief that if there's a bad outcome, then somebody must be to blame for it (no matter how sick or non-compliant the patient was), and somebody must be sued. Perversely, if a doc has really high medmal coverage, that makes them more likely to be sued - since the main rule of malpractice is "sue everybody in sight, but especially the ones with deep pockets". I had an employee once who thought he hit the jackpot and would put his kids through college by winning a malpractice suit. It's not supposed to be Lotto. Some specialties - OB/GYN notoriously - are just so expensive for malpractice coverage the doctors just get out of it, or do the GYN part and not the OB.

[Bayou Bum]

Here is a short referral list for the kinds of Doctors you will get with government health care.

Dr. Taliaferro Clark
Dr. Oliver Wenger
Dr. Raymond Vonderlehr
Dr. John Heller
Dr. Eugene Dibble