How would *you* reform health care in USA?

[Rain]

My first *serious* thread, interested to know what you think is the best way to reform health care. Lets limit to USA since otherwise it is too broad.

 

I will favour practicalilty over idealism. ie, ideal = complete health care provided free, for everyone, but it ain't going to happen.

 

Favour simplicity.

 

Insurance reform portion:

 

-mandatory universal health insurance (ie, private health insurers, with no exemption clause, price moderated with fixed maximum price increase depending on inflation and age band, broad and normal (as defined by existing private insurance coverage) range of services covered.

 

-this implies portability of course, since it is now no longer tied to employers.

 

-health insurance is effective across states - this is 1 country, not 52 countries.

 

-insurers free to offer add-on insurance (elective surgery, home care, more doctor choices) for extra cost, free to underwrite coverage for those as they wish.

 

-universal health insurance has an extremely high deductible, to prevent over-consumption.

Example: Deductible = $5k/year + 0% of first 2 outpatient consults/year + frivolous emergency room visits and ambulance calls will not be reimbursed + elective surgeries will be nominally covered.

 

I actually also think the doughnut is a very good idea, but since simplicity is important, should probably not be implemented yet.

 

Aim to differentiate between health care and health insurance. USA must be the only country where most people think the two are synonyms.

 

--------------

 

Welfare help portion:

 

-health insurance is mandatory, but subsidies exist. Different tiers of subsidies.

Example:

100% (including deductibles and out of pocket expenses),

50% of insurance premium and 50% of deductible/out of pocket,

25% of insurance and 25% of deductible/out of pocket.

[helene_t]

I think mandatory private insurers is a bad idea. Maybe there's no alternative in the US since many people are phobic towards "socialism". But the advantage of private insurers is that they are free to offer diverse products. Now if the government controls the insurance coverage, all the private insurers can do is to add overhead.

 

Maybe it's just a formality. There may be little difference between

1) A private, mandatory insurance that conforms to government-defined criteria

2) A public insurance the administration of which is outsourced to private companies

 

But here in the Netherlands we have 1) which really sucks. Enormous overheads and no flexibility. The worst of two worlds.

 

Anyway, I think the mandatory coverage should just be free of charge. We don't want anybody to die of appendicitis or a simple penicillin-treatable pneumonia just because they were unable to pay the insurance bill.

[pbleighton]

Gradually expand Medicare to include everybody.

 

It is a very well-functioning, popular system. Claims paid is 98% of dollars in, administrative and other costs are 2%. This contrasts with private insurance, where administrative and other costs are in the range of 15%-40% (though to be fair typically about 3%-4% of this is taxes).

 

At first, this should be on a paid-for, though subsidized basis. When everyone, or nearly everyone, is in, the program should be funded by taxes.

 

This will supply basic coverage. Those who wish for more complete coverage will purchase private supplemental policies, as is the case today.

 

I would support a "private-sector" approach, for political cover (see California and Massachusetts). This is a fundamentally intellectually dishonest approach, but if that is what's needed to pass Phase 1 of the laws, OK.

 

I worked in the insurance industry for years, including a stint of actuarial work, and the private sector isn't well set up for universal care. The problem is that the insurance model manages risks in two ways. First, individual applicants undergo screening ("underwriting"). Less healthy individuals are either charged more or denied coverage altogether. Second, the individual works for an organization. The bad risks are spread over a larger number of good risks.

 

The first approach sounds harsh, and is. However, it is completely necessary for insuring indivuals, for companies which don't do it wind up with higher rates for a less healthy pool. The healthy individuals then leave in disproportionate numbers, making the pool even less healthy, a process known as "anti-selection" (underwriting by companies to get a good risk pool is known as "selection").

 

Now think about the 40 million uninsured. They are less healthy, as a group, than those who are insured. Most of them don't have access to employer-sponsored insurance. If we assign private insurance companies the job of covering them, they will inevitably try some way of getting the healthier bodies, leaving the less healthy bodies for their competitors. The only way around this is to remove all pricing and selection privileges from the private insurors, leaving them only as essentially third party administrators for government-mandated benefits.

 

But as i said, this will probably be the way it happens.

 

And it will happen. Industry is getting away from the business of providing health insurance to their employees, and a market-only approach is politically impossible and economically suicidal.

 

Peter

[mike777]

It scares the hell out of me if the government starts messing around more and more with the Law of Demand and the pricing mechanism.

 

Health care today is much better than it was 200 years ago, 100 years ago and even 50 years ago.

 

I think the technological changes in health care the next 40-50 years will simply be amazing. One example will be scanning devices that catch many diseases at the extremely early stages compared with today. Diagnostic costs will come down dramatically allowing less expensive treatments to be effective at an extremely early stage.

 

If the government does not effect a massive takeover, I will bet my house 40-50 years from today health care will be significantly better than today.

 

One simple example of over government regulation today is in the matter of blood tests. If you want to blood test you must, must have a doctor involved. You cannot go down to a private lab and have the test done. Silly.

If you want an MRI or Catscan again you must have a doctor involved. Silly.

 

If you prefer a doctor, fine, but why impose needless costs and delay on the rest of us?

[pbleighton]

The mortality rates in the U.S. are higher than in most of the rest of the advanced industrial democracies (in spite of the fact that we spend twice as much per capita on), until age 65, when they become lower. The is a direct result of terrible rates of health insurance prior to 65, going to near zero after 65.

 

We also have terrible infant mortality rates.

 

But hey, that's OK with conservatives. That's market efficiency in action.

 

Peter

[mike777]

The mortality rates in the U.S. are higher than in most of the rest of the advanced industrial democracies (in spite of the fact that we spend twice as much per capita on), until age 65, when they become lower. The is a direct result of terrible rates of health insurance prior to 65, going to near zero after 65.

 

We also have terrible infant mortality rates.

 

But hey, that's OK with conservatives. That's market efficiency in action.

 

Peter

I do not know the rates but will check. Assuming this is accurate this is a perfect example of baised stats. You are only comparing with a few countries.

Are you disputing that health care is not better than 200 or 100 or 50 years ago and is improving at very fast pace?

 

In fact you seem to say health care in the usa is terrible.

[helene_t]

It scares the hell out of me if the government starts messing around more and more with the Law of Demand and the pricing mechanism.

 

Health care today is much better than it was 200 years ago, 100 years ago and even 50 years ago.

 

I think the technological changes in health care the next 40-50 years will simply be amazing. One example will be scanning devices that catch many diseases at the extremely early stages compared with today. Diagnostic costs will come down dramatically allowing less expensive treatments to be effective at an extremely early stage.

 

If the government does not effect a  massive takeover, I will bet my house 40-50 years from today health care will be significantly better than today.

 

One simple example of over government regulation today is in the matter of blood tests. If you want to blood test you must, must have a doctor involved. You cannot go down to a private lab and have the test done. Silly.

If you want an MRI or Catscan again you must have a doctor involved. Silly.

 

If you prefer a doctor, fine, but why impose needless costs and delay on the rest of us?

What are you talking about, Mike? Would you prefer a system in which insurers pay for all the exams the patients fancy without a fysician's approval? Or are you saying that you can't have a blood test without a fysician's aproval, even if you pay for it yourself?

 

Anyway, I think health care is getting more and more expensive, that quality isn't following the pace of the prices, that quality will improve even less in the next twenty years than it has done in the latest twenty years, and that health care is more expensive in the U.S. than in most other countries. For a number of reasons, one of them being that people require a lot of exams that are not necesary.

 

In particular, I think that the public's over-confidense in medical technology is a major factor behind the falling productivity in the health care. I can think of three major inovations in health care from the latest 150 years or so:

- The discovery of antibiotics

- The discovery that it helps if physicians wash their hands before treating patients.

- The discovery that salt, sugar and water can prevent many deaths from infant dehydration.

 

But has all this anything to do with this thread? I doubt it. If people want to pay a lot of money for useless health care, I don't think it's the government's (or anybody else's) business to talk them out of it.

[Winstonm]

Are you disputing that health care is not better than 200 or 100 or 50 years ago and is improving at very fast pace?

 

Mike, I don't thnk anyone disputes that health care is better and improving - it is access to that health care that is the problem. What good is it to have the world's fastest passenger airliners if no one can afford to fly?

[mike777]

Costs

1) 1.8$ trillion in spending

2) 15% of GDP

3) a third goes for hospital expenses

4) a third goes for doctors and clinical services

5) 25% goes for drugs

6) 10% nursing care and in-home care

Who pays

1) 16% individuals reaching into pockets.

2) 40% private health care

3) 33% feds

4)11% states

World spending

1) Usa 5.400 for every man woman and child. No one else is close

2) Swiss 3,300

3) Germans 2.800

4) Canada 2,700

5) Brits 2,000

 

70% of 1.8 trillion spent on chronic disease

210$ billion on cardio and stroke

192$ billion on Cancer

92$ billion on diabetes

22$ billlion on arthritis

Usa life expectancy

1850=37

1930=60

today=77

if you reach 65 then well into your 80's.

 

Doctors do not scale

Tech does scale

scalability is good.

[mike777]

Yes Helene you cannot have these tests even if you pay for them yourself without a doctor's note. That is a cost not scaling.

[mike777]

Are you disputing that health care is not better than 200 or 100 or 50 years ago and is improving at very fast pace?

 

Mike, I don't thnk anyone disputes that health care is better and improving - it is access to that health care that is the problem. What good is it to have the world's fastest passenger airliners if no one can afford to fly?

Winston scalability means more access for more people at a lower cost. It does not throw out the Law of Demand or the price mechanism.

It does mean the end of medicine as we(I) think of it now.

 

To paraphrase, Silicon Valley reboots your Doctor. :D

[pbleighton]

I do not know the rates but will check. Assuming this is accurate this is a perfect example of baised stats. You are only comparing with a few countries.

 

Advanced industrailized countries are more than a few. They are, in fact, the relevant comparison.

 

Are you disputing that health care is not better than 200 or 100 or 50 years ago and is improving at very fast pace?

 

In fact you seem to say health care in the usa is terrible.

 

No and no. Your statement is completely ludicrous. I am comparing health care delivery, via the mechanism of various types of insurance, among countries with comparable economies and technological levels. Health care in the U.S. is good, but it could be much better distributed. 40 million unisured is IMO a crime.

 

Winston scalability means more access for more people at a lower cost. It does not throw out the Law of Demand or the price mechanism.

It does mean the end of medicine as we(I) think of it now.

 

Why? Drug companies and doctors will remain private.

 

Peter

[pbleighton]

Here's some data on infant mortality and life expectancy by country:

 

http://www.infoplease.com/ipa/A0004393.html

 

And here's some on health care expenditures per country:

 

http://www.jhsph.edu/publichealthnews/pres...thspending.html

 

In 2002, Americans spent 53 percent per capita more than the next highest country, Switzerland, and 140 percent above the median industrialized country, according to new research from the Johns Hopkins Bloomberg School of Public Health. The study authors analyzed whether two possible reasons—supply constraints and malpractice litigation—could explain the difference in health care costs. They found that neither factor accounted for a large portion of the U.S. spending differential.

 

Peter

[mike777]

'QUOTE

Winston scalability means more access for more people at a lower cost. It does not throw out the Law of Demand or the price mechanism.

It does mean the end of medicine as we(I) think of it now.

 

 

 

Why? Drug companies and doctors will remain private.'

 

First off Peter you have not disputed one of my facts or my best guess of the future but thanks for asking the above question.

 

 

 

 

I am talking about technology that helps medicine get cheaper and scale like Silcon Valley.

 

Our skin gets peeled back for a quick look inside. This is the end of medicine as we(I) know it. In other words do not guess what is wrong inside of me, open me up and look. Imaging becomes mainstream.

 

Computer aided detection algortithms

scanning cadavers looking for patterns of death.

Medicare becomes means tested

Meaning if you can afford it, you don't get a government handout

 

The poor in the U.S. will still get the latest and greatest in health care, especially if early detection is a money SAVER over time. The middle class will pay their own bills, but what else is new.

 

Fourtunately supply and demand is one of those basic tenets of ecomoics that won't change. As devices get cheaper, early detection willbe a huge worldwide market.

 

Peter, the biggest problem as I see it will not be technology advancing but its rate of acceptance. Psychological acceptance is important but difficult.

 

We will need less chronic hospitals but more nursing homes as the Big three killers shrink to the Big one or less. :D

[pbleighton]

First off Peter you have not disputed one of my facts

 

I don't dispute that things are better than they were, Mike. I thought I made that clear. Things will get better still. It is the comparative effective utilization of technology relative to other countries that is the real subject of this thread. See my links above, if you dare :D

 

Peter

[mike777]

"It is the comparative effective utilization of technology relative to other countries that is the real subject of this thread. "

 

I discussed this issue. I am not sure if you agree or disagree.

 

"Peter, the biggest problem as I see it will not be technology advancing but its rate of acceptance. Psychological acceptance is important but difficult."

 

 

 

"The poor in the U.S. will still get the latest and greatest in health care, especially if early detection is a money SAVER over time. The middle class will pay their own bills, but what else is new."

[pbleighton]

I discussed this issue. I am not sure if you agree or disagree.

 

"Peter, the biggest problem as I see it will not be technology advancing but its rate of acceptance. Psychological acceptance is important but difficult."

 

Would you explain this, Mike? Perhaps give an example?

 

"The poor in the U.S. will still get the latest and greatest in health care, especially if early detection is a money SAVER over time. The middle class will pay their own bills, but what else is new."

 

The poor don't get the latest and greatest in health care now.

 

And as for the middle class, how does a family of 4 with an annual income of $45,000 (the median) pay their own bills? Much less the family making $20,000?

 

Peter

[mike777]

"Peter, the biggest problem as I see it will not be technology advancing but its rate of acceptance. Psychological acceptance is important but difficult."

 

Would you explain this, Mike? Perhaps give an example?

 

At one point in time there was no diagonstic test for HIV.

Very soon in the 80's a cheap, reliable test was there at your Doctor's office.

 

Technology advanced but there is still great psychological restance to taking the test. Even if you took the test one's hands may have trembled as you wondered if you really wanted to know.

 

Apply that to cancers or cardio issues, etc. Do you have mutated genes or cells?

 

I do think scanning is the start of something big. Perhaps the end of medicine as we(I) know it.

[the saint]

I can solve the US health care problem and energy crisis at the same time.

 

Get all the obese people. Stick them in hamster wheels hooked up to turbines. And make them run all that lard off them. Hey presto - healthier people and loads of electricity. Now once they have all learned to walk everywhere you won't need to drive as much. Wahey - long term benefits both in terms of lower healthcare AND prolonged lower energy consumption.

 

Easy peasy.

[Winstonm]

"The poor in the U.S. will still get the latest and greatest in health care, especially if early detection is a money SAVER over time. The middle class will pay their own bills, but what else is new."

 

When you are talking about health care you are in my field.

 

Thinking that improved technology will lower costs is to hold an overly simplistic view of the nature of illness and the human body. We have mapped out the DNA of humans but still can't really do much with that information because the interactions of genomes is so complex.

 

I can tell you how the doctors I work with operate on the technical level - first, they order a simple x-ray; when they doesn't show them anything, they next order a CT; if that still does not satisfy them they next order an MRI. Costs are not saved but actually compounded by the extra technology.

 

In the past few years, a new serum test to indicate MI has been introduced, the troponin level. I asked a cardiologist what the troponin level had done to aid his skills and he in all seriousness said that it allowed him to buy a 90-foot yacht instead of the 60-footer on which he had planned. He went on to explain that although troponin was extremely accurate in guaging cardiac damage, the level itself could rise with damage confined to an area no larger than the size of a pinhead - but because it had risen, he could then do an angiogram which is where the big money is had.

 

Technology does not always equate to lower cost. Autombobiles are of much higher techonlogy standards than the Model-T, but the costs are not comparible.

 

There seems to me to be in this country a serious disconnect between the haves and the havent's - when a claim is made that the middle class will foot the bill I wonder with what will they pay? More credit card debt?

 

I am strictly middle class and have been so my entire life - the only thing that has kept my head above water is the decrease in costs from going from a family of 4 to a family of 2.

 

I've said this before but I think it bears repeating - does anyone seriously believe that liar loans and subprime mortgages were created out of the goodness of the hearts of mortgage companies in order to assure disadvantaged could have homes? Does anyone really think that automobile financing was exteneded to 60 and 84 months because cars were affordable on 48-month loans? The only reason these adaptions were created was to lower the monthly costs so consumers could keep on consuming, regardless of the outcome to the consumer or anyone else.

 

The simple truth is that approximately 80% of the population is buried in debt, is losing rather than gaining annual income, and will in the near future be forced to adopt a lower lifestyle standard in order to survive.

 

And no amount of technological advances will cure that problem.

[mike777]

"And no amount of technological advances will cure that problem."

 

We agree to disagree.

[pbleighton]

At one point in time there was no diagonstic test for HIV.

Very soon in the 80's a cheap, reliable test was there at your Doctor's office.

 

Technology advanced but there is still great psychological restance to taking the test. Even if you took the test one's hands may have trembled as you wondered if you really wanted to know.

 

Apply that to cancers or cardio issues, etc. Do you have mutated genes or cells?

 

And how does this cure cancers?

 

And, more germane to this discussion, how does this help uninsured people pay for cancer treatment. This is not academic. I know someone who died of lung cancer because she got it when she was working at a job with no health insurance, and she couldn't afford the very expensive individual policies which were her only alternative.

 

This happens all the time.

 

Mike, you are consistently ducking reality.

 

Peter

[mike777]

The Science of Scanning is one of the fields that I strongly believe will double every 18 to 24 months.

 

Early detection will lead to more cost savings that will help the poor more than anything else I can think of.

 

Are you arguing for something else, if so what?

 

All I see written is cycinism and hand wringing and some religious belief in universal health care.

[pbleighton]

The Science of Scanning is one of the fields that I strongly believe will double every 18 to 24 months.

 

Early detection will lead to more cost savings that will help the poor more than anything else I can think of.

 

Are you arguing for something else, if so what?

 

All I see written is cycinism and hand wringing and some religious belief in universal health care.

 

Will you read and respond to the links I provided on comparative infant mortality and general mortality rates?

 

Do you care about tens of thousands of dead babies, or are your techno-fantasies too compelling to worry about something so mundane?

 

Peter

[mike777]

The Science of Scanning is one of the fields that I strongly believe will double every 18 to 24 months.

 

Early detection will lead to more cost savings that will help the poor more than anything else I can think of.

 

Are you arguing for something else, if so what?

 

All I see written is cycinism and hand wringing and some religious belief in universal health care.

 

Will you read and respond to the links I provided on comparative infant mortality and general mortality rates?

 

Do you care about tens of thousands of dead babies, or are your techno-fantasies too compelling to worry about something so mundane?

 

Peter

Peter I have in every one of my posts. What do you think this is all about. Saving lives. Saying technology will not save lives seems to be your fantasy, not mine.

Saying better imaging will not save thousands of babies is your fantasy not mine.