Health Care

[hrothgar]

I wonder why the fact Canadians with money can come to America and get better treatment than Americans without money can get in America is often sited as a positive for the American health care system.

and i wonder why canadians, with or without money, can come to the u.s. and get better health care than they can at home

The US has a much larger population and a much larger variance in income.

 

Its perfectly logical that the US would have a much larger pool of doctor's catering to patients with large amounts of money.

[kenberg]

First things first, Danny Williams seems like a sensible guy and I cannot imagine why anyone would criticize him or fail to vote for him for taking good care of his health.

 

The subtext of the post is, I assume, that the US system produces the best doctors or the best surgeons or the best something. Maybe not the strongest care for the average person, but the best of the top flight doctors. One could treat this as a serious question regardless of where the answer leads. The fact that the US has a larger population is not so persuasive an answer. He could have gone to the Uk, or France, or Belgium etc. He came to the US. One example proves nothing but still, if someone claimed that in a ranking of the top surgeons in Canada, the US, and the EU the US is represented with greater frequency than its population would suggest, I think that I would not bet against that claim. From what I have seen up close, US health care at its best is very good.

 

Where that leaves us with respect to the Senate bill is not so clear to me.

 

I have come to think that the Dems have screwed the pooch, but that is for another post. I don't see the experience of Mr. Williams as the main issue.

[Al_U_Card]

Robert Bourassa (first minister of QC in the 70's) went to the Mayo clinic for cancer therapy.

 

We have a good medical service here with some excellent clinics and treatments. For coal you head to Newcastle....

[kenberg]

Here is my reading of where we are:

 

I Republicans will not cooperate with this administration. Certainly not on health care and probably not on much else either. It's not just a matter of having different views. There will be no cooperation.

 

II As a result, the Dems have written a bill of their own. They intend to pass it, and probably they will. One way or another.

 

III The bill isn't very good, and if the typical guy, one with a job and with a decent health care plan, looks at it and says "What's in it for me?", the answer will be "Not much".

 

So the Dems have backed themselves into a corner. They have to push something through or they will look like fools, and when they do it, the large group of people somewhere in the center, the ones they need to win elections, will not applaud. Maybe virtue is its own reward.

[luke warm]

First things first, Danny Williams seems like a sensible guy and I cannot imagine why anyone would criticize him or fail to vote for him for taking good care of his health.

 

The subtext of the post is, I assume, that the US system produces the best doctors or the best surgeons or the best something. Maybe not the strongest care for the average person, but the best of the top flight doctors. One could treat this as a serious question regardless of where the answer leads. The fact that the US has a larger population is not so persuasive an answer. He could have gone to the Uk, or France, or Belgium etc. He came to the US. One example proves nothing but still, if someone claimed that in a ranking of the top surgeons in Canada, the US, and the EU the US is represented with greater frequency than its population would suggest, I think that I would not bet against that claim. From what I have seen up close, US health care at its best is very good.

i agree with all of this... the question that's raised, of course, is whether or not the u.s. has always had the best health care (even if only in some areas) or whether the system used in canada has itself led to this relative difference

[helene_t]

III The bill isn't very good, and if the typical guy, one with a job and with a decent health care plan, looks at it and says "What's in it for me?", the answer will be "Not much".

Well as I read PassedOut's concerns (which make a lot of sense to me), one of the main problems with the present situation is that those who have insurance pay for the non-insured who get emergency room care without paying for it (and as I understand it, emergency rooms are used for problems that could be cheaper and better handled by GPs).

 

So it's the people who have insurance that have an interest in getting everyone insured.

 

Of course the insurance companies also have an interest in getting everyone insured.

 

OTOH another (and maybe bigger) problem is that the healthcare is simply too expensive, no matter who pays for it. Maybe a mandatory insurance scheme would save some money by moving some patients from emergency rooms to GPs. But it is also easy to see how more widespread insurance could make the total costs even higher.

 

I think you guys need to make your mind up: does society have a responsibility for providing affordable, elementary health care for everyone? If yes, provide sufficient subsidies for basic insurance. If not, be honest to your principles and throw the poor bastards out of the emergency room and let them die of appendicitis or w/e their problem is (unless some private charity is willing to pay for them without billing the paying customers or the taxpayers). I suppose some middle way could be found, i.e. society provides free emergency care for easy-to-treat life-threatening conditions, but in other cases the patients are on their own.

 

Anyway if there really was wide-spread interest in an affordable insurance plan that only covered sensible things and not nonsense like Ritalin, antidepressants, second opinion, conservative medicine, caesarian section, antibiotics for people with viral infections, doctor shopping, malpractice lawsuit insurance and "general health checks", I suppose someone would have put such a scheme on the market. So most likely, people are just happy with status quo and Obama can keep the change.

[PassedOut]

I think you guys need to make your mind up: does society have a responsibility for providing affordable, elementary health care for everyone? If yes, provide sufficient subsidies for basic insurance. If not, be honest to your principles and throw the poor bastards out of the emergency room and let them die of appendicitis or w/e their problem is (unless some private charity is willing to pay for them without billing the paying customers or the taxpayers).

Yes, I would be fine with adults having the option of not buying health insurance if they would then be required to sign a binding refusal to accept medical care paid for by anyone else.

 

That still leaves the problem of eliminating the 50% or so of waste in US medical charges. The current health care bills start to address that, but much more will be required in the future. You have to start somewhere.

[hrothgar]

Yes, I would be fine with adults having the option of not buying health insurance if they would then be required to sign a binding refusal to accept medical care paid for by anyone else.

So, just to be clear:

 

John Doe, the happy go lucky 19 year old college student, determines that he wants to roll some dice. Odds are that he isn't going to need medical care any time soon. Mr. Doe signs a binding refusal to have his medical care paid for by anyone else.

 

Two monthes later, Doe gets creamed by a drunk driver while he is crossing Kirkwood Avenue in downtown Bloomington.

 

The ambulance team rush to the scene, but before they start treatment, they search through Mr Doe's wallet, and pull out his driver's license. They determine that Mr Doe

 

1. Has no real assets

2. Didn't choose to contribute to the insurance system

 

The ambulance team packs things up and leaves Doe to bleed out on the street...

 

Everybody wins.

[jdonn]

Yes, I would be fine with adults having the option of not buying health insurance if they would then be required to sign a binding refusal to accept medical care paid for by anyone else.

So, just to be clear:

 

John Doe, the happy go lucky 19 year old college student, determines that he wants to roll some dice. Odds are that he isn't going to need medical care any time soon. Mr. Doe signs a binding refusal to have his medical care paid for by anyone else.

 

Two monthes later, Doe gets creamed by a drunk driver while he is crossing Kirkwood Avenue in downtown Bloomington.

 

The ambulance team rush to the scene, but before they start treatment, they search through Mr Doe's wallet, and pull out his driver's license. They determine that Mr Doe

 

1. Has no real assets

2. Didn't choose to contribute to the insurance system

 

The ambulance team packs things up and leaves Doe to bleed out on the street...

 

Everybody wins.

Or they could treat him and just charge him a mountain of debt for decades to come...

 

Also it's not clear in this context a 19 year old should be considered an "adult". Perhaps in an ideal scenario he would be covered under his parents' insurance until he was 21 and a little less stupid (or perhaps at any age at which one attends college right after high school). Even under Passedout's suggestion I would recommend mandatory health insurance to cover one's children.

[hrothgar]

Or they could treat him and just charge him a mountain of debt for decades to come...

 

Also it's not clear in this context a 19 year old should be considered an "adult". Perhaps in an ideal scenario he would be covered under his parents' insurance until he was 21 and a little less stupid (or perhaps at any age at which one attends college right after high school). Even under this suggestion I would recommend mandatory health insurance to cover one's children.

Whose to say that John's parents aren't the ones feeling "lucky"?

 

Or, alternatively, picture Jane Doe, the 28 year old Randroid who also refuses to buy insurance, and has her own unlucky run in with a delivery vehicle...

 

As for the suggestion that John goes into debt...

 

I guess that we'll need to "means test" John and make sure that there is a reasonable chance that he can pay things off.

 

If John is an engineer or an econ major, its probably safe to treat him. If John's studying art history, its probably better just to let him die...

 

Just think, a whole new type of triage, only this time its based on your credit rating!

[PassedOut]

Except for people in Virginia, I doubt whether many adults would be stupid enough to sign a binding refusal of care, but some folks seem to feel strongly about having that right. So let them have it (not children, of course), providing it doesn't put the burden on the rest of us. Over time, should be beneficial for the population as a whole (Darwin awards on steroids)...

 

I hope that most people discussing the current proposal know the basics of what's in it (for anyone on the internet, there is no excuse not to know). A number of items aim to get a handle on costs over time. For example, Prevention of Chronic Disease and Improving Public Health.

 

It directs the creation of a national prevention and health promotion strategy that incorporates the most effective and achievable methods to improve the health status of Americans and reduce the incidence of preventable illness and disability in the United States.

 

The Act relies on the innovation of small businesses and state and local governments to find the best ways to improve wellness in the workplace and in our communities.  And it strengthens America’s capacity to respond to public health emergencies.

 

The Act empowers families by giving them tools to find the best science-based nutrition information, and it makes prevention and screenings a priority by waiving co-payments for America’s seniors on Medicare.

And the proposal contains a long list of items to address obvious problems: Policies to Crack Down on Waste, Fraud and Abuse.

 

The House and Senate health reform bills contain an unprecedented array of aggressive new authorities to fight waste, fraud and abuse.  The President’s Proposal builds on those provisions by incorporating a number of additional proposals that are either part of the Administration’s FY 2011 Budget Proposal or were included in Republican plans.

Starting over is not realistic, and any politician who suggests that is just posturing for fools. Any lack of bipartisanship cannot be laid on Obama, and the republicans have yet another chance to contribute. If they don't, I certainly hope that the democrats ram this proposal down their throats. The US can't afford the status quo.

[luke warm]

Any lack of bipartisanship cannot be laid on Obama, and the republicans have yet another chance to contribute. If they don't, I certainly hope that the democrats ram this proposal down their throats. The US can't afford the status quo.

there are many republican proposals that won't be accepted, or (if not republican) common sense ones... like, open up all insurance companies to all states, or limit (or eliminate) malpractice suits

[jdonn]

Any lack of bipartisanship cannot be laid on Obama, and the republicans have yet another chance to contribute. If they don't, I certainly hope that the democrats ram this proposal down their throats. The US can't afford the status quo.

there are many republican proposals that won't be accepted, or (if not republican) common sense ones... like, open up all insurance companies to all states, or limit (or eliminate) malpractice suits

Perhaps not everyone agrees those proposals are common sense. Also I was under the impression Obama decided to be open to some sort of malpractice reform.

 

I'm wondering from your post, can you think of any non-Republican "common sense" ideas that won't be accepted?

[luke warm]

I'm wondering from your post, can you think of any non-Republican "common sense" ideas that won't be accepted?

hey, maybe you forgot but i'm already on record as supporting a single payer type system, if it's done right... that was a common sense proposal that (some) dems wanted, but was shot down (and not only by reps)

[jdonn]

You're right, I either forgot or never knew.

[PassedOut]

there are many republican proposals that won't be accepted, or (if not republican) common sense ones... like, open up all insurance companies to all states, or limit (or eliminate) malpractice suits

Obama certainly supports limiting malpractice suits as he has said many times. In itself, that would not reduce costs much, but over time doctors would stop ordering so many unnecessary and expensive tests -- a good thing. The proposed initiatives to study and make available the relative efficiencies of competing diagnostic techniques would also tend to immunize doctors against unreasonable suits.

 

Obama has also expressed support for opening up insurance across state borders, recognizing that that is a much more complicated situation given the differing insurance regulations and commissions in each state. But the proposed insurance exchange is a step in the right direction.

[hrothgar]

Any lack of bipartisanship cannot be laid on Obama, and the republicans have yet another chance to contribute. If they don't, I certainly hope that the democrats ram this proposal down their throats. The US can't afford the status quo.

there are many republican proposals that won't be accepted, or (if not republican) common sense ones... like, open up all insurance companies to all states, or limit (or eliminate) malpractice suits

For the record, there are already significant numbers of insurance companies that operate in multiple states. Admittedly, these companies need to abide follow the laws that have been enacted by the various states; however, that's one of the costs of "Federalism".

 

When Republican's talk about opening up all states to all insurance companies, what they really mean is allowing insurance companies to incorporate in some hell hole like Texas and use this as an excuse to ignore any state regulations that they don't like.

 

Its truly remarkable to see the hypocrisy as the champions of state's rights attempt to gut states from enacting their own local regulations.

[PassedOut]

Another way to heat up competition among insurance companies, much less complicated than fixing the state-by-state situation, looks like it might come to pass quickly: Bust the Health Care Trusts.

 

President Obama on Tuesday announced his support of a House bill that would repeal health insurers’ antitrust exemption, and Speaker Nancy Pelosi signaled that she would put it toward an immediate vote.

It will be interesting to see by the voting on this who is, and who is not, in favor of competition.

[luke warm]

Its truly remarkable to see the hypocrisy as the champions of state's rights attempt to gut states from enacting their own local regulations.

states rights? hell, that antiquated philosophy went out in 1913 or thereabouts

[Rodney26]

Starting over is not realistic, and any politician who suggests that is just posturing for fools. Any lack of bipartisanship cannot be laid on Obama, and the republicans have yet another chance to contribute. If they don't, I certainly hope that the democrats ram this proposal down their throats. The US can't afford the status quo.

I agree the US can’t afford the status quo; it just seems impossible that further government intervention into health care will make it cheaper. Why wouldn’t it be more expensive than it is now? Consider:

1. The federal government has specifically intervened in the housing market to make housing more expensive in the last couple years.

2. Clearly, government intervention in the world of student loans has caused higher education costs to go through the roof to the point where the middle class can’t approach being able to afford college without taking on well into the 5 figures worth of debt.

3. Massachusetts, the state that has the closest thing to universal health care, has the highest per capita costs in the country despite being a relatively healthy state. The system isn’t the only driver of course (great hospitals & doctors, world class eye care & children’s care), but lower costs have not been realized.

4. The recent explosion in health care costs has occurred concurrently with state and federal governments’ increased roles as third party payers, which will soon cross 50%.

5. The idea that the profit motive for insurance companies is the major driver of rising costs is too often cited. The lack of competition is far more of a driver (and I agree Reich is onto something until he throws the public option out there, which is gamed competition). There are plenty of companies out there that have made billions of dollars for themselves and their shareholders, and yet a consumer gets a far better product for his or her money today than 20 years ago. Personally, I think medicine has gone in the opposite direction – twice as much money for the same or a slightly inferior product.

The wellness programs are a red herring as well I think. We’re far healthier in our habits than we were twenty years ago. These programs are great for us as a whole but economically they’re a nonfactor. Consumers need to care about how much things cost again. They’ll cross the street to save a penny on gas but 3 and 4 figure decisions in medicine are completely transparent to them.

[jdonn]

I think most of the last post is rubbish. For example, on 1 the specific goal of the government was to make housing more expensive! Or at the very least that was an obvious consequence of their specific goal and was not some unpredictable side effect. 3 is a non sequitor. And 5 contradicts the claim that government involvement wouldn't reduce cost.

[awm]

In response to HotShot's number five point, the observation I've seen and agreed with is that competition spurs innovation in the market.

 

This means if I'm running a restaurant, competition with other local restaurants will encourage me to produce better food (or I'll go out of business). If I'm running an auto company, then competition with other companies encourages me to produce better vehicles (or cheaper vehicles, or something) so again the competition has encouraged innovation.

 

But here the market is health insurance. Not medicine -- insurance. So competition will encourage companies to come up with more innovative insurance. Again, these companies are not designing better drugs or treatments. So what does innovation look like in insurance? Finding creative ways to kick the most expensive customers out of the plan as soon as they become expensive... check. Finding ways to get large numbers of healthy people to sign up for insurance by providing group rate discounts... check. Finding ways to accurately evaluate risk and refuse insurance to people with pricey pre-existing conditions... check. Finding ways to restrict (a.k.a. ration) coverage so that insured people don't get expensive procedures or visit expensive specialists... check!

 

Do we really want all this "insurance innovation"? Probably not.

 

And it's not just the company profits that are an issue here. Suppose that a big insurance company gets $5 billion in payments for insurance. If their choices are to spend $4.5 billion for medical care for the people they cover, or to spend $3 billion for medical care for the people they cover and $1.25 billion paying their employees to come up with ways to avoid paying the other $1.5 billion... they pick the second way. This makes their profits a bit higher (but only 15% overhead rather than 10%) yet the gap in payments received versus medical care is much higher. It's even in their interest to create annoying bureaucracy, to try to convince expensive folks to switch insurance if they can.

[jdonn]

Competition spurs better value, not (just) better products. Better value is achieved in either or both of two ways. Better products, and lower prices. Adam you seem to have ignored the second way entirely and thus reached a(n at least partially) faulty conclusion.

[hotShot]

In response to HotShot's number five point, ...

Have I posted in this thread?

[Rodney26]

But here the market is health insurance. Not medicine -- insurance. So competition will encourage companies to come up with more innovative insurance. Again, these companies are not designing better drugs or treatments. So what does innovation look like in insurance? Finding creative ways to kick the most expensive customers out of the plan as soon as they become expensive... check. Finding ways to get large numbers of healthy people to sign up for insurance by providing group rate discounts... check. Finding ways to accurately evaluate risk and refuse insurance to people with pricey pre-existing conditions... check. Finding ways to restrict (a.k.a. ration) coverage so that insured people don't get expensive procedures or visit expensive specialists... check!

 

Do we really want all this "insurance innovation"? Probably not.

 

And it's not just the company profits that are an issue here. Suppose that a big insurance company gets $5 billion in payments for insurance. If their choices are to spend $4.5 billion for medical care for the people they cover, or to spend $3 billion for medical care for the people they cover and $1.25 billion paying their employees to come up with ways to avoid paying the other $1.5 billion... they pick the second way. This makes their profits a bit higher (but only 15% overhead rather than 10%) yet the gap in payments received versus medical care is much higher. It's even in their interest to create annoying bureaucracy, to try to convince expensive folks to switch insurance if they can.

A lot of what you say is true, but the problem isn't the concept of insurance. It's the problem of the consumer not having the power to tell the insurer to pound sand since insurance is tied to one's job. Why haven't there been these types of double digit annual increases in auto insurance, home insurance, or life insurance? Those industries have the same incentive that you describe below to make money and control costs. The difference is they deal mostly with individuals who have competitive options. I could cry to my employer about how my health insurance company screwed me over, but in the end it isn't going to have any impact. If my auto insurance company screws me over, I can call a competitor right away and use them instead.

 

There's also I think an issue of perception. No one would think any less of Amica if they denied auto insurance to someone twice convicted of a DUI, or fire insurance to a pyromaniac. We accept that people on the coast should pay higher home insurance premiums than inlanders with all else being equal, since it is reasonable to do so because of climate associated risks. However, when it comes to human health, there are at times forces entirely outside of our control that change our perception. Someone is diagnosed with leukemia and the evil health insurance company won't cover them, even though it is a virtual certainty that the insurance company stands to lose money providing that care. I think a lot of what drives that is that we ourselves want to think we'd be taken care of if bad luck struck for us or our families.

 

Nevertheless, my main point is that there is no evidence that our medical costs will be less expensive if we go to single payer or some other federal provider program. Creating a monopoly always has the opposite effect -- those long distance phone bills from the 80's where ATT was allowed to declare that it costs 80 cents per minute to provide this service weren't that long ago. Too many people assume that cost reduction will be the case. It won't be.

 

I'd love it if we could go to the auto insurance model, stop "insuring" routine annual health care and ditch the corporate tax break so that we could make individual choices in terms of our insurance. The government could still charge a 2% tax or something on incomes to create a disaster pool for the unfortunate. We're a reasonable people when it comes to that sort of thing.