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Yes, Michael, American Health Care Really Sucks.

Posted by DENNIS SANDERS in Economy, Health, Politics.
Jun 12th, 2009 | Comments

Back in 2005, President Bush tried to reform Social Security. I don’t know if his partial privatization plan was the best, but at least he was acknowledging there was a problem with Social Security. Democrats, opposed to privatization, fought back against any reform by saying “there was no crisis.”

In the concern over health care reform this year, many Republicans and conservatives are basically saying the same thing about health care in the United States: there is no crisis.

Michael Barone, a writer for US News comes to such a conclusion in his latest column. He throws out several statements that makes it seem that Democrats are crying wolf about health care. Here is his statement about health care in general:

An April tracking poll conducted for the Kaiser Family Foundation shows that voters rank changing health care below strengthening the economy, stabilizing Medicare and Social Security, and reducing the federal budget deficit on a list of eight possible priorities. Democrats rank it higher, Republicans rank it at the bottom, and independents, on this issue like many others this year, look more like Republicans than Democrats.

The blunt fact is that most Americans are satisfied with their health insurance and don’t believe major legislation will improve things for them. This gives opponents of the Democrats’ rush to legislate a strong talking point.

Barone gives people the illusion that the Democrats are just pushing reform when there is no crisis. But as the blogger named “Henry Clay” notes:

While certainly decent compared to the alternatives, objectively speaking our health care system is a mess. The government subsidizes the care of the elderly by stiffing doctors, who then pass along those costs to the privately insured. In a post-industrial national economy, individual insurance decisions are subject to the regulations of 50 state insurance commissioners, undermining portability. The government provides massive and regressive subsidies to employer-provided coverage, while providing practically meaningless tax breaks to those who seek care in the individual marketplace.

In other words, the system is pretty lousy and needs work. Conservatives helped to make this case, first in the think tanks, then in President Bush’s proposal for health care reform, and finally during Senator McCain’s campaign.

It may be that the vast majority of Americans with private health insurance are satisfied with their coverage. But they certainly worry, particularly in this economy, about a health insurance system that largely ties your opportunity for coverage to your employment. And they understand that their share of coverage is consuming an ever larger portion of their income.

In other words, they might be satisfied with the system, but they aren’t ecstatic about it.

They might have real concerns about who will wind up holding the bag for the Democrats’ reform. But there is no special place in their heart for America’s insurers and pharmaceutical manufacturers.

Americans do worry about health care. Maybe they aren’t marching in the streets asking for a Canadian-style system, but they are worried what happens as health care costs rise and what happens if they lose their jobs.

But maybe the coup de grace of Barone’s comments is this one about young adults:

the segment of the electorate that did most to produce the Obama victory and give the Democrats large majorities in Congress is the least concerned and least informed about health care. That segment is the 18 percent of voters under 30. Young voters preferred Obama to John McCain by a 66 percent to 32 percent margin, according to the exit poll. Voters 30 and over preferred Obama by only a 50 percent to 49 percent margin. Some 63 percent of the young voted Democratic for the House of Representatives. Only 51 percent of the rest of Americans did so. Without the young, the votes would clearly not be there for what the Democrats are trying to force through.

But what do the young know or care about health insurance? They have the fewest medical problems of the whole population. Their image of health care, at least until they become pregnant and have babies, is university health services. You come in if you feel like it, someone else pays, you get some pills or some counseling, or whatever. As for the downside of government insurance, pollster Scott Rasmussen reports that the young favor capitalism over socialism by only a 37 percent to 33 percent margin. The rest of us prefer capitalism by a 57 percent to 17 percent margin.

But while young voters may be open to government health insurance, they surely don’t care very much about the issue.

So in Barone’s mind, twenty-somethings are basically carefree idiots.

Yeah, that’s a way the GOP can get a share of the youth vote.

I can tell you that young people under 30 do know a thing or two about health care insurance or lack thereof. Most people in their 20s are in jobs after college. Since you don’t normally end up in a corner office at 25, you might end up working in a very low-paying job that may or may not have health care. And if health care is available, you might not be able to pay for it.

I should know, since it happened to me.

In my 20s, I went through periods where I didn’t have health insurance. One of those experiences was 12 years ago, when I was 27. I had just moved to Minneapolis and was working at a coffeeshop. I was working full time and making $6 an hour. Health care was available, but when you make only $6/hour and have to pay for various things like food, health care becomes out of reach.

That fall, I got the flu, which then turned into pneumonia. I ended up in the hospital for two weeks. I didn’t have to face a big medical bill (or at least not so much) because a wise nurse practioner at the clinic I was going to, was able to get me on to General Assistance health care, which is Minnesota’s health care program for the poor.

The fact is, young people do face various illnesses. Twentysomethings are not fragile compared to the elderly, but they are not invincible. Right now, I know of a young woman who has health issues related to liver disease and her health care situation is perilous.

Republicans in my view are correct in opposing a public option for health care reform. But that doesn’t mean that we should pretend there is no crisis, as Henry Clay says, that’s the best way to ensure President Obama’s public option is a reality.

Crossposted at Neomugwump

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superdestroyer

What people with private insurance suspect is that the deal will get worse with nationalized healthcare versus what the yhave now. They probably also suspect that the elite and rich will not experience of the downside of nationaized healthcare versus the middle class. The middle class has the most to lose (control of healthcare, higher taxes, eliminaiton of healthcare jobs) and the least to gain (trading control of healthcare for some level of portability). The progressives on the left have not been low profile in their desire to eliminate private insurance and the desire for the government to regulate every healthcare decisions (expect abortion).

Until Obama demonstrates that he can produce private school results at America's inner city schools, maybe people should be suspect of a government program that looks so similar to public primary and secondary education.

GeorgeSorwell

There is a health care crisis in America.

And it's not about medicine. It's about insurance.

If you want to do something about it, have facts at your disposal. People opposed will use scary words, change the subject, bury you in random anecdotes, confuse you with emotional illogic, trim the facts about Canada.

People like their health insurance because they assume it actually provides coverage for their needs. But when you need it, you're probably going to be in for a shock.

For example, The American Journal of Medicine reports that more than 60% of personal bankruptcies in the United States in 2007 were caused by health-care costs associated with a major illness. These bankrupts include people who had insurance.

And don't count on Medicare to bail you out when you get old: If you live to be 80, you'll pay $80,000 in out-of-pocket medical costs. And remember, nursing home costs are in the neighborhood of $50,000 a year.

Here are some links:

About The American Journal of Medicine's report on bankruptcies [LINK].

Retired people's health costs
[LINK].

The Snopes page on Single-Payer Health Insurance in Canada. [LINK].

Bookmark these pages.

Have facts. Provides links.

Ask for sources.

GeorgeSorwell

Superdestroyer's comment is an example of the poor arguments against reform.

He doesn't provide a single source.

He uses scary words to frighten the middle class.

He changes the subject to inner-city schools.

Dr J

Superdestroyer doesn't seem to be arguing against reform, just against nationalization. The government's track record at running other social services like schools is relevant to the discussion.

GeorgeSorwell

Dr_J--

I don't see what locally run school districts have to do with nationalizing anything.

Dr J

"Locally-run" school districts are increasingly nationalized, through programs like No Child Left Behind. And according to your link, Canada's "nationalized" health care is really a collection of provincial and territorial systems.

GeorgeSorwell

Dr_J--

If you're saying Canada's health care is not "nationalized", what happens to your complaint about nationalized health care?

And when you quote somebody as saying Canada's health care is "nationalized", who are you quoting? Because you're not quoting me. And the Snopes link says Canada has a national health insurance program.

Care to quantify the amount by which locally run school districts are, as you put it, "increasingly nationalized"? Maybe even some description of what No Child Left Behind does that makes objectionable? Or how the school district model is similar to any proposal for health care reform?

And do you deny there is a health care crisis?

casualobserver

And do you deny there is a health care crisis?

Not for me, Georgie...........'cause I do this weird thing.............I pick out my own physician, I make an appointment, I discuss with him/her what their opinion is, I decide if it makes sense, and then let them proceed. After they're done, I take out my checkbook and pay the bill. I've always been satisfied and so, it seems, are they. Most of them actually take 20% off since getting paid by the patient at POS is such a novel concept these days.

Yes, I also have a HD policy for hospitalization which I pay for out of my HSA account.......which you, being a good liberal, help me fund by taking on my tax deduction.

Thanks for asking, Georgie, but I haven't had a crisis over healthcare my entire life.

roro80

I agree with George about the crazy that seems to get spewed when someone mentions the health care system in Canada. Most Canadians think their health care system is "annoying", and then are horrified to learn how many people actually die in the US due to lack of health insurance (suddently "annoying" doesn't seem too bad). They spend a much smaller percentage of their GDP on health care than we do, and every person in the country gets covered. The way I've heard it described by a couple of friends who live on the US-Canada border is that in the States, you have quite a few people who get A+ health care due to their ability to pay for it. Many people get F-grade care -- those who have no insurance. A large majority fall somewhere in between. In Canada, nobody gets A+ care, but every man woman and child gets B+ care.

roro80

CO -- that's a pretty funny answer. You're satisfied, you can obviously afford to go to the doctor, you've never been truly ill, and everyone in the world is exactly like you, so there mustn't be a crisis! That's some awesome right there.

GeorgeSorwell

I haven't had a crisis over healthcare my entire life.

I wish you nothing but continued good luck over the rest of your life, Casualobserver.

Seriously.

DLS

I have to say, Obama and his team are audacious. (I don't respect the stupid Congressional Dems and those Republicans who are going along to get along with the Dems -- they're just followers-on to Obama on health care.) Effectively, Hitler really is invading Russia seeking conquest (launching a vast health care initiative) before concluding things on the western front (waiting for and trying to get the economy to recover). He's really proceeding with it -- I saw (and wish I heard; I didn't) the "town hall" appearance.

It's reckless and shocking on its face (logically the economy should be allowed to recover first, and there is a desperate need to control and greatly reduce spending and borrowing by the federal government first, and to find an assured source of revenue to pay for the health care program), and I'm curious what is the reasoning (or lack thereof; I doubt there's a lack given Obama's record so far, though) behind launching this thing now. Not everyone is so naive and childish (Obama groupies; dependent, compliant sheep bowing obediently to Washington's every statement and action robotically) as to support rushing into this now. Presumably the Obama "campaign" behavior (which is inappropriate; the campaign ended in early November 2008 and so should have been all campaign behavior) is expected to still remain appealing to a vast number of (exploitable) people. The Dems have hordes of such cheaply-bought-vote people, and to exploit them as Obama has done may have rewritten how future administrations behave once they take office in Washington. (They don't want to wait, and don't care apparently about the gargantuan spending and borrowing, either.) Part of it may be the poor public relations that reflect "removed elites" who don't quite understand real-world society (we saw this with those Roman columns in the stadium during Obama's speech last year; we saw it with the "OFFICE OF THE PRESIDENT-ELECT" signs, and we see it when Obama makes a public speech before starting a Cabinet meeting, etc.) or who possibly believe (or know for a fact) that the horde of exploitable people (who actually may _like_ all this gimmickry and poor behavior) is larger than many may believe.

I'm wondering if he's rushing to start on health care merely for (superficial) "man of action" appearance's sake (actually another flirtation with fascism, in its own way), or if he's hurrying to exploit the extra-strong power the Democrats have in Washington as well as support among so much of the public, or to exploit the distraction the poor economy may have for many -- who knows.

As far as the details, I'll want to see more, but I fear we will have once again (given not only the elitism but also the fervent and pathological behavior among the many elites in Washington) needlessly complicated measures, as well as likely attempts to engage in window-dressing and "softening" of what Washington really wants. Including the insurance companies is just a way to make it appear to be in large part a "private" or "free market" concession, as well as to exploit the insurance companies desperate to stay in business in this field while they are still able to do so. (It also gives the little fascists the ability to get their paws into the workings of the insurance industry, and of course may be a way to familiarize themselves with the insurance infrastructure before eventual takeover and replacement of the industry with a fully public system.) The "public option" scheme is nothing like how liars such as Tom Harkin claim it to be, but is instead a way to slowly and carefully introduce public health care to more of the mainstream in society outside the scope of merely the elderly. (It's no different than what was sought exploiting children with S-CHIP by the Democrats months ago.)

I was left to wonder why these people insist on game-playing and needless complexity, given that what they want leads to the simplest and the most obvious alternatives as the logical solutions to what they want.

1. Simply extend Medicare to everyone; or,

2. Extend the same federal benefits of Congressional members, Obama administration members, and others to the public.

But that's too smart and simple, and not complicated enough, and not devious enough because it's too controversial. (Even though so much of the public would grasp and _approve_ such measures.)

* * *

In passing, note that what has just happened in Washington is a pretty (comparatively) subdued, small, but very sound victory for liberals and Democrats, wanted in particular since the Clinton years -- tobacco is now being put under the control of the FDA (it can now be regulated as a drug, there can be all new kinds of regulations and controls on tobacco, advertising, et cetera). I bet there's little outcry about this.

DLS

"The government's track record at running other social services like schools is relevant to the discussion."

You can add an automobile company now, Gummint Motors, "AmCars," to the scope as well now.

It's not only the track record (of failures, opposite results than intended, et cetera) but the nature of the interventionism and all the test that is at issue, too.

We'll see what happens. The "public option" (a la S-CHIP) is "transparently insidious"; the intent is _of_course_ to encourage people to shift from private to public health care insurance (later, provision). Pretending it's still "private" and requiring all people to buy insurance isn't even so much to try to set up a broadly-based "community rating" fake insurance market, but, because people have to pay for this if they are required to buy insurance, it sets up quickly the system and the public's conditioning for taxation of some kind to pay for this.

Note that just as with the beloved "cap and trade" scam-scheme that the little green fascists currently are anxious to implement, rather than risk public ire with the more honest as well as more effective direct tax on combustion fuels, all the game-playing that we're starting to see is needlessly complicated flirting with federal provision of health care for citizens (and non-citizens, too, so Dems win more approval and more votes thereby) without openly advocating what they really want (as have many activists for so many years), direct, open, honest, federal provision of health care. They're taking a complicated, indirect, incrementalist, "openly stealthy" approach. (In fine, stupid bungly-bureaucratic style, if you notice.)

"And do you deny there is a health care crisis?"

I do. There is no "crisis," and that word, "crisis," is mindlessly, stupidly overused by childish liberals everywhere, notably in the liberal media, who are subject to misusing this and other words for reasons as well, first and foremost due to sensationalism (sought by hyperbole).

At least with this issue -- at least, not yet -- we aren't subject to the same level of idiocy, dishonesty, and truly pathological extremes that we see with not only hyperbole, and more fear than ever existed in this country after the 9-11 attacks (as Obama noted in a speech not long ago), and outright alarmism as well as dishonesty and pathology -- in the case of global warming.

But fear not (pun intended). Before too long, the liberal media and the Obama people and Dems in Congress will begin to talk about the health care "crisis" more and more, not only joining but leading the stupid stampede of the Herd, right on cue, once the developing health care efforts in Washington become substantial.

GreenDreams

Oddly, sans the diatribe, I agree with your proposed solutions, DLS. Medicare and federal health insurance are intact programs with a good record. We don't need a spankin new complicated program. I think it's a chess game with the insurance companies to keep them from scuttling the reforms like they did with Hillarycare. As long as they can either continue to gouge their customers or feed at the public trough they might let us have some of the better healthcare enjoyed by the rest of the world.

GS, I really like your input on this issue, and appreciate the links. I just signed up to review the Kennedy bill for Huffpo.

GeorgeSorwell

GreenDreams--

Thanks. I hope you'll let us know when your Huffpo review appears.

Thanks also for your sensible reply to the diatribe.

Dr J

Would that it were true, GreenDreams. Medicare has an awful track record managing health care costs. McAllen, Texas, the second-most expensive market in the country in terms of Medicare payments, is not only not being forced to rein in costs, they had no idea they had placed second until the New Yorker showed up and told them. The interviewer confronted hospital administrators:
It was a depressing conversation—not because I thought the executives were being evasive but because they weren’t being evasive. The data on McAllen’s costs were clearly new to them. They were defending McAllen reflexively. But they really didn’t know the big picture of what was happening.
We cannot afford a whole country full of McAllens.

kathykattenburg

'cause I do this weird thing.............I pick out my own physician, I make an appointment, I discuss with him/her what their opinion is, I decide if it makes sense, and then let them proceed. After they're done, I take out my checkbook and pay the bill. I've always been satisfied and so, it seems, are they.

C.O., that's not weird at all. That is totally normal. That is what everyone does, except obviously for a few crackpots and ne'er-do-wells who have no health insurance and no job and no money in the bank to write checks on the spot for doctor's visits.

Um, like me.

GeorgeSorwell

From the New Yorker article linked by Dr_J:
The researchers asked the physicians specifically how they would handle a variety of patient cases. It turned out that differences in decision-making emerged in only some kinds of cases. In situations in which the right thing to do was well established—for example, whether to recommend a mammogram for a fifty-year-old woman (the answer is yes)—physicians in high- and low-cost cities made the same decisions. But, in cases in which the science was unclear, some physicians pursued the maximum possible amount of testing and procedures; some pursued the minimum. And which kind of doctor they were depended on where they came from.

A little later:
But he had often seen financial considerations drive the decisions doctors made for patients—the tests they ordered, the doctors and hospitals they recommended—and it bothered him. Several doctors who were unhappy about the direction medicine had taken in McAllen told me the same thing. “It’s a machine, my friend,” one surgeon explained.

From near the end:
In the sharpest economic downturn that our health system has faced in half a century, many people in medicine don’t see why they should do the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue.

And:
When I was in Tulsa a few months ago, a fellow-surgeon explained how he had made up for lost revenue by shifting his operations for well-insured patients to a specialty hospital that he partially owned while keeping his poor and uninsured patients at a nonprofit hospital in town.

This article doesn't blame Medicare. It blames the doctors who game the system for cash.

GreenDreams

Dr. J. One market? McAllen, just-across-the-border Texas? It appears to me that you are searching for support for your position, rather than looking at a dispassionate comparison of private versus public plans.

Private health insurers’ spending per enrollee grew 29% faster than Medicare spending between 1983 and 2006.
Private health insurers’ spending per enrollee grew 59% faster than Medicare spending between 1997 and 2006.
Spending was for comparable benefits.

Between 1997 and 2006, insurance premiums rose at twice the rate of Medicare spending, according to a report last year by the Office of Actuary, National Health Statistics Group. The differences in excess spending are even more significant. Excess spending growth compares the increase in spending to the increase in economic growth. Excess spending for the elderly has dropped to 0.3%, while excess spending for the privately insured has risen to 3.4%. According to the report, "much lower spending for seniors is due to Medicare's much stronger cost control measures." On the other hand the Federal Employees Health Benefits Program had 26% higher premium growth that Medicare spending. In fact, FEHBP plan costs rose at the same rate as other private health insurance plans. FEHBP does not seem as good a model as Medicare.

Employer paid health-insurance premiums have increased 9% a year since 1999. Those who argue that there is sufficient competition in the insurance marketplace ignore the actual statistics. In 40 states the top three carriers have 60% to 100% of the market. In 16 states, one dominant carrier as at least 50% of the market.

In the last seven years, profits of the private insurance industry have increased by 330%. The CEOs at these companies were paid an average of $10.5 million each.

And for all the complaining I've heard here about doctors and hospitals getting short shrift from Medicare, for-profit hospitals reported $43 billion in profits in 2007 alone. Health insurance industry costs for administration and profits have increased 12% a year from 2000 to 2005; 40% faster than overall health spending, and 50% faster than spending for hospitals and physicians. Private health-insurance industry employment grew 52% in the last 10 years. Just imagine the wailing we would hear if Medicare had added 50% to its staff.

Hospitals receive 25% less for their Medicare patients, yet virtually all hospitals participate. Physicians received 19% less from Medicare, yet most participate. 97% of doctors take new Medicare patients.

GeorgeSorwell

The report GreenDreams is referencing is apparently a PDF, which I am having trouble opening.

However, I found it--I think--in the form of a PowerPoint presentation, which, courtesy of Google, can be rendered in HTML. Here it is.

I hope that will work.

Here's the executive summary, in the form of a normal web page.

GeorgeSorwell

If anyone cares, I finally got the PDF open. Table 13 seems especially relevant. Warning: it's a PDF!!!

Also, here's a study from The Kaiser Family Foundation on health care costs. Quote:
Another option for affecting health costs is more government involvement in setting reimbursement rates or implementing new payment policies. For example, Medicare could serve as a model for payment reforms such as pay-for-performance or coordinated care. The government also could extend the prices it receives to other payers or take more direct actions to try to regulate costs. Less government regulation also is an option that could affect costs. Reducing requirements for providers or insurers could reduce the cost of supplying health care or health insurance generally, but less regulation also could leave some families exposed to higher out-of-pocket costs.

The part I bolded might be an answer to the problems referred to in the New Yorker article that Dr_J linked.

GreenDreams

Oops. I forgot to link to the report. Thanks for googling, GS.

Dr J

George, of course doctors are gaming the system. That's a big problem. One that Medicare hasn't made the slightest effort to fix. Medicare's job is to spend our money wisely, and making sure the outcomes it's paying for are the outcomes we want is just very basic management. Its failure to do it is a major red flag for anyone proposing to let it oversee even more.

GreenDreams, your comparisons of Medicare to private insurance are all fine. I'm happy to concede private insurance is a disaster, and for the sake of argument I'll even say it has been twice as disastrous as Medicare.

But I'm sorry, "only half as disastrous as private insurance" is not good enough. We should dethrone the private insurers from their over-powerful position, but Medicare's performance proves the government is also unqualified to run our whole system. We deserve better than either of these.

Dr J

Medicare could serve as a model for payment reforms such as pay-for-performance or coordinated care. The government also could extend the prices it receives to other payers or take more direct actions to try to regulate costs. Less government regulation also is an option that could affect costs.

George, of course Medicare *could* institute pay-for-performance, and the government *could* ease up on its heavy regulations. They've only had decades so far. How long shall we give them?

GeorgeSorwell

Dr_J--

It seems to me that "half as disastrous" is a good place to start.

GeorgeSorwell

Dr_J--

How long shall we give...doing nothing?

I presume that Medicare has been a political hot potato, subject to special interest pressures, for the decades it's been in existence.

GreenDreams

Dr. J, thanks for the concession. I'll also admit that Medicare could do better, though its costs are not unreasonable for the care provided (or rather, paid for). Still, according to one of the reports I linked to, of $300 billion paid out, $40 billion may be fraud. A part of the problem here is not that the government runs it irresponsibly, but that the "small government" mentality hampers their ability to get needed staffing to reduce fraud. That effort would need to be increased for the program to grow to cover more people. It seems to me there's enough in that potential $40 million of fraud to hire more staff and still come out saving money. Incidentally, private insurance fraud rates were even higher, despite the large numbers of legitimate claims they deny. So clearly there's a need for better scrutiny, and perhaps harsher penalties for those who "game the system."

Dr J

George, I disagree with DLS, I think we have a crisis. I support some serious reforms, and I liked the Swiss model outlined by Regina Herzlinger a couple weeks ago. It would wrest power from the private insurers and return it to consumers. Consumers are the only ones with a genuine stake in value delivered for money spent, and they're the ones who should be in control of the purse strings.

Dr J

GreenDreams, fraud is an issue, but none of the excessive charges in that New Yorker article would have qualified as fraud.

I hear you about government being hampered by "small government" mentality and a million other political pressures. But that's exactly government's problem, not just in Medicare but in everything it does. It's always trying to answer to 300 million not-very-attentive bosses who manage based on sound bites. It always favors pennywise, pound-foolish measures that play well on TV. It always skews its decisions toward smaller, louder special interests at the expense of the silent masses. Its track record in health care is no aberration.

As for doctors gaming the system, George's pay-for-performance suggestion is an excellent fix. There's nothing wrong with doctors doing what will pay them well, as long as we're paying them for the right things.

GeorgeSorwell

Dr_J--

What you say about consumers being the only ones with a genuine stake in value delivered for money spent is true enough.

I confess I don't know anything about the Swiss model for health insurance. A minute using Google showed a few things. Maybe it's like what they have in Massachusetts? I see there are government subsidies. And I see they also have cost problems.

What I found:

Report from the European Social Survey.

Report from NPR.

Dr J

I'm no expert on the Swiss model either, but I liked what Regina Herzlinger outlined (http://themoderatevoice.com/32855/good-luck-on-...), which could drive momentous changes with modest changes in laws.

1. Give to consumers the tax deduction that currently only employers get for health insurance, encouraging more consumers to buy it themselves.

2. Go further for the poor, giving government subsidies to ensure anyone could buy coverage.

3. Consumers, facing what insurers are actually charging for coverage today, would opt for cheaper, high-deductible plans in large numbers. Insurers would suddenly be demoted from gatekeepers-in-chief for all health care back to providing genuine insurance, that is, coverage against very unusual charges.

4. Providers would start having to answer to consumers directly, and consumers will start asking awkward questions like what they're getting for their money. Some of this is already happening on Yelp, where people review doctors and dentists like they review restaurants, often rather scathingly. The providers are so shocked at the unexpected scrutiny, they're in some cases suing. I find this an amazing breath of fresh air in our sclerotic health care market.

5. Providers will start learning how to answer value-for-money questions they never get asked today, and the answers will often surprise them. Just like happened in that New Yorker article.

6. New care models will arise, since consumers can't ultimately negotiate every detail of complex medical treatment on their own. Maybe fixed-rate, collaborative care models like the article envisioned will catch on. Maybe you'll hire a concierge doctor whose job is partly to negotiate on your behalf.

The information age has changed most other industries dramatically, but health care not so much. Yet. There are huge innovations waiting to happen if we can create the right conditions for them.

GeorgeSorwell

With all the discussion about Medicare, I forgot that the federal government actually runs a well-regarded health care system through the Veterans Administration.

Polimom

I get the distinct impression, both here and practically everywhere else right now, that there's some serious confusion over the term "insurance", and what it means (or does not mean) in terms of health care.

CO, upthread, talked about his method of handling healthcare. He describes writing checks at the POS -- something that we do as well -- and also mentioned a HD policy, which everybody just drove right on past.

I don't have to read CO's HD policy to know that it's much more closely aligned with the concept of "insurance" than, say, the Kennedy plan that GreenDreams is going to review.

Insurance is protection against unexpected loss. Doctor's visits, preventative care, etc., are not at all insurable, as the term is normally defined. Necessary? Yes. But health care plans that include them should not be confused with "insurance".

The blurred terminology is, I think, part of why we're in the mess we've got.

GeorgeSorwell

Some notes toward semantic understanding:

Health care is what you need.

Insurance is what you pay for.

Coverage is what you get denied.

I hope that helps.

Dr J

Polimom, it's more than blurred terminology, it's emblematic of the basic disconnect people are having over health care economics. People are somehow expecting "insurance" companies to play a much larger role of gatekeepers-in-chief of all medical treatment, and more than that, to engineer a massive wealth redistribution from "the rich" (or, near as I can tell, from thin air) to the middle class and the uninsured. The companies are failing, if you can imagine, and people are mad as hell.

George, interesting article about the VA hospitals, and news to me. Sounds like we've got a success story on our hands, which is a fine thing. And a turnaround at that, definitely not something I hear government pulling off very often.

GreenDreams

Here are some issues from my perspective. I haven't had employer-provided health insurance for over 10 years. I buy my own. I have not found that "catastrophic" or high deductible plans are all that affordable. Anyone over 50 finding ANY coverage for less than $350 a month? I found that the cost of catastrophic care and that plus some preventive and office visits was about the same cost. My deductibles beyond a checkup every other year and say a strep throat test or other routine office visit are very high. I had an injury that sent me to the ER. With a high deductible, it's all out of pocket. You think I can negotiate a better price in an emergency situation? HA!

In general I think patients have VERY little negotiation room with any doctor or hospital. So the idea that if we're the direct payer we'll get a better price is pretty questionable to me.

Next, if NO office visits or checkups are covered, maybe I'd avoid the doctor and not ever get a checkup. Is that going to reduce our health care costs? Avoiding care? Because that's exactly what would happen if people only have catastrophic coverage.

Now it seems we're more concerned about lowering costs than improving outcomes. So we could keep the insurance industry happy by making it easier, or even mandatory, to buy their products, then lower costs by cutting out "unnecessary" expenses like preventive care. Is that where we're headed? I still don't see that as approaching the full coverage and lofty results of European and Asian nations, or our neighbor to the north. It seems we're willing to sacrifice better health for lower cost, while maintaining insurance company profit. Pity.

By the way, adding tax exemptions as is suggested here, of course, reduces federal revenue, increasing the deficit. It's exactly the same, dollar for dollar, as the government paying. Isn't that "nanny state" too?

Polimom

George -- um. no. not a bit of help there.

"Health care is what you need.

Insurance is what you pay for."

I could agree with those statements individually. However, the distinction still appears to be getting lost. Insurance is NOT the correct vehicle for normal (read: non-catastrophic) health care.

Polimom

"Next, if NO office visits or checkups are covered, maybe I'd avoid the doctor and not ever get a checkup. Is that going to reduce our health care costs? Avoiding care? Because that's exactly what would happen if people only have catastrophic coverage."

Greendreams, I agree with you. I'm in no way suggesting that people should consider catastrophic insurance as their "health care plan". It is, or should be, an element of comprehensive health care.

People should be involved / engaged in preventative care. We (people) need a way to ensure (NOT to be confused with insure) that we can affordably access preventative / normal / routine medical care.

Unbundling these two very different concepts would not only reform the way we're currently approaching the question, it would enable much more realistic definitions and funding. If Obama et al are serious about health care reform, then imho, this is where they should focus their efforts.

GeorgeSorwell

Polimom--

I confess, I'm not getting your point.

Maybe you can make it plain?

Polimom

George, I'm not sure how much plainer I can get than saying that insurance is the wrong vehicle for "health care".

There's nothing unexpected about routine health care. Doctor's visits aren't catastrophic loss against which one should insure.

That's about as basic as I can figure out. Hope that helps?

Dr J

GreenDreams, you have more negotiation room than you think with hospitals, but you get it after you leave the emergency room.

In any case, I agree, we have a health care culture where patients/consumers have very little clout and hardly any of them even *ask* what something's going to cost. Because they don't care. Because someone else is picking up the bills. And that someone else is a giant bureaucracy that only asks once a year and doesn't even care much what the answer is, because they're just passing the cost on.

Even if you ask a hospital what your stay will cost, they won't be able to tell you. Because they're not set up to. Because no one ever asks. Get 500 people asking them, every day, and they'll learn how to answer.

If you put the checkbook in the patients' hands--not just a few, but all of them--the dynamics will change dramatically.

Checkups are just like new tires on your car. Get them if you think you should, don't if you don't. But don't expect your car insurance company to pay for them without simply passing the cost (plus their overhead) back to you. Same story with balancing lower costs vs. improved outcomes. You should be deciding those priorities, not your insurance company, and not some Washington lobbyist. Of course, you don't have the data you need, because hospitals don't know their outcome stats any better than they know their costs. And they won't start tracking them down until their customers start caring and demanding change.

Those foreigners' results you talk about are a decidedly mixed bag. Europe's cancer survival stats are a good notch worse than ours, and George's snopes link paints Canada as a culture of queues.

GeorgeSorwell

Well, Polimom, maybe you could tell us what the right vehicle is?

Polimom

George, I don't personally think that routine visits / preventative care (vaccinations, annuals, screenings, strep antibiotics, etc) need a specific vehicle.

But my point here is that if a health care reform bill is going to encompass cradle-to-crave comprehensive health care, then it in no way resembles, and should not be confused with, insurance.

GeorgeSorwell

Polimom--

I originally thought you were going to say something like, people should just pay for the routine stuff out of their own pockets. But then you agreed with GreenDreams about how that would discourage routine check-ups. As you said:
We (people) need a way to ensure (NOT to be confused with insure) that we can affordably access preventative / normal / routine medical care.

I sure agree with that.

GeorgeSorwell

Dr_J--

I have to agree with GreenDreams--I doubt that it's practical for sick people to negotiate with hospitals. And what to do about the Emergency Room, where you seemed to concede there's no negotiation possible.

I don't know anything about European cancer survival rates--the link you provided is for subscribers only--but I'm willing to believe you. I imagine that better early-detection cancer screenings would help the Europeans.

I would, however, note that life expectancy in general is longer in France, Iceland, Italy, Spain, Norway, Greece, Austria, the Netherlands, Luxembourg, Germany, Belgium, The United Kingdom and Finland than it is in the USA. Japan, Singapore, Hong Kong and South Korea are also better.

And Canadian life expectancy is almost two years longer than ours.

Dr J

George, sick people negotiating with hospitals is a bogeyman argument. You could as well argue that the starving wouldn't be able to negotiate effectively with grocery stores, so the government should run them all. But there's no need; the millions of consumers who price shop every day keep the system transparent and efficient, without anyone explicitly having to haggle.

These statistical comparisons are a dismal exercise. There are plenty of data points to go around either way, and a million ways to misinterpret them all. Infant death survival rates differ because countries tally them differently. The classic chart showing we spend more than Europe is itself a bit of a fraud. Canadians are probably required to live two years longer so they can wait in the queues.

But it's all ultimately about arguing who's not quite as awful as the other guy. The fact is early-detection would help European cancer stats only because we still haven't flippin' cured it. Let's quit aiming so low and start demanding a lot more from an industry we're spending 17% of our GDP on.

alphonsegaston

I want to note that many of you posters here have a vastly optimistic view of the ability of the general public to handle the complexities of our modern medical systems. While most of you seem to me to be quite capable of it, we aren't talking just about individuals such as yourselves. Get real.

GeorgeSorwell

Bogeyman, Dr_J?

And your counterargument is that starving people have access to grocery stores?

Have you ever heard of WIC, Dr_J? Do you think government programs like WIC have had anything to do with reducing hunger her in the USA? Anything at all?

How long do you think it will take to fix the problem of lack of price transparency? What do you think we should do in the meantime about the 46 million people who currently don't have health insurance? Maybe we should just let that number keep growing until we can get things just right?

What do you think we should do about the comparatively low cancer survival rates in Europe, if not improve early detection? Do you think we ought to tell the Europeans who get cancer to just keep dying younger until we've flippin' cured it?

And when you say, "statistical comparisons are a dismal exercise"--you remember that you're the one who brought up European cancer survival rates, right?

And your comment, "Canadians are probably required to live two years longer so they can wait in the queues."--?

Seriously, Dr_J?

That's what you've got?

Dr J

George, calm down. You'll remember I came out in support of government subsidies to make sure everyone could afford health care. And I'm certainly not against earlier cancer detection, since that's all we've got, but no matter when you catch it, cancer treatments are still awful. So let's not be satisfied with earlier detection.

I'm concerned you're setting the bar too low, aiming for a system that will better deliver the same half-loaves we're getting today. I think that's a mistake, we should think more about what full loaves would look like. Health care doesn't have to be outrageously expensive. We could be making much faster progress against cancer and a million other problems we don't treat well. Look at wheelchairs and prosthetic limbs: people have been living with the same centuries-old designs, until someone like Dean Kamen comes along and suddenly reinvents them. And he's just one guy; imagine what we might get if the system encouraged millions of people to innovate.

GeorgeSorwell

Dr_J--

I'm not sure where you got the idea that I'm opposed to innovation.

Dr J

Because you're not calling for a system that will deliver it. You're saying "let's do what those guys are doing," rather than "let's get a system that does a lot better than anything out there." Canadians may live to 80, but what will get us to 100? How do we deliver health care cheaply enough so it doesn't consume 20% of GDP and 90% of the population isn't desperate for someone else to pay their bills? What's going to deliver the cure for cancer?

And if your imagination is having trouble stretching that far, here's a limbering-up exercise: how are we going to settle once and for all what a healthy diet looks like? Lord knows the current system hasn't even answered this one, despite spending trillions treating obesity, diabetes, heart disease, et cetera.

GreenDreams

Good discussion. Some more comments:
PM: Unbundling these two very different concepts would not only reform the way we're currently approaching the question, it would enable much more realistic definitions and funding.
Maybe so, but I think the single-payer system is better. If people need care, whether cancer treatment or just a checkup, they can just go and get it, without worrying if they can afford it this month. Both the costs and the outcomes are better than we've been able to achieve. In fact our health statistics have more in common with a Third World country than with the first world countries who pay far less than us. It seems to me that in this discussion we are prioritizing lower cost above better health, and I think that's a mistake. Any solution we come up with, I believe has to improve both, and for right now the benchmark has to be those countries that currently pay less for better health care.
DrJ: If you put the checkbook in the patients' hands--not just a few, but all of them--the dynamics will change dramatically.
This seems to be at odds with the warnings voiced here that doctors will flee the scene if reimbursement levels fall to that currently paid by Medicare (a 19% savings). It cannot be both ways; it cannot be legitimately argued that doctors and hospitals are not paid enough under Medicare, and that they would accept less from their patients directly.
PM: I don't personally think that routine visits / preventative care (vaccinations, annuals, screenings, strep antibiotics, etc) need a specific vehicle.
The alternative to a specific vehicle is what Dr. J. seems to suggest, that patients themselves be responsible for all care except catastrophic care. As I said, this would probably result in less preventive and routine care, poorer physician income, and worse health care outcomes.
DrJ: Sick people negotiating with hospitals is a bogeyman argument... The classic chart showing we spend more than Europe is itself a bit of a fraud. Canadians are probably required to live two years longer so they can wait in the queues.
I assume you're joking here. Full analysis of single-payer systems suggests that, for example, waiting for treatment could be eliminated in the UK by their government paying 60% of what we do, instead of 50%. In other words, if they paid a little more, but still far less than us, this criticism would evaporate. I hasten to add that we have waiting lines too, as well as outright denial of treatment.
Dr J: These statistical comparisons are a dismal exercise. There are plenty of data points to go around either way, and a million ways to misinterpret them all. Infant death survival rates differ because countries tally them differently.
I think it's a disingenuous argument to say that the best health-care statistics we have are "dismal". These studies are done by the best healthcare institutions we have, and if the companies with a stake in this, the insurance industry and the AMA for example, believe the research is faulty, they could certainly fund studies of their own. I suspect they have, but the absence of studies by our best institutions disproving the UN numbers indicates to me that we cannot get better numbers by doing the research at better institutions. In particular, life expectancy and infant mortality figures are based on extremely finite endpoints, namely death. I can't believe that deaths are under-reported in Japan, France or Germany. These countries are certainly as capable of accurately reporting that endpoint as we are.

GeorgeSorwell

Dr_J--

I really hate it when someone out here quotes me as saying something that I never said. Mainly I hate it because the words they put into my mouth are usually a pretty crummy argument.

So, when you quote me as saying, "let's do what those guys are doing, " rather than "let's get a system that does a lot better than anything out there," I think you're being unfair to me. Also, since this is a public thread and everyone can see you putting a crummy argument into my mouth, I don't think you're really doing yourself any favors, either.

I do think the current Canadian system is better than the current American system. I can't tell if you disagree with me about that.

Still, for the record, I am in favor of innovation.

For the record, I am in favor of delivering health care cheaply enough that it doesn't consume 20% of GDP. (I think, though, that you're exaggerating when say 90% of the population is desperate to have the other 10% pay for their health care.)

Since you've raised that, maybe you can tell me how we get there.

Maybe you can tell me how long it will take to get there.

Maybe you can also tell me what we should do in the meantime about the 46 million Americans who currently don't have health insurance.

Dr J

George, sorry if I'm misrepresenting what you said. What shall I take "it seems to me that 'half as disastrous' is a good place to start" to mean?

How do we get a system that's long on innovation and value for money? Through decentralizing control and setting up rules where people can make a few bucks by improving their corner of the industry, along the lines I described before. Courage, GreenDreams, but the P-word is our best friend as long as people are making profits for the right things. The best way to encourage millions of brains to improve the system is through their wallets.

What the private sector will not deliver is progressive subsidies, so this is the right role for the government. But it should do it as cleanly as possible, not by micromanaging prices and procedures and policies the way it does today. The solution to the 46 million people who can't afford insurance: write them a check.

GreenDreams

write them a check

Disagree. The current system is too expensive for poor outcomes. A government subsidy to pay more into a broken system doesn't seem like a good place to start. I'm with GS. If there's a system that's only HALF as expensive as ours with better outcomes, that is indeed a good place to start. Anyone who can come up with a system less than half as expensive and/or with better outcomes, great. But profit motive has not always been our friend.

My starting position in this debate is that insurance companies will never care as much about our health as their profit. That does not match our national goal of better health care for all at the best cost. The starting point has to be how do we improve health care and lower cost. Profit does not equal innovation (European drug makers, with government negotiated prices, have overtaken ours in both size and innovation, for instance. Many of our best medical procedures were developed by doctors, hospitals and researchers elsewhere at costs far less than here). Despite my rep here as a liberal, shoveling government money into the same broken system, versus shoveling employer money into it, is not a solution. It's rearranging deck chairs on the Titanic.

GeorgeSorwell

What shall I take "it seems to me that 'half as disastrous' is a good place to start" to mean?

It means I think the current Canadian system is better than the current American system. And it means that I think moving to that kind of system would be an improvement over what we now have.

It doesn't mean I'm opposed to innovation. You had to make up a quote for that one, right?

Also, how long will it take?

Dr J

Giving more power to the government would indeed improve some aspects of the current system. I'm sure we'd get more complete minimum coverage than we have. But it would come at the expense of innovation and accountability, because the government does badly with both. Taking a step toward the Canadian model would set us back in the long run.

How long will it take to reform the system? It depends how you do it. You could attempt reform by freeing the private sector from the perverse regulatory incentives the government heaps on it today and letting the market work its reliable magic. Or you could expand demonstrably incompetent programs like Medicare. The first way will be a lot faster.

GeorgeSorwell

Dr_J--

You keep talking about innovation. Do you have any way of measuring innovation or it's absence? Some actual metric or methodology? Some source? Or is that just your opinion?

For example, Medicare was passed in 1965. It seems to me that there's been a fair amount of innovation in health care since then. Maybe--probably?--you would say that without Medicare there would have been more innovation. But do you have any evidence of that? What is the source of your evidence?

And would you say other government agencies, like the Centers for Disease Control, or the National Institutes for Health, have also stymied innovation?

You've also referred to Medicare as "demonstrably incompetent". Can you demonstrate its incompetence? Again, I'm looking for some sources. Something beside your own opinion.

seahunt

I work daily with Canadians. I have heard some horror stories. A client's dad had heart trouble and was on a waiting list for a very long time (6 weeks or so) to get scheduled for surgury. The family was very worried during this waiting period. There is a shortage of Doctors and no sense of urgency. That is just one story....i've heard several and they all involve long waits. They also involve that attitutude that I have experienced at say...the post office. The attitude that the patients/cusomers needs are bothersome. I'm sorry, but that attitude tends to be much more common among government workers...which is what the Canadian system is made up of.

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