Fixing Health Care: Keep the Debate in the Gutter
The debate over the nation’s health care system is big and getting bigger. While the debate over a large-scale overhaul is being carried on in the context of the presidential election, we also have ongoing debates over extending the State Children’s Health Insurance Program (SCHIP) and reforming the Medicare drug benefit.
Polls consistently show that expanding coverage for children, and reforming the Medicare drug benefit to allow Medicare to negotiate directly with the pharmaceutical companies for lower prices, are both highly popular policies. These steps would be important in their own right, but they also would help lay the basis for more large-scale reform.
While the Republicans may seem to be on the defensive -- resisting the popular will -- the New York Times inadvertently told readers exactly how they plan to defeat these measures: appeal to ideology.
The issue immediately at hand is whether the government should double the size of the SCHIP program, which would enable it to covering nearly all uninsured children. This would be financed by eliminating the subsidies to private insurers operating within the Medicare program.
According to the Medicare Payments Advisory Commission, Medicare pays an average of 12 percent more per beneficiary for people enrolled in private insurance plans, than it does for people in the traditional Medicare program administered by the government. If Medicare eliminated the subsidy paid to the private insurers, and paid the same amount per beneficiary, regardless of whether a person was enrolled in a private plan or the traditional Medicare program, it would save the government approximately $50 billion over the next five years. This would be enough to pay for the expansion of SCHIP.
But the Republicans don’t want to have debate over the relative merits of extending health care insurance to kids or subsidizing private insurers. Instead, they want to debate ideology over the proper role of the government in the health care system.
That is exactly what Allan B. Hubbard, assistant to the president for economic policy, told the New York Times. Apparently based on this assertion, the NYT was kind enough to the Bush administration to then assure its readers that this debate over cutting insurance company subsidies to cover children is in fact an “ideological battle.”
Excuse me, if I am missing the role of ideology here. I don’t know of any ideology that says that it is the role of the government to subsidize insurance companies that are unable to compete on a level playing field. It surely is not conservative ideology. Conservatives want to leave things to the market. If companies can’t compete then they should go out of business. In this case, if beneficiaries vote with their feet and opt for the traditional Medicare plan, why would any honest conservative want the government to subsidize the insurance companies that lose out.
In the same vein, reforming the Medicare drug benefit is a question of whether the government will give the pharmaceutical industry unfettered patent monopolies, or whether it will put restrictions on the prices that it will pay through Medicare. Again, I don’t know of any ideology that says that drug companies are entitled to get a complete monopoly from the government and charge whatever price they want for lifesaving drugs. (There are better ways to finance research, but that’s another question.)
In short, this is a battle between the popular will and powerful special interests, the insurance and pharmaceutical industries, both of whom make large campaign contributions to the Republicans and some Democrats. This is a debate about money versus access to health care. Those who dress it up as a battle about ideology are doing the bidding of the insurance and the pharmaceutical industries.
Comments (92)
The problem with health insurance in America isn't that there are so many without it....its that there are still too many with it.
July 9, 2007 12:09 PM | Reply | Permalink
You're missing several important facts here. Privatization in Medicare was NOT the work of Republicans, and you're discussing this as though the government is just randomly subsidizing private insurers. HMO-style Medicare plans are known as Medicare Plus Choice; this is a part of Medicare (Part C), and it came to us in the Clinton era. Also, you're confusing the costs of Part C plans to Medicare with their costs to members. While these plans are quite costly because of risk-pooling problems, the members aren't necessarily "voting with their feet", because the out-of-pocket costs are often lower in Part C than in traditional Medicare (which can be staggeringly expensive to those on fixed incomes).
In short, I appreciate your enthusiasm for the subject, but understanding health politics requires a lot more homework than you seem to have done here.
July 9, 2007 12:24 PM | Reply | Permalink
Tom Coburn is, I think, my least favorite Senator. Right down there with James Inhofe. That Hillary Care crack if nothing else demeans the man and the office he holds. DeMint keeps a lower profile, but he's no gem, either.
This is part and parcel of the campaign which one sees gearing up on Fox and elsewhere, equating a National Health System with Terrorism. (Caution, wait at least an hour after eating before following the preceding link). We'll be lucky if we can keep this campaign in the gutter: these kinds of Republicans are dragging it toward the sewer with all the muscle they can muster. Harry and Louise, where are you?
aMike
July 9, 2007 12:48 PM | Reply | Permalink
"Health politics" is a term I hope to see become as obsolete as "Ox carts" in this country. Health and politics should never be mixed in any proportions.
Understanding the whole health care issue has to be simplified so anyone can get the basics with a 5 minute reading. And, the principle "basic" is that insurance companies provide nothing to improve health care. They are superfluous to the health care issue. Once that "basic" is understood, improving our health care system becomes simple enough that even Republicans can figure it out.
Hoppy in Sacramento
July 9, 2007 12:54 PM | Reply | Permalink
Why shouldn't we relish a debate of the role of government in health care -- or anything else. For far too long the so-called conservatives have disparaged government and glorified the free market. It is a false choice. There is room for and a place for both in health care and many other economic spheres.
I do wish Democrats would begin challenging the conservative/libertarian argument against government. It is not only falllacious, it is insulting since supposedly we, the people, are the government.
July 9, 2007 1:30 PM | Reply | Permalink
I think Emma's right: I'd much rather frame the debate about the future of health care than of taking care of our children, just as those who favor slowly expanding medicare to the broader public don't want it to be about looking after the elderly. (BTW, I personally don't know enough about Medicare, with its various A/B, A-L medigap, and basic/hmo/php varieties to tell you if that's the best approach.)
John
http://www.haberarts.com/
July 9, 2007 1:44 PM | Reply | Permalink
On CNBC, which I assume is not unique, anytime healthcare is a topic the words' "socialist medicine" or "socialized medicine" are used to end any debate. The there needs to be more than just Paul Krugman discussing the state of healthcare in England, Canada, France and Germany. It must be laid out including flaws. There also has to be more of what Moore does in "Sicko" telling the the story of those who are insured and the cost to everyone of having large numbers of people uninsured. Lastly, there needs to be less ideological pumping for a singlepayer system and more pressing of the benefits to both corporations and individuals of trading higher taxes for complete medical coverage for no longer paying healthcare insurance premiums.
It would be very helpful to have debates over what will happen to doctors salaries and what happens if doctors chose to leave rural and other less populated areas. What will be covered under a universal system. Who will decide when new technology will be covered. What will will happen to the production of new drugs? Moore talks about "free healthcare." It is free nowhere. The questions how universally is it paid for and who decides what is paid for. Perhaps TPMCafe can start a tab devoted to serious discussions on the subject. I would love to hear not just Krugman but Uwe Reinhart from Princeton and others on the various topics. If the debate can be made continual, understandable and honest then a universal system, built on a Medicare like system seems possible.
Daniel A. Greenbaum
July 9, 2007 1:50 PM | Reply | Permalink
I prefer to keep debates on solid ground. When it gets abstract, people get lost and are open to Harry and Louise idiocy. The debate over cutting insurance subsides to cover kids is a debate over whether tax dollars should be used to subsidize private insurers or cover kids.
People are welcome to wrap this in any idelogical clothing they want, but the actual issue is tax dollars to kids versus tax dollars to insurance companies. The Republicans (and many Democrats) know they get killed on that one, which is why they want an abstract debate over the government's role in health care, which will have absolutely nothing to do with the immediate issue at hand.
July 9, 2007 2:02 PM | Reply | Permalink
The "free market" in health care really operates in terms of the providers. Providers are, in effect, competing with each other for patients.
How the providers get paid should not have to involve another level of "free market."
Imagine if, instead of going to a bank, you had to go though a "middle man" - an organization that funneled you into this or that bank or financial product. That's what we have in health care right now! It's nonsense to restrict health services due to the whims of middlemen called "insurance companies."
We don't have to go to a middleman when the garbage needs collecting. Or when the snow needs plowing. Or to get our water from the tap. So why should we have to do that for health care?
We don't talk about socialized garbage collection. Or socialized water or snow removal. What is so sacred about health care that it has to be part of a "secret priesthood" of insurance companies?
July 9, 2007 2:24 PM | Reply | Permalink
If there is going to be an ideological debate, we need to be prepared to wage it, and it is time to push the burden to the other side. For the duration of the conservative movement, the Right has been able to maintain that markets are more efficient that government and that given greater freedom, market forces will distribute both tangible and intangible goods more effectively than government.
As we can see quite clearly with health care and education, markets do not produce the efficiencies and equitable distributions promised by right wing ideologues. This discussion ties in with the other discussion here on TPMCafe about educational vouchers. Markets are not better strategies in several areas, because the measure of success in those areas are, through some mechanism, insulated from market pressures.
We now need someone to do some serious theoretical and empirical work to determine what kinds of activities respond to market forces and what kind of activities do not respond to market forces. If we can do that, then we will be prepared to have the ideological debate.
The debate will then not be about the role of government, but rather about the role of markets. We can easily win the ideological debate in that way by putting everything in its proper place.
July 9, 2007 2:24 PM | Reply | Permalink
The Reaganites used to say "Get government out of the way." Perhaps health care reformers might start saying; "Get insurance companies out of the way.
July 9, 2007 2:30 PM | Reply | Permalink
wrong location
July 9, 2007 2:31 PM | Reply | Permalink
Duncan C. Kinder
http://www.billingsgatereport.net
So-called liberals have "laying the basis" for more large-scale reforms for the past 15 years now. The result: zilch, nadda, zippo, nothing.
At the rate you are going, I will be eligible for Medicare anyway by the time you get anything done.
Unless healthcare reform is for everyone NOW, it is bogus.
July 9, 2007 2:32 PM | Reply | Permalink
You forget the liberals haven't had power in 25 years? Hillary, a non liberal tried it and the Republicans handed her her head.
The Republicans and the DLC have been the power for lo too many years.
July 9, 2007 2:37 PM | Reply | Permalink
Call me naive, but why isn't possible to look around the world at various single-payer plans and adopt one? Must we really invent our own 'wheel?' Do we really need to keep trying to make a square one, a rectangular one, an elliptical one work when a round one does the job.
People who've studied the plans out there agree that the French one is probably the best one. Hell, we love what they do with the potato; maybe we'll end up loving what they've done to insure good, affordable health care for their people.
July 9, 2007 2:39 PM | Reply | Permalink
The 600 pound gorilla in the room is the tax cost for universal health care, whether by the French model, the English model or the Canadian model. We need to acknowledge up front that taxes have to go up to pay for any enlarged or new government program. That lets us demonstrate the actual cost savings to an average person of a universal health care system, using realistic dollar amounts. Would Joe Sixpak still object to paying more in taxes if every higher tax dollar were offset by $1.25 in reduced insurance cost? I don't know the answer to that question, but without that answer we can get no further.
Hoppy in Sacramento
July 9, 2007 2:57 PM | Reply | Permalink
You bring up an important point, cost, and the question,; "what is the difference between taxes and insurance premiums?" The answer is 'spelling', they're spelled differently. Republicans and their cohort constantly refer to the "taxes" that will have to be paid for single payer, universal healthcare, never mentioning there will be no insurance premiums to 'for profit' insurance companies. Just the savings in bureaucracy costs of the thousand or so insurance companies will be enormous.
By the way, the only "profit" anyone wants to do away with is the profit of the middle man, the insurance companies; not doctors, pharmacies, nurses, hospitals, or pharma.
And...it won't be socialized medicine as the government won't own any part of the medical delivery system.
If paying attention to politics for the last 30 years has taught me anything its that if you want to sell something to the public, hire Frank Luntz so he can come up with some simple minded, black vs white, easy to under stand catch phrase, like "Death tax", "Socialized medicine", "Get the government out of my medicine cabinet", and my favorite, "We have to fight them over there so we don't have to fight them over here" etc.
Something that doesn't require much thinking.
July 9, 2007 3:30 PM | Reply | Permalink
Uwe Reinhart is a champion of single payer. If I manage to get my family's dinner on the table (meaning, if I can tear away from TPM!) I'll do some searching for some of Reinhart's articles to post links.
I do not think we need to waste any time engaging in debates when the research is done, the answer is known, the time-tested single payer mechanism is proven and proven and proven. Debates just keep the $$$ diversions heading away from provision of service and toward enrichment of those irrelevant to those services.
July 9, 2007 3:55 PM | Reply | Permalink
I loved this one. It also got me thinking (I do that occasionally). The insurance premium paid by my university to provide health care for me is right there on my pay stub, and I never pay any attention to it. I know it is mucho bucks. Alas my pay stubs are in my office, so I can't blab. If this post is still alive (and if I remember) I'll come back and post it. If my taxes go up and my salary goes up because my employer no longer insures me, It will be a wash. My suspicion is that if the total my employer pays were distributed to me I'd actually be ahead even with the higher taxes.
aMike
July 9, 2007 4:18 PM | Reply | Permalink
Maybe a bunch of MBA's sit around talking about markets but I don't think that's how most Americans react to policy at the gut level and that's the level you have to at least start with to get their attention.
I think the problem is really the Democrat Party's "centrists" who will do nothing about this issue unless backed against the wall. For example, our state just elected another member of the coward caucus who responded to questions about universal health care during the campaign by dismissing it as "unrealistic". There is NOTHING we can do to achieve universal coverage as long as Democrats in blue states are appeasing the Republican ideology.
You know what the centrists want us to fight for? Hot off the presses from our new centrist Dem: SAFE TOYS.
Unless we can begin fielding a party of grown ups, we're lost.
July 9, 2007 4:18 PM | Reply | Permalink
As I understand it, the French system resembles a model of our Social Security System. The point is generally, unless health insurance is provided by an employer, people ages 18 to about 35 don't pay into any private insurance plan because, rightly so, they figure they're not going to get seriously sick. And they're right.
The result is a relatively small pool of money paid into by older people who do get sick. The upshot is to increase the size of the pool by requiring every adult to contribute.
(If Social Security is a tax, then this would be a tax.)
July 9, 2007 4:23 PM | Reply | Permalink
One word to all of you clamoring for the government to take over our health care system, please remember that this is the U.S. government we're talking about. Given the staggering incompetence I've witnessed over the past 6.5 years and what I know about the corruption in our budgeting process, I wouldn't trust this government to change the oil in my car, let alone take over health care. I'm just saying . . .
July 9, 2007 4:33 PM | Reply | Permalink
An interesting return on the universal healthcare being terrorism approach is that if there is ever covert bioterrorism, the likeliest early warning will be patterns coming from electronic health records. Without universal care (and the associated medical informatics), those records won't exist.
--
Howard
*equal opportunity offense to both extremes*
"Those who cannot remember the past are condemned to repeat it" [George Santayana]
July 9, 2007 4:36 PM | Reply | Permalink
"Health and politics should never be mixed in any proportions."
So, you want a fully privatized system, then? :)
July 9, 2007 4:39 PM | Reply | Permalink
Howard srtikes again with another excellent thought.
July 9, 2007 4:43 PM | Reply | Permalink
One more thing, aMike -- in at least some businesses there will be upward pressure on wages in excess of the tax increases. That's because employers will no longer have a tax advantaged way of offering payment as health benefits. People would suddenly be free to seek higher paying jobs because they would no longer feel a need to keep the benefits their employer has offered them.
Health care is a pretty coercive employee retention tool. I'd like to see us get back towards competing on wages, bonuses, profit sharing and equity.
thosethingswesay.blogspot.com
July 9, 2007 4:50 PM | Reply | Permalink
Either very subtle irony or missing the forest for the trees. Surely I would not automatically trust the current government, but item #1 on regaining the White House would be to return the agencies to the professionals that we doing fine in the Clinton years (e.g. FEMA under James Lee Witt).
This bunch has sought loyalty over expertise, with predicted results.
July 9, 2007 4:53 PM | Reply | Permalink
The government won't take over the health care system. The providers and hospitals will continue to do health care. What the government can do is gather all of us together into one huge group - a huge "insurance group" if you want to think of it that way. But actually a huge social group, like we already have with social security. Indeed our social security could simply include health security as part of it.
People try to obfuscate the issues and substitute one thing for another. Providers deliver health care. And still will. Currently the tab is picked up by the government for all government employees, including the military, and also the VA, the elderly, children, and disabled. In addition the government pays for the Centers for Disease Control, public health, and a great deal of medical research.
It would actually take very little to insure everybody else and fold it all into one big pot. The bigger the pot, the more the risk is spread around. So all the government really would do is cover risk and due to a huge pool of people, that makes coverage much less risky for all of us.
National health insurance is a no-brainer! Unless you want to profit from it. But insurances never profit from insuring everyone. They pick and choose, so they insure the people who are not sick. By definition if you're working you are "not sick."
Greed is the only thing that stands in the way of a national health insurance. And that is shameful!!
July 9, 2007 4:54 PM | Reply | Permalink
Like most things, we recognize institutions where they fail: where they succeed they are largely invisible. I think this is as true of governmental institutions as it is of others.
My mom's social security check comes regularly every month (I found out the most popular baby names for 2006 when searching for that web link. My name came in second for male babies...how about that?), the national parks, historical and scenic, open and close on schedule and the park service rangers (historical and scenic) know what they're doing and do it well, mostly. The Library of Congress is second to none in the world. I think it nuts that the Federal Aviation Administration has instituted a gender-appropriate dress code for Air Controllers, but I don't worry too much about a mid-air collision when I fly. The Tennessee Valley Authority seems to get electricity out to its customers. The Bureau of the Census counts us, more or less, and tells us lots of interesting things about ourselves. My mail mainly winds up in my mailbox, and cheaper than similar mail winds up in the mailboxes of my counterparts in Britain.
So maybe I'd be better off to deal with the Government when it comes to health (I already do, when it comes to tracking epidemics and protecting me from bird flu), than deal with the agencies described in Sicko (Can you believe it...Fox News Loved it).
aMike
July 9, 2007 5:03 PM | Reply | Permalink
. . . whether tax dollars should be used to subsidize private insurers or cover kids.
Or are the tax dollars subsidizing not the private insurers but rather medicare beneficiaries?
Currently, most private insurers offer Medicare Advantage Plans (HMOs) with small copays at no charge to the insureds. Compare that with the much higher costs of Medigap policies to accompany unsubsidized, traditional Medicare.
So who's being subsidized?
July 9, 2007 5:05 PM | Reply | Permalink
NPE, look back before the past 6.5 years, when (eg) FEMA was a universally praised model of effectiveness and not a crony farm. But your reaction is exactly why, while I love Dean Baker's "tax dollars for kids or insurance companies?" for the SCHIPS fight, overall we can't run from the ideology argument. That means not only pointing out the hypocrisy of the "free market" types, who are actually corporatists, but embracing our "good government" history, from Social Security to Medicare (both long decried as "socialism") to FEMA, Clinton's versus Bush's (and that's BOTH Bushes' FEMAs, btw). It's pretty simple, really: if you want government to work, don't put it in the hands of people who hate government.
July 9, 2007 5:20 PM | Reply | Permalink
I'm sorry, but I must have missed where the government was going to take control of any part of healthcare delivery. Could you provide a link?
--
Howard
*equal opportunity offense to both extremes*
"Those who cannot remember the past are condemned to repeat it" [George Santayana]
July 9, 2007 5:27 PM | Reply | Permalink
Unless we can begin fielding a party of grown ups, we're lost.
Well said.
July 9, 2007 5:30 PM | Reply | Permalink
Actually, I would trust this government to change the oil in my car.
This government is particularly good with oil.
Hey... why'd I just get a $345,000 bill from Halliburton? You guys said it'd be $19!
thosethingswesay.blogspot.com
July 9, 2007 5:34 PM | Reply | Permalink
I believe that is mistaken as those who say singlepayer is socialist medicine end of debate. I believe Germany does not have a full singlepayer system. Further, the United States is much larger than either England and France and has a larger population than Canada. This is likely to have an impact on any system.
Also as with the tax code there might be plans that would be great if you were starting a new country. However, we aren't. There are doctors who chose specialties and live in certain regions because of the current system. What impact on doctors will a shift have. Would the single payer get to determine what specialties doctors can choose or where they can live?
Will the you allow people to have additonal coverage beyond the single payer? Who will get to determine what is covered.
Lastly to answer Michael Moore's question what sort of country are we? We are neither a Catholic nor an Anglican country. We are a Calvinist country. Thus we are more individualistic, anti-goverment, the one that revovlted against the king forever, than the examples used in "Sicko." Combine that with that most people have insurance coverage through their employer, I don't, and thus have little reason to be all that unhappy with the system. Ending the debate means the current system will continue.
Daniel A. Greenbaum
July 9, 2007 5:54 PM | Reply | Permalink
NPE, under a single payer system, the government takes over only the FINANCING of healthcare, not the provision of services. We have seen for far more than 6.5 years that the administrative costs of private financing is around 16% of the total cost VS 3% for Medicare, the government FINANCED system....
July 9, 2007 6:00 PM | Reply | Permalink
CNN BULLETIN: George W. Bush leaves Presidency, becomes thoracic surgeon. First patient to be the reknowned h c berkowitz.
July 9, 2007 6:06 PM | Reply | Permalink
NASA (hubba hubba Hubble)
Those handy weather satellites and their GPS friends
Agricultural extension service, USDA, FDA
CIA World Factbook
US Geological Survey
At-my-fingertips climate data from NOAA
Don't forget that subset of Library of Congress, the Patents and Copyrights offices.
July 9, 2007 6:20 PM | Reply | Permalink
"Solid ground." Dean, I know what you're saying, but it's not that I'm arguing for moving from concrete (whom to cover, who's ill, who's screwed) to abstract (the role of government in an ideal society). It's about whether we're talking about health care or taking care of children. There's a lot of momentum for the former. You phrase it in terms of the latter to get a feel-good issue, and you squander your momentum and accomplish nothing. You even divide up the electorate.
The GOP has always made it about charity for the needy (which surely the private sector can handle) versus handouts for the undeserving. The point ever since the victory of social security was to unite society: we're all on the same page, middle class and poor. That includes a lot of people worrying about their future. You blow that and you try to build on "care for children." How do you do it? You don't. You just made a horrible mistake, and we're all stuck with it. Otherwise, we'd have got from care for the elderly to universal health care decades ago.
It's this knee-jerk DLC thing that we can't change anything, so let's forget the whole thing. Iraq? Golly, that'd mean debating foreign policy and security, and that's way too ambitious. Tell you what, we'll insist on bringing home the one-eyed lame vets sent back into combat, because people will understand that issue. It's so real. (But you're not.)
John
http://www.haberarts.com/
July 9, 2007 6:35 PM | Reply | Permalink
Germany and Japan, as two industrialized countries, do have multipayer structures. Their insurers are heavily regulated, much more so than in the US. Japan does have a backup national healthcare benefit.
Germany's system is quite complex, but it is essentially mandatory to have coverage in a "sickness fund". Under 1 percent of Germans do not contribute to sickness funds, and, of those, the poor are covered by a government program.
There's no simple answer to this question, which, realistically, is going to have a time-phased answer. I say it is time-phased, because one of the major determinants of specialty is the quite different income potential of different specialties, coupled with how much debt new physicians carry from medical school and graduate medical education.
Another determinant is that primary care, in the US, does not get as much academic status as specialties. This is truly complex, as both economic (i.e., profitability to hospitals and medical schools of certain specialties), and noneconomic factors are involved.
In the US, the individual specialty boards decide, without any particular coordination, how many graduate medical education slots will exist, which determine the number of each kind of specialist. In Canada, the specialty slots are decided in a national exercise, with at least half going to primary care.
If medical students have a choice of getting public funding of their education, versus incurring debt for what is apt to be 7 to 13 years of post-baccalaureate training, I suspect that students will make decisions more on what they actually want to do, and/or where they feel some motivation. In particular, primary care physicians -- who still usually have specialty certification (family practice, general internal medicine, pediatrics, some OB/GYN) -- feel incredibly pressured. This also applies to people, usually internists, who have subspecialty training but, due to economics, have to do a fair bit of primary care and then the subspecialty work in a group practice.
I've seen doctors deal with this in different ways. One endocrinologist I know decided to do pure endocrinology, spending the amount of time that he felt he should spend with patients -- not what the business manager thought. He's in solo practice, making less money, and is a lot happier.
One of the major objections, by physicians, to the Clinton plan was the general prohibition of care outside the plan. This isn't just a money issue, but a fairly widespread belief that nonstandard coverage gives some reasonable experimentation with alternatives.
Free-standing surgical centers largely are a product of cosmetic surgery, which almost never was covered. There was good news and bad news in this; it was shown that certain procedures could be done more cheaply, and often with more patient satisfaction, than in a general hospital. It was also learned that some procedures, such as liposuction, can be considerably more dangerous than first thought, and should be done in hospitals when there was any question of risk.
--
Howard
*equal opportunity offense to both extremes*
"Those who cannot remember the past are condemned to repeat it" [George Santayana]
July 9, 2007 6:35 PM | Reply | Permalink
I rather respect surgeons that, before a procedure, write "cut here", with a conscious patient and an indelible pen, and sign the line. It's not common, but operations do get done on the wrong limb.
In the case you suggest, however, I would be concerned that he would give a signing statement that while the patient was coming in for coronary arterial bypass grafting, GWB intended to do a hemorrhoidectomy. Of course, in his case, one could probably do the latter procedure at either end of the alimentary tract.
Cheney, on the other hand, may be a unique example of installing a pacemaker/defibrillator in a patient with no heart.
--
Howard
*equal opportunity offense to both extremes*
"Those who cannot remember the past are condemned to repeat it" [George Santayana]
July 9, 2007 6:41 PM | Reply | Permalink
It shouldn't matter what your politics are - this is the modern world, and in this world health care is a right that all of us should have. Politics isn't part of that. It is morals, judgement, compassion, economics, etc. that should be behind the discussions about how best to do health care in this country. The details of health care are something health care professionals, doctors and nurses, should be most heavily involved with, not politicians. I trust no politician to have the background or the point of view to make the decisions about the best form for delivering health care to Americans. No, that doesn't mean I want a privatized system.
Hoppy in Sacramento
July 9, 2007 6:43 PM | Reply | Permalink
Re: Call me naive, but why isn't possible to look around the world at various single-payer plans and adopt one?
Because very few nations have pure single payor plans. Most have a mixed system, but with private insurance quite subordinate to the public system and regulated in the manner of a public utility.
Re: The 600 pound gorilla in the room is the tax cost for universal health care, whether by the French model, the English model or the Canadian model.
Right. And that six hundred lb gorilla has a mate in the other corner: she's the amount of money we save when we (and our employers) no longer have to pay sky-high premiums to insure us. To the extent that employer-provided health insurance goes away we do need to make it a law that employers must pay the difference by increasing wages proportionally.
Re: People would suddenly be free to seek higher paying jobs because they would no longer feel a need to keep the benefits their employer has offered them.
People are free to do that now since most higher-paying jobs will have similar if not better benefits. However people will also be freed to seek self-employment which does not come with benefits and hence is really only available to the young and healthy, or to those with well-insured spouses.
Re: I wouldn't trust this government to change the oil in my car, let alone take over health care.
Even the current US government manages to handle Social Security OK.
July 9, 2007 6:44 PM | Reply | Permalink
So let me get this right. We are a Calvinist country that has revolted against the king forever and so we are not in favor of universal health care provided by our government which is not a monarchy (last I heard) but a representative democracy? Is that the thought salad you really want to express or am I missing something?
July 9, 2007 6:52 PM | Reply | Permalink
If living were a thing that money could buy ...
(for those under 30 it continues, the rich would live and the poor would die.)
That is, unless you gum it up and pay insurance companies in which case we in the US -- still one of the richest countries -- have shorter life spans and worse health than people in Canada, France and Cuba.
Obviously, I have just watched Sicko. So the proper question is not just would I prefer to pay a dollar in taxes rather than $1.25 in insurance premiums but also whether I would prefer to live longer.
July 9, 2007 7:39 PM | Reply | Permalink
To be fair, I assume the longevity numbers are averaged for the whole population in question. Your particular insurance may, or may not, buy longer life than Canada's, but the average person has a shorter expected span here.
So it's best to ask if we want an overall healthier (happier) population. I do, and think it's a no-brainer.
July 9, 2007 7:59 PM | Reply | Permalink
In the cold hard world of determining cost-effectiveness of medical interventions, years of life saved per dollar (or multiple thereof) has long been replaced by 'quality-adjusted life years' (QALYs) and 'disability-adjusted life years' (DALYs). There are multiple scales, of course, to measure the quality index, but they are all improvements over the maximize-lifespan-at-all-costs approach.
--
Howard
*equal opportunity offense to both extremes*
"Those who cannot remember the past are condemned to repeat it" [George Santayana]
July 9, 2007 8:03 PM | Reply | Permalink
Well, one thing that skews our longevity statistics is an absurdly high infant mortality rate (relative to other industrialized countries) -- caused mostly by the fact that people who are uninsured or underinsured can't afford medical treatment for their newborns...
Another problem that would be solved by a public health system.
thosethingswesay.blogspot.com
July 9, 2007 9:31 PM | Reply | Permalink
This country needs an enema! We need to stop trying to milk a buck out of everything that exists under the sun.
I worked at a toy company over a decade ago. There was a man that worked for a subcontractor that sat in on brainstorming meetings and listened intently to ideas as they flew around the room (rarely contributed anything original). When a particularly good idea came up, he'd sit there for a few minutes and silently refine the one idea while we all continued to brainstorm. After several minutes he'd chime in with a modified version of the previous idea and sign his name on a piece of paper and announce "2 points" indicating the percentage he expected from the imaginary forthcoming profits. That seems to be America in a nutshell. We seem more focused on our own personal gain rather than the collective goal.
Silly? Yes. But the idea that we in this country must take everything under the sun and try to make a buck selling it to everyone else is insulting to me. There are things that should rise above this kind of selfish competition. There are plenty of opportunities for trade and business that we do not need to take things like health care and education and make them the next Woolworths, K-Mart or Target (depending on your generation). If that's what we've come to then things are indeed in dire straights.
Dammit all, why can't we show something other than make-a-buck greed in this country in every single thing we do? It's like charging your parents rent for a room when they are very old and you are taking care of them... oh wait, we now have shoddy retirement homes we can stick them in on their dime while pocketing the change... nevermind...
(yes I am very cynical when it comes to this & forgive me if I've wandered into the gutter)
July 10, 2007 12:29 AM | Reply | Permalink
If I had the capital, I'd start my own HMO that specialized in paying in cases where it makes sense only for overseas health care.
Fly the patients to India for surgery (again, in cases where it makes sense - obviously not in cases where the patient needs intensive care. Unless you can put a staffed ICU in a 747.)
Conservatives ought to like that proposal as it cuts costs. Liberals ought to like that proposal as it could make universal health care feasible.
Additionally, why can't we import doctors and nurses from India and employ them at a cut rate? In the case of healthcare which is unethical in this Country, I think we can justify outsourcing as the lesser of two evils.
July 10, 2007 1:11 AM | Reply | Permalink
Silly rabbit, we already do import physicians from India and Pakistan to staff our hospitals, not to mention nurses from The Philippines. You just don't live in the right area to see the effect. At my spouse's hospital in the Northeast, the doctor's staff is probably half south Asian in ethnicity. They've been coming to the US for thirty years.
One thing which does cut down on their spread across the country is the doctor's union, the AMA and bigotry on the part of locals. I suspect the reaction of some folks in the South to being touched by an Indian physician (likely a high caste Hindu who follows a rigorous health regime due to his religion) would rival anything seen in the Raj of a century ago.
July 10, 2007 3:28 AM | Reply | Permalink
Using GWB and hemorrhoid in the same sentence is appropriate.
As to Cheney, he is, of course, the posterior opening of the alimentary canal.
July 10, 2007 3:41 AM | Reply | Permalink
With regret, I must disagree with you about Cheney's anatomical role. The posterior opening of the alimentary canal has at least one useful function.
--
Howard
*equal opportunity offense to both extremes*
"Those who cannot remember the past are condemned to repeat it" [George Santayana]
July 10, 2007 6:59 AM | Reply | Permalink
Further, the United States is much larger than either England and France and has a larger population than Canada. This is likely to have an impact on any system.
Why?
July 10, 2007 7:11 AM | Reply | Permalink
Actually we do know that answer. We know it logically--we know for sure that insurance companies add substantially to the cost of health care and do not provide any significant positive value added. The only justification for their existence is to create a party to the process who has an interest in avoiding unnecessary care. That's not what has happened--much necessary care is not being delivered. And, of course, the reason to avoid unnecessary care is to lower costs. But costs are skyrocketing.
Moreover, as Sicko apparently points out at length, we know empirically that taxpayer funded universal health care systems are both cheaper and more effective than the US system. All of the OECD has lower per capita costs, and better measures of mortality, morbidity and coverage.
So this is not an open or difficult question. The difficult part is that the political leadership is all beholden to the insurance and pharmaceutical companies, so it is necessary for a great deal of constituent pressure be brought to bear to eliminate the current role of insurance companies in the delivery of health care, and, like the rest of the OECD make it about doctors and their patients.
July 10, 2007 7:22 AM | Reply | Permalink
Corvid
To reframe the same good point: Why should the debate be about the proper role of government in health care? Why shouldn't it instead be about why profit-driven, recidivist sociopaths (insurance companies) should have any role in health care?
July 10, 2007 7:25 AM | Reply | Permalink
I, too, had assumed that the rich stiffs could buy their health in our system. Answer is no: The worst off in the British system have better health than the wealthiest in ours. Go figure.
July 10, 2007 7:26 AM | Reply | Permalink
26.3% of American Physicians and Surgeons are Foreign Born.
aMike
July 10, 2007 7:43 AM | Reply | Permalink
As a practicing family doc who sees under insured and uninsured patients every day and who spends 20% of my office overhead and untold personal hours away from taking care of patients dealing with often absurd, complex, and extraordinarily arbitrary and powerful private commercial health insurance companies I see these problems on line in real time every day. Like the Medicare finacial subsidy of 12% to create a "market" for seniors, the commercial health industry is given all kinds of public policy "subsidies" to allow them their success. Commercial insurance companies and the costs of dealing with the artificial market they control consumes an estimated $500 BILLION off the top of health care insurance premiums (about equal to the Pentagon budget) and diverts it from taking care of sick people. Think of it(and all the intellectual obfuscation of most Democratic Presidential candidates): if there was universal entitlement to health insurance (like the Medicare program for people over 65) there would be NO reason for the marketing, "medical rating" (i.e. exclusionary) activities, benefit restrictions, and administrative follies of the commercial insurance companies. All of this overhead expense would be saved and they would start to wither away. No wonder they are fighting back so hard and raising ideology issues.
July 10, 2007 8:00 AM | Reply | Permalink
July 10, 2007 8:02 AM | Reply | Permalink
I wonder if any were the students
who were going to med school in Grenada, you know, the people Reagan saved from the horrid Cubans at the same time he was saving himself from Impeachment for
overruling his military and putting those Marines in Beirut.
July 10, 2007 8:05 AM | Reply | Permalink
There won't be an ideological debate, just a debate conducted partly in the language of ideology. I'd love for this to be an actual ideological debate, but there's no real chance of that happening.
July 10, 2007 8:08 AM | Reply | Permalink
Damn straight. Make it clear that this fight is about the insurance companies. They're not just glorified bookies; they rig the games, too.
July 10, 2007 8:12 AM | Reply | Permalink
This might be one of the golden opportunities to have one's cake and eat it too (not too much, however, as that would affect life expectancy).
The United States Ranks 29th in Life Expectancy in the World
The United States spends 15% of its Gross National Product on Health Care
Every country with a greater life expectancy spends a smaller percentage of its Gross National Product on health care than the United States Does.
Many if not most of them have single payer insurance. In most of the rest, the government participates in the health of the nation by some combination of regulation private insurance companies, caps profits of them, rules for what and who must be covered, or subsidized payments on behalf of the less well off sections of the populace.
aMike
July 10, 2007 8:15 AM | Reply | Permalink
Yep, and it has a negative effect on industrial competitiveness in the global industrial market. One of the things which makes me hopeful that change is in the offing is that some pretty big players in the economic field (car manufacturers, heavy equipment manufacturers, electrical generator manufacturers and the like) are getting behind government provided insurance so they don't have to compete with companies in countries which offer this as a matter of course.
aMike
July 10, 2007 8:20 AM | Reply | Permalink
You have that exactly right. We are a democracy and by and large the comunitarian views expressed at TPMCafe and represented by Michael Moore in "Sicko" have a great deal of opposition in the United States.
Therefore, let me see if I can be simple about this. The culture in America is much more individualistic and skeptical about government programs. We tend as a nation to see individual success as a sign of personal worth and failure as a sign of laziness or other moral failings. People in America very often don't like paying for the laziness of others, even if that is not what is invovlved. Thus Americans own guns like virtually no other country in the Western World, Switzerland excepted. Americans are rushing to create programs to help new parents or those who need other types of assistence to help "family values." Moores' underlying theme is to look at the wonderful life the French, the English and the Canadian have by paying more taxes and working together. This is a country that had a " tax revolt." We don't have universal healthcare and other communitarian policies because Americans aren't like the French, the English and the Canadians.
It is not brain salad to look at America as it actually is and recognize that will have an impact on any policy no matter how well intentions or useful.
Daniel A. Greenbaum
July 10, 2007 8:20 AM | Reply | Permalink
Because allocating medical services and getting people to care will be a lot harder. How will doctors be paid? Will they be paid whatever they choose to charge? Will they be paid the same if they practice in New York, and LA as in Mississippi and Alabama?
Moore talked to doctors in London and Paris. I have no idea what services are like far from those national capitals. If you were going to interview American doctors and how they live and how they practice where would you go, Washington, D.C, NYC, Boston, Chicago, L.A. or Appalachia?
What is the cost of a CAT Scan or an MRI in different parts of the U.S.? Which region will determine the reimbursement?
Daniel A. Greenbaum
July 10, 2007 8:27 AM | Reply | Permalink
Ah, so it's not the size of the country your talking about but the economic diversity of different regions. Yes, I think you're right--France is more economically homogeneous than the US is--although Paris, New York, London are all places unto themselves as far as costs go.
This does not seem like a major problem to me. Medicare and Medicaid have already addressed this issue.
Now, there's something of a real objection floating around here--will I, living in NYC near major teaching hospitals, see my quality of care decline in a national system? I don't see why, particularly. And I do think any system will preserve the first tier of our health care system in one way or another--right now corp executives get much better plans than worker bees. It may be that those insurance plans continue, or that the rich revert to fee for service from docs who won't participate in the national plan.
But, no, these don't seem insurmountable to me. My father's treatment in Maine does not seem to be materially different from the treatment of relatives in NJ under medicare. And it's way better than my health care under the current system.
July 10, 2007 8:48 AM | Reply | Permalink
But:
(1) can you necessarily count on competent, non-corrupt administrations always being in place?
(2) can you count on Congress's ability to allocate a massive amount of money wisely and fairly?
July 10, 2007 9:12 AM | Reply | Permalink
Not true. It depends on the system. In the UK the NHS is very involved in provision - it runs the hospitals and salaries the doctors.
July 10, 2007 9:15 AM | Reply | Permalink
Medicare and Medicaid have already addressed this issue.
Hmm.
"Wennberg and his colleagues say . . . that Medicare's typical lifetime spending for a 65-year-old in Miami is more than $50,000 higher than for a 65-year-old in Minneapolis. In a further analysis, they found that . . . the federal Medicare program pays more than twice as much per person per year as it does in Minneapolis: $7,847 in Miami, $3,663 in Minneapolis." NYTimes, 7/21/2002
July 10, 2007 9:30 AM | Reply | Permalink
your standards are too high. can we expect good management? yes. Perfect management? Nope, especially if we keep electing right wing nutjobs.
July 10, 2007 9:58 AM | Reply | Permalink
Howard,
well, both expel the same product.
July 10, 2007 10:27 AM | Reply | Permalink
Another huge factor, which I have not seen you address, is how medical education and malpractice insurance would be handled with respect to allowable charges. Younger doctors, especially, tend to go into practice with a huge educational debt. There are now loan forgiveness programs for people that practice in underserved areas, or for specialties really needed by some healthcare organization.
Further, malpractice insurance can be extremely expensive, well into six-figures in high-risk specialties. High-risk obstetricians, for example, rarely are outside an academic center or very large group practice, which will provide malpractice coverage.
Look in the recruiting ads in the back of any major medical journal, such as JAMA or NEJM. Where there is competition among the providers (not necessarily based on reimbursement), you'll see loan repayment, malpractice coverage, and continuing medical education incentives as sweeteners. They can't be ignored as possible incentives for new physicians. Debt-free physicians won't necessarily seek as high an initial salary.
As an aside, under certain current financing arrangements, in places in the US but definitely in Canada, certain facilities, such as medical imaging, get a flat "capitation" fee, usually quarterly. That would mean that there are a certain number of CAT** scans that will be covered, and, if you are non-emergency, you may be scheduled into the next quarter.
Canadian imaging centers, however, are allowed to provide fee-for-service, non-capitated services to veterinary practices. So, you may have to wait several months for your CAT scan, but your cat, if you are willing to pay the rate, can get immediate CAT or MRI services. I do get two Cat scans every morning, but those use rough tongues rather than ionizing radiation.
** yes, I know the proper term now is CT, since not all computerized tomography is axial (the A) any longer. Nevertheless, CAT has so many more opportunities for humor, even if what you need is a multislice helical CT scan.
Seriously, there is a push to use more MRI and ultrasound when possible, although CT remains a valuable tool when indicated. Recent studies have found that the radiation exposure, especially with some of the newer CT techniques, does increase cancer risk -- although that risk may be overshadowed by the benefits.
--
Howard
*equal opportunity offense to both extremes*
"Those who cannot remember the past are condemned to repeat it" [George Santayana]
July 10, 2007 10:33 AM | Reply | Permalink
A friend of mine was born in Brooklyn, but, since he went to Grenada and then another foreign school, had to pass the Test of English for Foreign Medical Graduates. Given Irv's Brooklyn accent, I was slightly surprised he passed the oral part, which he took in Baltimore.
While he wasn't on Grenada during the invasion, he was there for at least once coup. He commented that the anatomy lab was short of cadavers before the coup, but there were plenty afterwards. Further, the pathology professors joined with the anatomy professors to use the cadavers for lectures on bullet trauma as well as basic anatomy.
Seriously, that number may or may not include "fifth pathway" students who are American born, but graduates of foreign medical schools. My friend ran into admission problems because he started medical school at age 29, changing careers from computing (and a graduate degree in biomedical engineering). Still, he was able to play the system sufficiently to wind up with a residency at Johns Hopkins.
--
Howard
*equal opportunity offense to both extremes*
"Those who cannot remember the past are condemned to repeat it" [George Santayana]
July 10, 2007 10:39 AM | Reply | Permalink
I had in mind an immigration system for doctors and nurses - they have to work in the US at 1/4 the pay of the going rate for 5 years before aquiring their citizenship. Then once they are citizens they can make their $150,000 to $350,000 or whatever the going rate is.
Of course this isn't so realistic as they are probably already getting their citizenship at the end of medical school.
(I realize the diversity in hospitals and medical offices and have seen it first hand. I'd like there to be more of them studying overseas is all as the medical school tuition is one part of the problem in the US.)
July 10, 2007 10:42 AM | Reply | Permalink
Hospitals are compensated for Medicare patients with fixed payment for what the Center for Medicare and Medicaid Services (CMMS) calls Diagnostic Related Groups (DRG), which actually lump together several diseases and pay little attention to severity. I am familiar with some ways that the hospitals look for more cost-effective ways to deliver therapy.
One large system, which uses computer systems from a client of mine, found that their most common DRG for Medicare admissions was congestive heart failure (CHF). There is no question that some CHF patients need ICU-level monitoring, such as those that have such things as Swan-Ganz catheters or left ventricular assist devices.
The hospital had had a policy, however, of keeping all CHF patients who received intravenous nesiritide or furosemide on the ICU. As long as they were at a certain level of stability, and did not need some other treatments or monitoring, it was found that they could go to a less expensive cardiac stepdown unit. To be safe on that unit, however, they needed to get frequent observation by nurses with additional qualifications. We developed an extension of the computer system that recognized CHF patients with these drugs being administered on stepdown units, and would page the appropriate nurses with reminders to check these patients at the needed intervals. The system also confirmed that the paged nurse entered the patient room, and would escalate the request to backup nurses if the nurse didn't respond in a timely manner.
I have no financial interest in this system, just pride of involvement. This is an example of how a hospital can deliver care more inexpensively without compromising quality, but with accepting an up-front cost for implementing the extra systems and training nurses and pharmacists in their use. Indeed, there is a good deal of research going into using clinical pharmacists to do direct patient monitoring when the patients are on certain drugs.
I'd note that pharmacists, who, in the US, no longer take four-year BPh programs but usually 6-year PharmD, are a greatly wasted resource, especially in retail pharmacies. There is a good deal of effort going into finding models, including reimbursement, where they can provide outpatient monitoring of patients with challenging medication regimens.
--
Howard
*equal opportunity offense to both extremes*
"Those who cannot remember the past are condemned to repeat it" [George Santayana]
July 10, 2007 10:53 AM |