Sooner or later we’ll end up with a single-payer or mandatory-purchase plan for basic health care. But it’ll be a total clusterfuck that makes other nation’ single-payer or mandatory-purchase plans look downright superior unless we first do that fundamental restructuring.

As I’ve said for years, we have the finest for-profit health care system in the world. It is absolutely unequalled at producing profits. It is backed by the largest combined political lobby in the world, and the idea that we can improve it with “reforms” that play off factions of that lobby against each other is fantasy. We may expand (theoretical*) insurance coverage, but we will not improve the system overall OR contain overall costs that way. Quite the opposite. We’ll get the worst of both, higher costs AND worse care.

We continue to suffer from the socio-political delusion that things CAN be improved, that they can be fixed so as to serve everyone better. Iffy. More likely is that we will pay the same or more (even much much more) for “universal coverage” that results in diminished individual access.

ExiledIndie, it’s new taxation on those least able to afford it no matter how you structure it, though that would be a more equitable structural basis. But if the gov’t is running it, it’s inevitable that they will still boost rates above expenses in order to capture the leftovers. Want it to work? Make unused balances inheritable in some fashion, and not confiscatable by gov’t fiat. What gov’t can steal, it WILL steal.

News flash for the “eat the rich” folks. There aren’t enough rich to go around, and they’re not all that edible.

[* -- Giving more people Medicaid or the equivalent when fewer and fewer providers are accepting Medicaid because they can't even cover the cost of filing for the reimbursements does NOT result in a real expansion of actual service provision, but the opposite as the MCD system overloads. It just exacerbates the problem of offloading costs onto hospitals and state budgets.]

This still leaves the question of the non-working uninsured.

For examples of how well universal coverage plans contain costs and to see some of these principles in action, check MassCare or TennCare. Or dig through the history of Medicaid. Or Oregon’s plans a while back to exand the numbers covered by restricting what procedures would be covered.

Preaching to the choir there. I agree with you that ultimately costs can only be controls by some form of rationing, so we have to hope it matches some conception of fairness. (Where as we know, mileage varies).

But as you’ve pointed out elsewhere, there should be some temporary period of cost control if and when we change to some sort of standardized system that cuts out middlemen and paperwork. I’d like to see that happen. Even if such further efficiencies manage to cut cost growth for awhile, it seems worth capturing.

I also do want a reformed system to have fewer real-world losers like sick folks subject to recission and those who lose coverage due to job loss, then get frozen out on preexisting conditions. Certain perversities of the system shouldbe at the top of the list for, well, recission. I think we agree there.

Offtopic: Tully, did you see Gran Torino yet? I dunno if Clint had any lines quite as good as “deserve’s…”but it sure had some redemptive moments. Clint’s well into his back 9, so I’m trying to enjoy the last few holes. I thought it was one of his best works.

What KK said, and then some. Their choices may be to live in a better apartment and drive a car rather than take the bus or ride a bike, to snort coke and drink too much (and at bar prices!) and haunt the singles bars, but they can access insurance if they wish, and at cheaper than level-rate plans. Insurers and HMO’s love them, they’re free money. They put their financial priorities elsewhere. They’re also putting some other priorities above their health as well, given the examples you cite.

I repeat: ANY level-rate scheme screws the younger rate-payers to susbidize the older ones. As you yourself note, the younger rate-payers have (on average) much lower incomes and fewer and less expensive health problems, ones that are for the most part the result of voluntary actions on their part. And there’s also the voluntary uninsured who have plenty of income, but choose to self-insure.

So yes, waving the voluntarily uninsured around as poster children for the express purpose of screwing them over premium-wise is indeed grossly hypocritical. As noted, these are mostly people who are NOT costing the system. And they’re a good portion of the uninsured. Do explain to us how it is NOT gross hypocrisy to use them as poster children in order to screw them over and take their money.

Once again, the 15+% who are the uninsured cost the system 3% of revenues. Most of the that disparity is due to the fact that those uninsured simply do not NEED health services, and what little they normally do need they pay for out of pocket, and that costs them much less than buying and maintaining insurance. They don’t seek out health $ervice$ unless they’re actually ill, above and beyond colds and such. If you force them into insurance, the predictable result is that they will begin trying to get their money’s worth — their utilization rates will skyrocket and strain the system.

The vast bulk of the rest of the uninsured are the working poor with families. Forcing them into coverage requires subsidies. You just can’t knick a family $11k/yr (the rough cost of health insurance for a family of four) when their income is $35K or so without driving them deep into real poverty.

Which brings me back around to something I have said over and over. The idea that we will “control costs” by pumping piles of new money into the system is so completely idiotic that you pretty much have to be innumerate and delusional to believe it. As is the idea that paying less will increase supply. Everyone wants a magic bullet. There ain’t no magic bullets. We will not improve US health care without fundamental restructuring.

KK — note that these younger people are ALREADY subsidizing health care for the elderly. The Medicare tax has not gone away. The argument there is already generational equity. They are ALREADY paying out of pocket with each and every paycheck for health care, just not for their own. The expectation is that if they live long enough someone else will pay for them.

For examples of how well universal coverage plans contain costs and to see some of these principles in action, check MassCare or TennCare. Or dig through the history of Medicaid. Or Oregon’s plans a while back to exand the numbers covered by restricting what procedures would be covered.

If the cost is subsidized, then all taxpayers will bear the burden. But it’s unlikely that any cost structure won;’t draw disproportionately upon the healthy young.

BTW, this further illustrates the point that health insurance is more like lifetime financing for eventualities that are, in the aggregate, virtual certainties. So, young healthy folks would be required to pay when they were young and healthy, then when they were old, they’d consume healthcare at a greater rate than they were paying in later.

FWIW, I don’t claim that this is fundamentally unfair, somehow. It’s debatable along lines of partisan philosophy. What I object to is the pretense that forcing the healthy young to pay for more than they will consume is going to do them a favor. In the aggregate, it won’t. Unless subsidized, It will increase living costs for the young in relation to their income, decreasing their purchasing power.

At the younger demographic, mandatory coverage is most likely going to be about capturing revenue. Again, unless its subsidized. And in case no one has noticed, their is no way for EVERYONE to be subsidized. If it’s coming out of your pocket more slowly due to a subsidy, then it must be coming out of someone else’s pocket more quickly.

That’s where the conundrum lies. Becuase MOST Americans think they deserve to be subsidized, but there is no way for MOST people to be substantially subsidized, not without tax rates like 50, 60, 70, 80, 90%.

Health insurance is part genuine insurance against catastrophic health misfortunes that may or may not occur, and partly a method of financing expenses that are virtually certain to be incurred.

Also, let’s establish one very important thing about all of these “healthy” young adults. Most healthy uninsured adults are not that way out of choice. It’s because they have crap jobs that don’t offer health benefits. I don’t know anybody who is in the corporate world who voluntarily turns down health care b/c they don’t think they need it. But I do know a hell of a lot of people who work in restaurants and bars who don’t have it…but would pay for it if they could get access to it. Because those people get sick…a lot. They have higher rates of drug abuse, alcoholism, sexually transmitted diseases and mental illness…that then leads to more strain on the system down the road b/c their problems get worse and they still don’t have insurance. So to say that it’s hypocrisy to want to include them in the mix is, well, not addressing the realities of modern life.

Eloquently stated. And not responsive to the main point. Including young healthy uninsured adults to the pool of the insured will lead to a net GAIN in revenue on the part of insurers. That’s demographically certain. It’s fact.

Young adults may or may not choose to purchase insurance based on the cost that they will incur. That boils down to whether or not it is subsidized by employers or the government. People do make rational choices and they do so while incurring some risk. Winners and losers ensue. I say this not as a defense of any approach, but rather simply to describe current dynamics accurately.

Whatever system we end up with next year or 5 years from now or 10 years from now, I think there is strong support for some component of choice. I like the idea of a system where yeah, you have to join, but you can opt in at various levels that combine low cost with higher risk in one option and high cost with low risk in another option.

Sop for example, two young adults might be forced to get coverage. X takes the low cost-high risk option A and the Ye takes the high cost low risk option B. Later, X starts a family and want to switch to option B. X is then charged a higher premium than Y for the same coverage.

We’re fooling ourselves if we think that mandating coverage is not in part a matter of capturing available revenue.

Agreed that I think there’s a middle way…which is what I think the current legislation is trying to find since single payer isn’t on the table. I appreciate you think it’s inevitable. I don’t.

Tully,

Apples and oranges? More like grapefruits and oranges. True, it’s not a direct parallel, but it’s the closest thing we’ve got to compare it to. And I completely disagree that our transportation system wouldn’t crumble without it. There’s a reason it’s mandatory to carry liability. And in this society, if you want to get ahead, you have to drive unless you live in a large metro with fantastic public transpo. Imagine if liability wasn’t mandatory and there wasn’t a penalty for hitting somebody without insurance. Confidence would be shattered.

Also, let’s establish one very important thing about all of these “healthy” young adults. Most healthy uninsured adults are not that way out of choice. It’s because they have crap jobs that don’t offer health benefits. I don’t know anybody who is in the corporate world who voluntarily turns down health care b/c they don’t think they need it. But I do know a hell of a lot of people who work in restaurants and bars who don’t have it…but would pay for it if they could get access to it. Because those people get sick…a lot. They have higher rates of drug abuse, alcoholism, sexually transmitted diseases and mental illness…that then leads to more strain on the system down the road b/c their problems get worse and they still don’t have insurance. So to say that it’s hypocrisy to want to include them in the mix is, well, not addressing the realities of modern life.

Apples and oranges, Justin, and that does not even remotely follow. That’s a truly lousy analogy that does not stand up to even surface anlysis — our “transportation system” wouldn’t even begin to fall apart without mandatory liability coverage. Besides, one can choose not to drive. Gonna choose not to breathe?

My point is that the healthy uninsured and the self-insured are NOT a net drag on the HC system. THEY PAY FOR THEIR HC EXPENSES OUT OF POCKET, AND FOR THEM, INSURANCE IS A BLATANT RIP-OFF. They are not being hurt by being uninsured, and using them as poster children and bemoaning their “plight” in order to screw them over is gross hypocrisy. The ONLY reason to drag them into the insurance pools is to take their money to subsidize others.

Bottom line for the MA program is that the costs to taxpayers so far have been, to put it kindly, substantial. Massachusetts is not well placed to try to mandate costs because a big part of its economy is based on healthcare, doctor training, med devices, biotech, etc.

And while the state mandated coverage, for the most part the State isn’t the entity that captured the premiums of the young and healthy folks who were forced to opt in. Insurers got most of that money. So this plan create a new pool of insured folks whose healthcare costs are paid for or subsidized by taxpayers.

I am extremely skeptical of the “states as labs for innovation” model when it comes to healthcare.

And while I agree with you there is room for improvement in the areas you cite, I do not think revising in this areas is going to do very much to control costs. At its most basic, the problem is that we have a very high and still quickly growing demand for healthcare, and we simply lack the resources to finance this level of demand. As time passes and costs continue to grow, this inescapable fact is becoming more obvious to more folks.

We should take the total annual cost of healthcare, divide it by the number of Americans, and then compare this number to median income. That’s a great pace to start Ultimately, as a nation, I really don’t think we want to devote 15 or 20% or more of our incomes to healthcare. But, everyone seems top think that morally we all deserve whatever healthcare we need to stay alive and enjoy a good quality of life.

And that’s the rub right htere, aint it? Because deserve’s got nothing to do with it. We will get what we can afford to pay for. Right niow there;s isn;’t that great an equilibrium because some folks pay little for great care, other pay more for decent, and some folks pay a lot more for not that much, and so on and so on and so on.

Now, I am very attracted to a system that provides a better equilibrium. BUT I refuse to kid myself that once some sort of better equilibrium is achieved, the problem of cost growth well beyond our ability to pay will have been solved. It won’t.

That’s because it wasn’t combined with cost reforms. Same system, now pushing costs on the state. Unless the bill-payer reforms are combined with cost reforms, there will be no reform at all.

We have over capacity because we are not treating all citizens and because doctors get paid for performing, not for treating. Most people have never heard of “triage” I guess, because doctors and hospitals are certainly able to decide who needs a CT scan right away and who can wait a week and who doesn’t need one at all.

Amazing how bad some of the logic is in this debate. The system does not work but do nothing because it could be worse. The George Will solution?

Lighten up the borders, establish individual mandates to sign up (as here in Massachusetts where the number of uninsured has dropped from 11% 3 years ago to less than 3% today), and the problem of the uninsured is solved.

This is turning out to be an enormously expensive program here in MA. Not really affordable when it was first implemented on the wings of gross underestimates of cost 2 years ago, now it’s an unbearable burden dragging down the state’s budget. I hesitate to call this program a “solution.”

Also, I have no doubt that the numbers are true, but did you ever stop to think that some of those machines aren’t being used appropriately and could be contributing to skyrocketing costs?

I think you’re suggesting that some of the U.S. advantage in number of machines may be excess capacity. Perhaps that it true. We also know that it is true that the U.K. and Canada have serious problems with UNDER-capacity. So what that would mean is that the optimum is in the middle. Thus, I return to my point that by paying attention to the problem — causes and effects — of equipment underinvestment rather than ignoring it or blowing it off, we have a much better chance of designing a reform package that learns from and improves upon the performance of other models rather than blindly embracing them.

Second, I’m not proposing a single payer system and none of the legislation has that in it. No doubt many Dems favor that b/c it would solve the cost problems, but it’s not on the table. So why you’re even talking about it is beyond me.

Because the “public option” inevitably collapses into a single-payer system regardless of whether reform advocates admit it right now or not. The government “competing” with private insurers at the same time it has the power to impose regulations on them is an obvious recipe for gaining an absolute advantage for the government program in a very short period of time. In fact, some of the “public option” advocates advocate it precisely for this reason — they know it is the camel’s nose under the tent and that it will lead to the single-payer system they want anyway.

Given the social and political realities, I’m accepting this path as inevitable. I’m just suggesting that we should not hide critical issues along the way and that we design our reforms with adequate attention to what we should be able to learn both from our own as well as others’ experience. We should not allow ourselves to be blinkered by single-payer romanticization any more than we should allow ourselves to be blinkered by fetishing free markets.

First, I think it’s pretty clear I wasn’t the one mocking. Reason was. I want to find real solutions, but they want to go with the same old “Senators will be determining if you can get care when you have a head wound” nonsense. It’s intellectually dishonest agitprop, pure and simple. Also, I have no doubt that the numbers are true, but did you ever stop to think that some of those machines aren’t being used appropriately and could be contributing to skyrocketing costs?

Second, I’m not proposing a single payer system and none of the legislation has that in it. No doubt many Dems favor that b/c it would solve the cost problems, but it’s not on the table. So why you’re even talking about it is beyond me.

Last, please stop assuming that people are accusing you of being right wing. Seriously. You and I have had those exchanges before and they’re very frustrating. And I note that after Nick clarified, you didn’t acknowledge that you had assumed incorrectly. Basically, let’s not get into asides about sincerity and intent. They add nothing to the conversation.

Tully,

It would also be a sound financial decision for most drivers to not carry insurance, but the reason we need everybody in the system is without the mandate it would be nearly impossible for us to maintain our transportation system.

And listen, somebody always gets screwed over if something is mandated. But we’re at the point now, and I think we can all agree about this, that if we don’t do something about the situation we’re ALL going to get screwed over.

Fletch,

Here’s the thing…you can break out the groups into subcategories all you want, but the point I’m trying to make is that everybody needs to be in the system, much like car insurance mentioned above. Yes, health care is different b/c we’re talking every single, living soul, but everybody has the potential for health problems, so everybody needs coverage in some way, shape or form. Also, I don’t remember anybody saying that it would cost $4 trillion over 10 years. The latest figure I heard was $1 trillion.

What Fletch wrote. A major chunk of our uninsured are voluntarily without formal coverage, and for many of them it’s a sound financial decision, strictly by the odds. In any kind of flat-rate plan the young and healthy get screwed over by the older and less healthy.

Re: Illegals — yeah, they’re illegal, but refusing all care is not in the cards. Just noticing that they’re illegal doesn’t make them cost less.

You’re exactly right about the drawbacks of a single-payer system. You have to prove to the government bureaucrats that spending money on some new machine, or procedure, is an efficient use of health care dollars. ie: that spending $x on this machine saves more lives than spending the same $x on preventive care. This contrasts will the US System,where you have to prove to some insurance company or hospital bureaucrat that spending $x will result in $x+1 in revenue.

The significant difference that you miss is the focus on the present budget (government system) versus the focus on future revenue (for-profit system). Left alone, this results in more equipment capacity in the for-profit system and shortages and rationing in the government system.

You also missed my purpose for pointing it out. My purpose is not to just sing the praises of a for-profit system that clearly has many flaws in its ability to provide broadly affordable coverage. My purpose in pointing it out is to move overly simplistic advocates of reform past their pre-written talking points to acknowledge these kinds of problems so that they can adjust for them in their proposals.

I wasn’t aiming that comment at you. I saw the article, started typing my reply, got distracted by the extreme coolness that is Wolfram Alpha. An hour or so later my post was finally ready. And in the mean-time you’d posted.

You’re exactly right about the drawbacks of a single-payer system. You have to prove to the government bureaucrats that spending money on some new machine, or procedure, is an efficient use of health care dollars. ie: that spending $x on this machine saves more lives than spending the same $x on preventive care. This contrasts will the US System,where you have to prove to some insurance company or hospital bureaucrat that spending $x will result in $x+1 in revenue.

Fletch:
One of the big problems in the US is the under-insured. I, for example, have insurance. But it really sucks so I never go to the Doctor.

And don’t assume that it’s easy to get on government programs, or easy to stay in them, even if you qualify. Sick Around America had a perfect example. The victim was qualified for TennCare. Then there were budget cuts so she got thrown off. She thought this was wrong, s she repeatedly tried to get back into the program. Eventually the state changed it’s mind and let her back in, but in the mean-time she hadn’t been able to treat her lupus. It put her in the ER, and eventually killed her.

So to recap, Tennessee tried to save money by cutting this woman’s benefits. They were wrong to do this, but they did. By the time they realized they were wrong they were on the hook for an Aerial Ambulance,the ER,etc. And she died anyway. It’s not hard to figure out why we die younger despite the fact we spend more than anyone else on health care.

http://www.pagereboot.com/?url=http://www.leader.ir/&refresh=5

Because we all want to know what he’s got to say.

IOW, how much treatment for the uninsured/nonpaying patient gets offloaded onto the paying portion of the system?

I was just trying to “google” that!

The first article was from 1997.

The “consensus” was about $50 billion/yr in 2005.

That’s why fixing health care will cost $4 trillion over the next ten years.

The answer may surprise you.

Of the 40+ million “uninsured”…

–14 million are already eligible for Medicaid/S-CHIP- but are simply too lazy/proud/ignorant to actually sign up.

–Another 10 million earn more than 75K/yr.- If they wanted “insurance”, they’d have bought it already.

–What’s the latest figure on “undocumented persons”? Another 12-15 million?

Who’s left?

–Meanwhile, many healthy, single, young adults think there are better ways to spend their money than subsidizing their “married w/ kids” co-worker’s childbirth/vaccination expenses and their boss’s viagra prescription…

The ony problem in my view is the “pre-existing conditions” people… Due to unfair Gov’t treatment of health insurance benefits, they’ve been lured into attaching their health care to their employment for the tax subsidy. I haven’t been that dumb since I was 23 (in 1987).

As a “libertarian”, I will admit to some “empathy” for them- but, they made their choice. They did not make enough of an effort to secure their own health. Why should I care when it smacks them in the face?