Expanding FQHCs would be a better idea than single payer

[Recursion]

Last edited Mon Nov 2, 2015, 05:41 AM - Edit history (1)

Somehow, at some point, the board seems to have more or less decided that supporting single payer is the only thing a liberal can do. But that's not true. While Canada does have single payer, pretty much no other country in the world does (Taiwan is often cited, but it charges fees at delivery). Most countries have found a different way to achieve universal health care, which we should remember is the actual goal here.

The one I like is one that Senator Sanders is a strong supporter of, and amended the ACA to strengthen: the Federally Qualified Health Center (FQHC).

http://kff.org/report-section/community-health-centers-a-2013-profile-and-prospects-as-aca-implementation-proceeds-issue-brief/

FQHC's provide primary and specialist care for 25 million Americans a year on average, and charge on an income-based sliding scale to do so. In return, they receive an operating budget from the Federal government. There are currently 1200 of them in the US; I would like there to be 12,000.

http://kff.org/other/state-indicator/fqhc-revenue-by-source/

They currently get a lot of their funding through Medicaid and Federal grants (which Sanders expanded in the ACA). Those grants do not financially reward them based on the particular services they provide, but on the population they serve and their overall outcomes.

This is a much better idea for a national healthcare system than simply keeping our extremely expensive provider system in place and paying for it through taxes. FQHCs are cheaper than hospitals and private physician practices. They already serve the poorest segment of our population, so adding richer (generally healthier) people would improve their finances, particularly since they charge on a sliding scale at delivery (currently that's about 6% of their funding; it would go up if richer people went to them).

Single payer is not a good idea with our current provider system. Changing the provider system is a good idea, and if we did that we wouldn't need single payer anymore because the clinics themselves would be affordable. This idea would save money and save lives, and I think it's a much better idea than national single payer.

[eridani]

1. Single payer would change the provider system with global budeting n/t

[Recursion]

2. That's an assumption, and we don't really have evidence for that

OTOH we do have evidence that the FQHC model does give primary care to poor populations affordably.

This brings up the other advantage of FQHC: we don't need a single "switch-over" moment. We can just continue to expand them until they're the more attractive choice for most people.

[eridani]

4. Yes, we do. See Canada's per capita health care expenses

Much lower than ours. In WA State before the days of the Internet, we used to take busloads of people up to Canada for drugs and medical appointments, ad half the cost or less. Their providers and hospitals negotiate capital and operating budgets.

[Recursion]

7. At one point GM and Toyota were collaborating on something. The Saturn, maybe?

Anyways the GM executives were floored by how productive the Japanese plants were. They sent somebody on a tour with a camera and said "get me a photo of every square foot of their plant". When they came back, they built an exact replica and started production there. They couldn't understand why they still weren't as productive as the Japanese plant.

The obsession with single payer is like that. That's a model that worked for Canada. We're not Canada. Our population and our health problems are very different. Our density is different. Our politics are different. The linguistic and cultural barriers providers face are different. You cannot simply copy the structure of Canada's system and assume we would get their results.

[eridani]

11. We are like Canada in one very important respect

Provinces have a great deal of autonomy, just like states here. Their single payer is administered by provinces according to national standards. They could not get single payer until it had been vetted in Saskatchewan. (Seems that all the doctors that were against it saw their incomes rise by a third after it was passed, and changed their minds.) Our density isn't all that different--if you are in the wilds of Nunavut you have serious access problems, just like thinly populated rural areas here.

Single payer here would include drug benefits from the start. Canadian single payer did not, and they are stuck with employer and government workarounds.

[Recursion]

16. But not even Nunavut is Mississippi

Look at the states that refused Medicaid expansion. Any solution that involves the states, at least right now, is a non-starter.

[eridani]

17. There is a possibility of getting single payer in blue states

Holding off because red states are sociopathic is not an option either.

[Recursion]

18. Sure, but I think a clinic system would be a better idea

I think the high prices providers are able to charge are the fundamental problem, not the particular way we pay those prices.

I mean, obviously there's some feedback between the two.

[eridani]

19. That is a supplement--not a program that covers everybody for everything

Although I did like is that Sanders was able to get funds for clinic expanded in ACA.

The reason that prices are high is that they are not NEGOTIATED between providers and a universal payer. Elsewhere, in countries that do not have systems directly run by the government, provider and hospital capital and operating budgets are directly determined by such negotiations. In contrast, providers here gouge whatever they can out of people.

BTW, one reason they are motivated to do that is the humongous loans they need to finance their education. In most other advanced countries, this education is either free or highly subsidized.

Another reason is that medical malpractice insurance costs 10 to 100 times here what it does elsewhere. In Japan, $100/month gets you the insurance plus the medical journal, with specialists paying more. Why so cheap? Here, people with unfavorable outcomes often sue any deep pocket to be able to pay for the extra cost of fixing those outcomes--whether there has actually been any malpractice or not. If health care is a right of citizenship, there is no motivation to do that, so malpractice suits are much less common in places where that is so.

[Recursion]

20. So let's just have a government board that sets prices

There's no reason we can't do that. I'm fine with it. The government limits prices on all kinds of things.

[eridani]

21. That is not going to fly. The negotiation has to be two way

Patients want more care for less money; providers want more money for less work. No way to find a middle ground except through negotiation.

[Recursion]

22. Fine, but either way that doesn't require a monopsony

The government can simply pass laws regulating how much things can cost.

[eridani]

23. So the negotiations would then take place in congressional committees.

Probably better to do it administratively, as we are bogged down in Congress enough already. And yes, it really does require either a monopsony or a monopoly, or close to them. Other countries provide a wide variety of examples.

[Recursion]

24. Germany does it without one

The government sets (fine, "negotiates&quot prices and regional insurers provision the insurance.

[eridani]

25. There is too much variation in costs among states to make that work here

That's why Canada sets general parameters rather than specific prices.

[Recursion]

26. But that's the entire point of FQHCs; that's why I like them. They have a price schedule

The government has managed to get an income-sensitive price schedule up and running over a very diverse cross section of America through the FQHC system. It actually does work. It didn't take a monopsony (direct grants are about a third of their revenues, and the schedule is under Medicare rates).

[eridani]

27. Not seeing how they could be expanded to cover EVERYBODY

And if they did, you'd have the British NHS, which is a political no-go here.

[Recursion]

28. Well, sure, but single payer is a political no-go too

As long as we're talking about no-go's, I'm advocating the one I'd prefer.

But the beauty of this is that unlike single payer, you don't have to switch everybody over all at once. We can expand these as much as we want. If 1200 can treat 25 million, let's double the funding to make 2400. Could that treat 50 million? We can see. We can expand this as much as we want as quickly or slowly as we want, and we can walk back expansions that don't work.

Plus, it's not the NHS in an important way: people who can pay do pay, some. Americans seem to like that, and this keeps that aspect of our healthcare system (I think there's a reason absolutely free-at-delivery healthcare is relatively rare worldwide). But what they pay is much, much less than they pay at traditional fee-for-service providers.

[eridani]

29. Single payer allows for states to make progress without waiting on the feds.

Not saying that the clinics are a bad idea--they'd help a lot. Sanders certainly agrees with that--see the funding for them he added to ACA. The clinics would pretty much have to be funded by the feds.

[Recursion]

30. Yes, I think Sanders's tripling of FQHC funding in ACA was a brilliant coup

It's funny, though: I was literally just thinking "FQHC's let the Federal government make progress without waiting for the states".

I think we both kind of have a point there.

[Paulie]

14. That was the NUMMI plant in California.

They were building shared platform cars like the Pontiac Vibe/Toyota Matrix/Chevy Prism.

That plant was closed by GM/Toyota. Reopened under a new brand, Tesla Motors, in 2010.

[Recursion]

15. Oh cool, thanks! (nt)

[Fumesucker]

3. Because only *those* people go to the clinics

There is a huge stigma against going to a clinic for all but the very poorest, because that's who goes to the clinic.

It's an admission that you are poor and as we all know Americans think of themselves as temporarily embarrassed millionaires.

Frankly this sounds a lot like the NHS but just for poor people.

[Recursion]

5. Well, that will take some fixing. But at least that's a tractable problem.

You have a point (same thing happens in India, too). But if we expand them into less poor areas that might change. Particularly if we market them well.

[Fumesucker]

9. I'm not sure you understand the mentality of people who are losing ground economically

They are often desperate to keep some semblance of the life they had before the wheels came off.

I had long conversations some time ago with a family member in her mid 80's, during the Depression they literally had a dirt floor shack to live in and even raised sugar cane they would take to the mill and have crushed for their sweetener. One thing she said that struck me was that they didn't know they were poor, everyone else around them was basically in the same boat economically and they didn't have television to let them know how badly off they were comparatively.

Being poor where almost everyone else is poor is one thing, being poor where it looks like everyone else is rich is entirely another and far more soul destroying.

[Recursion]

10. Well, sure, I mean that's America in a nutshell

The Federal poverty line for an individual puts you in the top 5% by PPP income worldwide, but it sure doesn't feel that way inside the US.

And it still seems more feasible to me than keeping our current provider system and paying for it with public money.

[eridani]

6. Expanding such clinics would be helpful, but only in urban areas. They need a certain--

--population density in order to work.

[Recursion]

8. Nope. About 40% of FQHCs are rural (nt)

[eridani]

12. They must be more expensive, then? n/t

[Recursion]

13. Sure, delivery is more expensive in rural areas, and their grants have to be higher

We subsidize rural phone lines, too.

Though several of them do "mobile clinics" (i.e. an NP or PA in a van with a webcam and a feed back to a physician in the clinic -- I actually worked on some of the early generations of that software back in the Pleistocene) which help make delivery closer in price to urban sites' prices.