The Real Problem with Health care

[Nederland]

From the reaction I've gotten from many at DU recently, this isn't going to be a popular post.

Here is the root of the health care problem: the patient is not the customer. In our system, I believe something like 90% of the time health care bills are paid either by the government or by an insurance company. The money is not coming from the patient, it's coming from a third party, and the bottom line is that for any person or business, the entity paying the bills is the entity that you have to please. I know many doctors, and I think the vast majority of them have are wonderful people that have their patients' best interests at heart. However, the system is rigged against them. Ask any doctor you know if they have ever done something, not because they or the patient thought it was a good idea, but because an insurance company thought it was a good idea. Or more likely, ask any doctor you know if they have ever NOT done something because an insurance company thought it was a good idea. Have that conversation and you'll realize who really calls the shots.

Here is the unfortunate thing: single payer doesn't change that equation. All single payer does is replace that insurance company bureaucracy with a government one. The patient is still not in charge, government is. I know that many of you will say that government is different from an insurance company, that unlike an insurance company motivated by profit, government is really looking out for you. Say that to any of the thousands of Iraq war veterans fighting with the VA to get the treatments they need and see if they agree. While I would agree that government will probably do a better job than insurance companies, single payer still doesn't solve the problem.

As if getting lousy service isn't bad enough, this arrangement has a secondary effect: increased costs. When a patient with insurance or Medicare walks into a doctor's office, they don't care about the cost. They pay their co-pay, and anything on top of that comes from an insurance company or the government. When it comes time to decide whether you want a particular treatment or service, and you aren't paying for it, the answer is always yes. Why not? Saying yes doesn't increase your cost.

Here is a simple example. My wife and I are going to an infertility clinic right now. I'm extremely lucky to have excellent insurance, and we quickly blew past the $150 deductible. So at this point, we pay a thirty dollar co-pay every visit and everything beyond that gets picked up by my insurance company. So yesterday we are at the clinic and they are doing blood work and the doctor asks if we want to do some genetic screening for these four conditions. We answered yes. It wasn't until we were riding home that we wondered how much it costs. It never occurred to us to even ask--we aren't paying for it. This is a ridiculous situation. You can't name another situation where someone asks you if you want something and you say yes without having any idea what the cost is. At least not a situation where the cost might easily run into the hundreds or thousands of dollars.

The result of this payment arrangement increases costs in more subtle ways too. Hospitals routinely get the latest and greatest equipment even though their existing equipment works perfectly well. Drug companies spend millions of dollars to develop new drugs even though existing drugs work perfectly well. Why? Because the answer is always yes. "Do you want to get scanned by this ten year old CT machine that works perfectly well for the condition you have, or this brand spanking new machine developed to better analyze some obscure disease you don't even have?" "Put me in the new machine!" "Do you want this new drug that has a 20% chance of making you less dizzy than this old drug?" "Give me the new stuff!"

When decisions are made in the absence of monetary concerns, bad decision are made. I don't care how much of a saint you are, if your kid is sitting in the hospital you want the best doctor/gadget/drug available and you don't care what it costs. This is a completely human impulse, but it unfortunately totally out of tune with reality. At some point, costs matter. We pay the price for having a system that obscures them from us.

I know many of you might say: "No! You be able to get whatever you need to save your kid's life!" Really? No matter the cost? What if it costs a million dollars? Ten million? Twenty million? Health care is not an infinite resource--there are a finite number of doctors and a finite number of dollars available. If you spend twenty million dollars to save a single kid, you can't spend that twenty million dollars on other things. Things like, I don't know, vaccinating every kid in the country. What would you say if you were asked to choose between saving a single kid or insuring that millions would live free from debilitating diseases? I know what I would say if it were my kid, but it's not the right answer.

What is the solution? I don't have a good answer for that. I think one answer is that we need a system that forces us to pay for more things out of pocket. I know if I had been asked if I wanted genetic screening done and been told it cost $500 per test, I wouldn't have said yes to four tests. And why should my wife and I be getting infertility treatments practically for free? It's not as if this is an emergency or an unexpected event. Something tells me that if my wife and I want to have another child, perhaps we should be forced to find out how much the treatments cost and save up until we have enough money. Or borrow the money and pay it off later. Either way, paying out of pocket would force us to make some hard choices that we never even contemplated. Why should we have?

We weren't paying for it.

[Zoeisright]

1. That's the same bullshit argument the insurance company used against me

and my husband when he had cancer.

Many bills were denied or paid less than we owed because the charges were 'above the median charge for your area'. As if we were going to go shopping for the cheapest care for cancer surgery, chemotherapy, and radiation. For Christ's sake, we were barely able to function. I literally forgot how to grocery shop at the store; just stood there paralyzed. And you wanted me to be able to shop for the cheapest treatment for him?

The only time your 'scenario' would work when it's for voluntary, non-life-threatening situations. Telling people to save up for a life-saving procedure is cruel and stupid. And short-sighted.

Sounds like you have never had a serious illness that needed urgent medical treatment. Trust me, that will not be the case in the future.

More than 20,000 Americans die every year because they can't 'SAVE UP' for treatment. And your 'choice' is bogus. There are not many treatments that cost twenty million dollars. Or even ten million. Or even ONE million.

[Nederland]

4. Response

I think you might think about it differently if you added up the real cost of insurance. A 22 year old person just starting work today at a company that provides insurance for her/him will pay a total of 1.7 million dollars to insurance companies over their lifetime. 1.7 million dollars. Imagine if your husband got cancer and you had access to that much money to spend however you wished. No arguing with insurance companies, no haggling with bureaucrats. Just you and your husband deciding how to best spend all the money you had accumulated.

I ask you, would that have been easier for you?

[Raineyb]

9. In other words, the insurance company was correct to dick you around because apparently

you didn't do you due diligence by either being born or marrying rich.

There are no words to properly express how disgusting this line of "reasoning" is.

[Nederland]

42. I have no idea what you are saying

My example is of how much money a middle class person will spend on health care over their lifetime, not someone rich.

[Carl Skan]

13. Source on the 1.7 million? That's $34,000 a year assuming you work until 72.

I give my employees pretty darn good coverage and don't pay anywhere near that much.

[Nederland]

40. Link

I made a mistake in my post. That figure is meant to capture all health care dollars: employers and government. Also, I don't think you are taking into account that prices are always increasing.

The source for my figure is on page 3 of this article: http://www.theatlantic.com/doc/200909/health-care/1

[Zoeisright]

45. He was TWENTY FIVE YEARS OLD when diagnosed.

And your response is heartless and cruel.

How ... progressive of you.

NOT.

And you answered my question. You haven't had to worry about a serious illness. You will. And then you'll regret this attitude.

[Nederland]

51. You are making bad assumptions

You assume that I'm suggesting a system that only gives you access to the money you have at the time of tragedy. I'm not. Government could easily create a system that gives large sums of money directly to individuals in events like yours. It is not unimaginable. Banks will give you hundreds of thousands of dollars to buy a house based upon the assumption that you can pay them back over a long period of time. I see no reason why government cannot create a system that gives you hundreds of thousands, even millions of dollars to spend on health care based upon the assumption that you will pay them back over a long period of time via tax dollars. Sure, on occasion people would be unable to pay back the money, but on average it would all work out. Of course, in the vast majority of cases people don't need those kind of sums until late in life, so such a system would have plenty of money to deal with cases like yours.

[Zoeisright]

47. What a stupid response.

Yes, of course it would have been MUCH easier if we could have spent the money THE WAY THE DOCTORS WANTED TO.

What is wrong with you? Nobody is going to spend money until it runs out. They spend money as the DOCTORS WANT TO.

I hope that when someone in your family develops a serious illness someone is as insensitive to you as you have been to me.

[Name removed]

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[Name removed]

53. Deleted message

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[Raineyb]

2. So what?

You shouldn't have to forgo medical treatment because you can't afford it. You shouldn't have to ask how much it's going to cost if its something you need to get well. There are some things that should not be subject to the whims of the market. Health care, like roads, the postal system, the military and our police and fire departments are among these.

If a single payer system is so costly why is it that countries that have it pay less per capita per person and have better outcomes?

If you think that the problem is not enough people worry about how they're going to pay for their health care then I really don't know what kind of discussion you expect to get but I suspect you'll need flame retardant underwear and rightfully so.

[Nederland]

6. Response

You shouldn't have to forgo medical treatment because you can't afford it. You shouldn't have to ask how much it's going to cost if its something you need to get well.

As I explained in the OP, that is an unrealistic attitude. Health care resources are not unlimited, and one way or another, hard choices have to be made.

[Raineyb]

8. No it's not an unrealistic attitude. It's the same attitude other countries use

They may not pay for everything but they pay for a hell of a lot more than insurance companies here do. And you don't hear of people being denied cancer treatment to the point where they end up dying because of the delay because an insurance company wants to pad it's profits. Your reasoning is sickening, wrong and utterly unreasonable.

Like I said you'll deserve every flame going your way with that attitude.

[Nederland]

11. It is reality

You may think that single payer countries have magically overcome the problem of limited supply, but you are wrong. People in single payer countries die from lack of treatment too. It's just in single payer countries the decision on who live and who dies is not made by looking at a persons wallet. A more just system for sure, but still one that has to deal with reality.

[Raineyb]

14. What the hell does that have to do with your ridiculous argument that the problem

with OUR health care system is that not enough people pay for their own?

THAT was your premise which implies that the current system of people dying of easily treatable illnesses because of lack of money is one you find acceptable. That's a far cry from saying people die because they may not get some extraordinary treatment. In this country people die because they can't get fairly routine treatment and you don't find that to be a problem which makes a discussion rather pointless.

The argument that people don't pay enough for their health care and that's the problem is not one worth rebutting, the grossness of such an argument is far too obvious to bother expending energy in such a manner.

[Nederland]

31. That is not my argument

Please re-read the OP. My argument is not that people don't pay for their own health care. They do, and they pay far too much for it. My problem is the circuitous route by which payment flows from patient to doctor.

[Raineyb]

39. Then I don't know what your issue is with single payer. People paying out of pocket for medical

isn't going to fix the problem. Most people can't afford to pay for even a not so major illness. In addition, a single person in the marketplace pays the most for services. Keeping insurance companies with their private jets and gold leaf plates (which comes out of the money people pay in premiums and does not go taking care of anyone) isn't a good solution. That's why single payer is really the only good solution there is. The government has the power of numbers to negotiate prices and those prices would be easily available as part of the public record. Public health is a public good like police and fire. We don't talk about the problem with police and fire is that people don't pay enough directly to these entities what difference does it make if it's paid through the government? That's a hell of a lot more transparent than the current system and people would know how much it costs if they cared that much about it. But the truth is no one cares how much their treatment costs when they need it they want it done so they can get well and there's nothing wrong with that attitude at all. It's people who have to decide whether they are sick enough to warrant paying for their doctor who end up pushing off treatment until it's a hell of a lot worse and a healthy citizenry is infinitely more important than worrying about the money it costs to treat them.

Governments do not have to run as for profit entities and as a result are the best entities to pay for health care. The insurance companies are the last ones we should be entrusting our health to.

[Nederland]

56. Not all health care is emergency care

In fact, a slight majority is not. What I'm suggesting is that we have a national catastrophic insurance plan (yes, this is essentially single payer, but only for catastrophic events) but force non-catastrophic care to be paid for out of pocket. Government subsidized loans would be made availible so people could pay for fairly expensive but routine, predictable events (e.g. pregnancy), and these loans would be paid back over time from your taxes.

[The Magistrate]

62. Most Of the Expensive Stuff Is, Sir, An Emergency, Or An Urgent Requirement

[Nederland]

64. I'm not being clear

Imagine a system like this:

Government offers a mandatory catastrophic insurance plan for expenses that exceed $50,000, and a program that requires mandatory contributions to medical savings accounts for expenses under that. I know what your thinking, $50,000!?!, that's a lot of money. It's not though, spread out over your entire life time. Government could allow the balance on your account to go negative for portions of your life based upon the assumption that on average it will get the money back. Government would also put money into the medical savings accounts of poorer people that can't afford to make contributions themselves.

So it works like this. Break a leg? Pay for it out of your account. Have a kid? Pay for it out of your account. Get leukemia? The catastrophic plan kicks in and pays for everything over the 50k. As an incentive to be mindful of your costs, you get to take money out of your account if it reaches a certain size at a certain age.

Maybe 50k is too high or too low. Not really sure, but you get the idea. You want a number that is high enough to give people an incentive to control health care costs, but low enough to be affordable.

[The Magistrate]

66. You Are Quite Clear, Sir: You Are Plumping For Gingrich's 'Medical Savings Accounts' Swindle

Most people do not have the income to sequester a appreciable sum for the purpose. And it is beside the point anyway. People do not decide to go out and break a leg, or have a heart attack, or contract pneumonia on top of the flu, or drop a pot of hot coffee over their tights, or contract a staph infection. or whatever the matter is. Paying for these things 'out of their own pocket' would not effect their occurrance, frequency, or severity. It is not the same as a standard consumer market model, in which the things for sale and purchased are excess to necessities, so that all transactions are wholly volunteer.

[Nederland]

67. Not really

There are many things in that proposal that Newt would hate, like the nationalized insurance plan and subsidies for the poor.

The frequency of events is irrelevant, and I'm not sure why you think it matters. People don't choose to have car accidents, stopped-up plumbing or broken windows either, but we have a perfectly good market for auto repair, plumbing and window repair.

[The Magistrate]

68. You Continue, Sir, To Ignore The Difference In The Stakes

My grandsons routinely ruin window-screens; we repair them, but it is a trifle of little importance, the flies get in in summer-time anyway.

Even broken plumbing can be lived around for a while, while one assesses the prices and competence of various tradesmen.

Get that vivid line leading up the leg from a cut gone septic near the ball of an ankle, perceived through a haze of pain, and the stake is limb or life, and there is no time to waste in investigating prices.

[Nederland]

70. In the long run, people will alter their behavior

Let me give you a simple, real life example.

A few years back during a point in time that my wife and I did not have health insurance, our son got a fever. What we did represents a sad but unfortunately all too common tale. We agonized over whether or not to go see a doctor because we worried about the cost. Late into the night, the fever hit 104 and we said fuck it, we don't care what it costs we're going to the hospital. Our son was seen by a doctor who spent maybe five minutes with him and we sat in a hospital room for three hours with a nurse checking up on us every half hour or so. The fever went down and we left. In sum total, maybe 15 minutes of professional time was spent with us, and a dose of Tylenol given. The grand total for those services? $1600, paid for out of pocket.

Now, I will grant you that under those circumstances nobody is going to "shop around" to see what hospital is going to give you the best deal. But imagine what would happen if we had a system like I described--a system where costs like that had to be paid for out of a personal account by everyone. What would happen, sir, is we would have been charged that outrageous sum and never gone back to that hospital ever again. And we would have told every single one of our friends and co-workers what happened, and they would never go back to that hospital ever again. And every single other couple who had that happen to them at that hospital, and every one of their friends, would never enter that hospital again.

Do you think maybe such a market force would, sir, have an affect on how much money that hospital charged?

Market forces work, even when events are not chosen, even when events are unpredictable, and even when there is no time to shop around.

[The Magistrate]

75. So, Sir, You Have Had A Welcome To the Real World Of This

The charges levied on you went to subsidize care given to persons unable to pay, and lower charges forced on the hospital by large insurance concerns, and even by Medicare. Having no insurance, and being in no position to avoid the debt, you were given an impromptu tax to fund a necessary public service. Any hospital would have treated you the same; none exist or could exist at present that would do otherwise. Nothing in your proposal would alter this, because there will always remain, under our economic arrangements, a substantial body of persons who cannot pay for medical services from their own resources, no matter by what means one attempts to extract it from them in full.

One of the great virtues of a government administered single-payer system is that it levels, and it always pays. Save through the medium of taxation, no one subsidies anyone, and necessary subsidy is borne by those best able to pay taxes, or in other words, those who are most favored by our economic arrangements.

[Nederland]

77. You make no sense sir

The charges levied on you went to subsidize care given to persons unable to pay, and lower charges forced on the hospital by large insurance concerns, and even by Medicare.

Let me get this straight. At a point in time that I couldn't afford health insurance, I received a ridiculously large hospital bill...to help people that can't afford health insurance?

There is no benefit to distorting the true cost of things. None. Hospitals should be forced to publish how much procedures cost and how much they charge for them. They should leave redistribution of wealth and subsidies up to the government.

More importantly, I noticed that you completely ignored the fact that I conclusively demonstrated that the market can indeed have an effect on health care prices.

[The Magistrate]

78. It Is Not Me Who Makes No Sense, Sir

You were charged what you were charged for the reason and the purpose described. That is how the present system works. There is nothing in your 'savings account' proposal that would change that, since a great many people would still be unable to maintain such accounts, absent a direct subsidy from the government. If the government is going to pay, which it would have to, it might as well skip the intervening step, and pay the provider directly. Under a system of government administered single-payer reimbursement, the hospital would have got its 'true price' for every service provided anyone, including you, and been shorted by none nor forced to pile charges onto any.

[Nederland]

79. You do not understand, Sir

The reason you have accounts is to give people a reason to care about how much their health care costs. If government just writes checks, that incentive gets lost. There is a huge benefit to having hundreds of millions of people scrutinizing costs and looking for ways to save money. And yes, that incentive would apply to poor people as well. Government would contribute to their medical spending accounts, and if they work hard to stay healthy and keep their costs low, they could pull money out of the account as described in post #64. Sure it's a transfer of wealth and Newt Gingrich would hate it, but I love the idea.

[The Magistrate]

81. The Disbursing Authority, Sir, Always Cares How Much It Pays Out

Large insurance companies pay less to doctors than small one, persons without insurance pay individually more than even persons insured by smaller companies; Medicare pays like a large insurance company. Medical facilities have fixed costs in plant and personnel that must be met; there are limits to the price elasticity of even non-profit private hospitals. Your system depends on government money being paid directly to people who are on the lower end of the income spectrum, and so introduces an unnecessary complication to the payment process, and to no benefit. You may forgive me for my disinclination to genuflect before the altar of 'the free market': it is a false idol, and does not receive my worship.

[Nederland]

83. You keep saying there is no benefit, Sir, and you are wrong

I repeat: there is a huge benefit to having hundreds of millions of people scrutinizing costs and looking for ways to save money. Right now you have a small handful of people at insurance companies and government working hard to lower costs--I'm talking about expanding that pool into millions of people. And let's be honest about all those people working for insurance companies trying to lower costs. If they discover a way to save a million dollars, how do they benefit? They don't, the fat cat at the top of the insurance company does. Not a very big incentive, eh? The bigger crime is how insurance companies and government try to lower costs. They try to lower costs by refusing payment and creating byzantine rules and regulations that seek to determine whether or not a particular procedure is "needed" or "covered". This overhead is completely unnecessary and disappears in my system, replaced by millions of people that will do it for free.

[The Magistrate]

84. You Are a Devotee of An Economic View, Sir

Which makes conversation with you a little difficult. Regarding outcomes, the actual fact is that countries similar to ours employing government run systems in one form or another have better life expectancies, better performance at preventing untimely deaths, and lower costs. The reason we do not imitate these examples of successful systems is the presence of entrenched special interests dedicated to wringing profit out of a human necessity, and managing to do so well enough to own a sizeable portion of the Congress and our political parties. You are claiming, out of an excess of devotion to free market theory, that a rigged up system involving forced savings by and government subsidies to individuals will do a better job than government run systems already successful and in place throughout the developed world. There is no particular reason to think this. Medical treatment has no natural equilibrium between demand and price. In individual instances, the demand is either urgent desire to avoid death or crippling or pain, in which calculations of cost are no object, or the thing can be forgone more or less indefinitely according to taste, while the plant and personnel necessary to deal with the worst must be maintained in readiness for episodic utilization.

"In theory, there is no difference between theory and practice. In practice, there is always a difference."

[Nederland]

85. I have Evidence, Sir, not Dogma

First of all, my suggestions are hardly those of a free market devotee. There is much that I have suggested that would cause Ayn Rand to roll over in her grave. In the minds of free market devotees, perfectly efficient systems appear magically out of thin air curtsy of the invisible hand. I have proposed a system created by government, regulated by government, and run by the people. That is hardly libertarian.

More importantly, my opinion is not driven by dogma, but driven by the evidence. You are correct in asserting that there are other countries with single payer systems that have better outcomes than we do. I have never denied this. What I assert is that we can do better than even those countries with single payer systems. The evidence for this is the model of Singapore. Singapore has a model much like I have described, complete with compulsory medical savings accounts and significant government assistance to the poor. The results speak for themselves. Singapore spends (per capita) one third of what Canada and France spends on health care, and yet their life expectancy and infant mortality rates are lower. Don't you think that a system that spends one third the amount while producing better results is worth emulating?

[The Magistrate]

87. Not Really, Sir

Your pocket-sized example has radical differences with our society, even beyond the tremendous difference in size. That is a place where people are fined for chewing gum, and where the level of government intrusion, intrusion happily accepted by the populace, verges on the bizarre. Things cannot simply be scaled up, in any case: a mouse the size of an elephant would look very like an elephant, at least in the legs and spine and pelvis and ribs. it could not sustain its own weight otherwise.

[Nederland]

88. It's size works against it, Sir

Everyone knows that in order for a market to function well, it must have a certain minimum number of consumers and producers. The fact that Singapore is significantly smaller than the US and the system still works well only serves to further demonstrate it's effectiveness.

[Raineyb]

93. Your problem seems to be that you view health care as a commodity not unlike

cars or televisions and as such people can be expected to save up for it and not obtain it if they don't have the money for it (or worse go into debt to pay for it which by the way is the reason why over half of bankruptcies happen in the first place, people use credit to pay for medical care and 75% of those people HAD insurance to begin with) Health care is part of the commons and as such should not be treated like a product which people can go without. It should be on par with police and fire protection. Are you proposing that we give up our single payer military and have everyone negotiate or take out government subsidized loans in order to take care of a criminal matter that comes up?

As long as you adhere to the monstrous ideology that the market solves anything nothing no matter how well explained will make sense to you. The Magistrate is correct here and you are dead wrong (pardon the pun) your idea of giving money to the individual who is least able to negotiate prices rather than using the tax system and its size to get the best prices possible is for lack of a better phrase ass backwards.

[Nederland]

101. That is a dogmatic argument

Your argument seems to be that because my solution is based on the principles of the free market, it won't work. Besides disagreeing with your categorization of my solution being free market, that is not a logical objection, it is a dogmatic one.

[The Magistrate]

107. Since You Are Pressing a Dogmatic Argument, Sir, You Forfeit That Ground Of Objection

You have yet to deal with the ways in which the need for obtaining medical intervention does not fit into standard market models, which suppose wholly voluntary action by both parties to a transaction.

[Nederland]

110. That is not true

In post #64 I have conceded the need for a national catastrophic health insurance plan that is single payer based. That concession covers the instances where medical intervention does not fit standard market models.

[The Magistrate]

95. No, Sir, It Assists On Several Levels

Compactness, uniformity of condition, degree of control and personal quality of supervision down to smallest detail, benefit any program. In a country which has both a high per capita income and a reasonable flat income distribution, with the upper tenth enjoying only a fifth of the income and the lower tenth still possessed of a twentieth of the whole, health outcomes will be better whatever the system employed. By comparison, in the United States, the lower tenth commands little more than one percent of the national income, while the upper fifth enjoys half the income total.

[Nederland]

100. You argument flies in the face of the facts, Sir

Have you ever heard of economies of scale? Per unit costs drop when size increases, they do not rise. A larger nation can deliver services to its population at a lower per capita cost. This is an empirical fact.

[The Magistrate]

105. No, Sir, It Does Not

Your attempt to scale up what is done in one tightly run city to a continental scale ignores basic facts of the different societies.

Economies of scale, by the way, do not affect craft work, which the practice of medicine definitely is. Craft work must be converted to industrial labor on pattern in order to take advantage of scale economy, or in other words, must change its nature from that of a single person applying skilled labor to several persons with little or no specific skill working by rote. In the practice of medicine 'economy of scale' can be had only in purchase of supplies and equipments.

[Nederland]

109. You are not speaking of the difference between the systems, Sir

You are correct in asserting that medicine is craft work. However, in the context of what were are debating, that is irrelevant. In both the US and Singapore, the actual practice of medicine would be identical. The claim you make is that the number of people in a US system would adversely affects unit cost. Not only is that not true, it is precisely backwards. The cost of developing software to manage the health care records for a country with 300 million people does not cost 30 times more than one designed for country with 10 million people. The cost of running and maintaining such software does not differ by a factor of 30 either. And that is but one example of many which I could list for you.

You continue to deny what is patently obvious: economies of scale apply in this case.

[The Magistrate]

112. Are You Seriously Pressing This Further, Sir?

You are now claiming your suggested system will have lower administrative costs than what is essential a several times upscaled Medicare program?

Your system requires means-testing for subsidies, and loans, and maintainance of sequestered bank accounts, means-testing for collection of loans, collection of loans, a sizeable number of different private companies with different policies, separate facilities, and that is just off the top of my head. This you feel will have lower administrative costs than a system where all medical establishments send a bill to a single government authority, which pays with a check on the Treasury according to a schedule worked out by a single office within legal guidelines set by the Congress. The contrast between administrative costs of Medicare and the sum of those of private insurance companies already makes hash of your supposition: yours costs far more to administer, in total.

Again, what is paid for basically in the provision of medical care is the application of personal skill to a problem, and that is the bulk of the charge billed. Certainly the costs of drugs can be subject to economies of scale; indeed, a monopsonist purchaser can dictate prices, and that is what a government administered single-payer authority would be, in chemically pure form. This sort of power over price cannot possibly be provided by the fragmented system you are pressing for cost containment.

[Nederland]

114. You misunderstand me sir

I must apologize, because I edited my previous post to more clearly make my point, but you had already responded. You asserted that the Singapore model would not work in the US because of differences in size. You make the incredible claim that because it is a bigger nation, if the US were to apply the Singapore model its unit costs would be higher. This assertion flies in the face of both reason and experience, as the example I provided details.

[The Magistrate]

116. That Is Simply One Of Many Reasons, Sir

A sufficiency of which were set out plainly.

You are evidencing here, Sir, an instinct for the capillary, and that just will not do....

[Nederland]

121. Let us consider the others then, Sir

Breaking apart post #87 sentence by sentence:

1) Your pocket-sized example has radical differences with our society, even beyond the tremendous difference in size.

2) That is a place where people are fined for chewing gum, and where the level of government intrusion, intrusion happily accepted by the populace, verges on the bizarre.

3) Things cannot simply be scaled up, in any case: a mouse the size of an elephant would look very like an elephant, at least in the legs and spine and pelvis and ribs. it could not sustain its own weight otherwise.

Sentences #1 and #3 both have to do with your claim that the Singapore model cannot work in the US because of differences in size. I believe I have sufficiently dispensed with that ridiculous notion rather persuasively.

That leaves one further reason, stated in sentence #2. How you consider one further reason to be "one of many" I do not know, but I will address it nevertheless. Yes, there are certainly cultural differences, but the same can be said of European countries. In fact, this argument strikes me as disturbingly similar to right wing arguments as to why single payer would not work here like it does in England. England, they say, has a population that is very different from America. Cameras are everywhere and government engages in a level of intrusion that Americans would never accept. The argument is, of course, ridiculous. Whether or not a particular health care system works depends upon whether that system accurately models how people think and feel about their health and the maintenance of it. I would argue that how people think and feel about health care is a result of human biology, not culture. The urge to care for one's offspring, and a willingness to pay any cost to insure their survival, for example, is a common urge regardless of culture because it is rooted in our shared biology. No sir, I believe you will have to come up with more than a difference in chewing gums laws to prove that models based upon needs and desires derived from biology are not applicable to humans everywhere.

[The Magistrate]

123. It is Not My Custom, Sir, To Often Repeat, But a Reminder Of No. 95 Seems Warranted Here

"Compactness, uniformity of condition, degree of control and personal quality of supervision down to smallest detail, benefit any program. In a country which has both a high per capita income and a reasonably flat income distribution, with the upper tenth enjoying only a fifth of the income and the lower tenth still possessed of a twentieth of the whole, health outcomes will be better whatever the system employed. By comparison, in the United States, the lower tenth commands little more than one percent of the national income, while the upper fifth enjoys half the income total."

You have not to the slightest degree 'dispensed with' the obvious differences between a system extending to the city limits and one encompassing most of a largish continent, between a small number of people of fairly uniform condition and employment and a large number of people of greatly variant condition and occupation. One wonders how much you suppose the Transportation department of Rhode Island could teach their of California or Texas about maintainance and engineering.

[Nederland]

126. You are correct, Sir

I failed to include those objections and will dispense with them immediately. Your arguments, sentence by sentence:

1) Compactness, uniformity of condition, degree of control and personal quality of supervision down to smallest detail, benefit any program.

2) In a country which has both a high per capita income and a reasonably flat income distribution, with the upper tenth enjoying only a fifth of the income and the lower tenth still possessed of a twentieth of the whole, health outcomes will be better whatever the system employed.

3) By comparison, in the United States, the lower tenth commands little more than one percent of the national income, while the upper fifth enjoys half the income total."


1) I'm not sure what you mean by "compactness". If this is a restatement of the size issue, I have already dispensed with that argument effectively. With regard to "uniformity of condition", I disagree. Certainly there is a greater diversity of employment in the US, and that may result in a slightly different cross section of diseases, but I fail to see why that would have a crippling effect. Degree of control is completely dependant on the legislation you pass. If you need a certain degree of control, you write it into the legislation. The only limit is the Constitution, and I fail to see how my proposal would violate that. Personal quality of supervision assumes that their is a significant difference between the abilities of Singapore citizens and US citizens. I have not seen any evidence of that, but am open to hearing of it.

2 & 3) You seem to assert that the difference in distribution of wealth between the US and Singapore makes the application of the Singapore model in the US impossible or at the very least unwise. I would have to point out that this exact same argument could be made of single payer. If the differences in wealth distribution are significant, how can you argue that the differences between the US and Singapore are relevant, but the differences between the US and Canada are not? Regardless, you have not explained why differences in wealth distribution matter. I fail to see why they are. Certainly one result of that difference is that in the US a larger percentage of the population would require subsidies to their medical savings accounts. Why this would make things impossible I am at a loss to explain. It seems akin to arguing that a income tax of 25% will work, but one of 35% will not. It is simply not true. If you need more money, just raise the rate. Whatever amount of money you need will be similar regardless of how you achieve universal coverage, so if you have a logistical or economic problem here you will have it with single payer too.

Finally, you seem intent on pursuing the lost cause of size making a difference. I cannot fathom why you continue to press this. I have already conclusively demonstrated that there are certain advantages to having more people in the system such as reduced per unit administrative costs. Your example of Rhode Island being unable to teach Texas about transportation fails to apply. Rhode Island has a vastly different population density than Texas, and it is obvious why that makes a difference when building roads. While I do not deny that the US and Singapore are also different in terms of population density and other factors, it is not obvious why that affects the operation of medical savings accounts. You cite the differences, but do not explain why they matter. To prove your point, you must do so.

[The Magistrate]

127. You have Made No Demonstration, Sir, That The Difference In Size Of the Social Units Means Nothing

And there is nothing to be gained by repeating the exchange over and over. If you cannot see the differences by now, nothing will get through to you. Anyone who has followed the exchange to this point will be able to make up their minds on the question. We are just spinning wheels at this point....

"Say something once, why say it again?"

[Nederland]

130. The burden of proof is on you, Sir

For you have made an extraordinary claim. You claim that medical savings accounts cannot scale up. You make this claim inspite of the plain fact that all other instruments of civil society scale up and exist in countries both large and small. Systems of courts and jurisprudence, means of assisting the poorer elements of society, systems to provide education, even single payer health care systems--all of these things exist in countries both large and small. What then is so special about medical savings accounts that make them impossible to scale? You have given no reason, and so you have proved nothing. If I were to say to you:

"I know that Malta has an excellent single payer method of delivering health care, but such a system cannot possibly scale up to a country the size the the United States. This pocket-sized example has radical differences with our society, even beyond the tremendous difference in size. Things cannot simply be scaled up, in any case: a mouse the size of an elephant would look very like an elephant, at least in the legs and spine and pelvis and ribs. it could not sustain its own weight otherwise. Compactness, uniformity of condition, degree of control and personal quality of supervision down to smallest detail, benefit any program. In a country which has both a high per capita income and a reasonable flat income distribution, with the upper tenth enjoying only a fifth of the income and the lower tenth still possessed of a twentieth of the whole, health outcomes will be better whatever the system employed. By comparison, in the United States, the lower tenth commands little more than one percent of the national income, while the upper fifth enjoys half the income total."

How would you respond, Sir? Would you concede that I had proven that a single payer model cannot possibly be scaled up? I think not, nor should you, for I would have proven nothing unique about the nature of single payer health care systems, just as you have proven nothing unique about systems of medical savings plans. The very fact that I was about to cut and paste your posts without alteration proves my point. Your posts do not even contain the term "medical savings account". I ask, Sir, if your posts do not contain the term "medical savings account", nor any description of them, nor any direct discussion of their nature, how can you possibly claim to have proven anything about them?

It is a logical impossibility, Sir, and proof that you have lost this argument.

[The Magistrate]

133. That Is A Very Tired Wheeze, Sir, And Will Impress No One

Essentially, it is simply a confession on your part you are begging the question, assuming as proved already what you are setting out to prove. Your simply stating a thing is true prior to another's comment on it does not entitle you to claim a burden of proof falls on subsequent commentators; seniority in order of comment does not entail any presumption of truth. Nor is it in any way an extraordinary claim to say that the arrangements of a city-state cannot readily be translated to the arrangements of a continental power; indeed, that has been well appreciated throughout political history, and particularly marked in discussions of democracy and taxation. Your 'example', above, falls of the weight of its ignoring much larger political units, within the same general cultural pool and historical stream, in which the measure mentioned obtains, and does so successfully.

In your promotion of Singapore, you over-look a number of factors. One is that its 'healthy life expectancy', the measure of the expected number of years to be lived without reduced functioning due to illness or disability, is lower than that of European countries. Another is that the proportion of elderly persons among its population is markedly lower than in European countries, as well as the United States and Japan; the increase in population of the place, rising with its prosperity, is recent, and so its population mix still approximates more that of the developing rather than the developed world. Taken together with other factors already mentioned, this suggests that the city-state's medical system has yet to be truly tested, and it remains to be seen how well it will cope with an aging population, such as is encountered in large Western countries. By far the largest portion of medical billings are generated in the last few months of life, and are concentrated on the elderly. In Singapore, individuals pay roughly two-thirds of medical expenditures, a higher proportion than even in the United States, and this is workable only in a polity with a reasonably even distribution of income, which certainly does not obtain in the United States. A further factor is the large population of 'guest workers' imported into Singapore, who work very cheaply at a number of tasks, including basic nursing aide care, and who do not appear in the city-state's health statistics, which relate only to its citizens, and do not seem to be covered by its health care structures. This introduces a considerable fudge-factor into both costs and claimed outcomes for the system. If one simply excluded the lower fifth of the population in the United States from its health care statistics, these would improve drastically in terms of life expectancy, disease outcomes, etc.

[Nederland]

134. A simple question, Sir

Do you concede that in posts 87, 95, and 105 you make no mean of the term medical savings account, nor do you describe any of its attributes?

To assist you, here are your posts:

Post #87: Your pocket-sized example has radical differences with our society, even beyond the tremendous difference in size. That is a place where people are fined for chewing gum, and where the level of government intrusion, intrusion happily accepted by the populace, verges on the bizarre. Things cannot simply be scaled up, in any case: a mouse the size of an elephant would look very like an elephant, at least in the legs and spine and pelvis and ribs. it could not sustain its own weight otherwise.


Post #95: Compactness, uniformity of condition, degree of control and personal quality of supervision down to smallest detail, benefit any program. In a country which has both a high per capita income and a reasonable flat income distribution, with the upper tenth enjoying only a fifth of the income and the lower tenth still possessed of a twentieth of the whole, health outcomes will be better whatever the system employed. By comparison, in the United States, the lower tenth commands little more than one percent of the national income, while the upper fifth enjoys half the income total.

Post #105: Your attempt to scale up what is done in one tightly run city to a continental scale ignores basic facts of the different societies.

Economies of scale, by the way, do not affect craft work, which the practice of medicine definitely is. Craft work must be converted to industrial labor on pattern in order to take advantage of scale economy, or in other words, must change its nature from that of a single person applying skilled labor to several persons with little or no specific skill working by rote. In the practice of medicine 'economy of scale' can be had only in purchase of supplies and equipments.

[The Magistrate]

135. You Have My Thanks, Sir, For Re-Posting My Material

Repetition is important in moving perceptions. The science of advertising is based on understanding that what people recall greatly influences what they think, and what they are exposed to most often is what they first recall. Purchase of time is based on a calculation of what will ensure the exposure of a target audience to the material a number of times deemed to sufficient to be sure it lodges solidly in the mind, and will be recalled when the need to be satisfied by the product comes to the fore. There is not much difference between the purchase of candy and the settling of positions on political issues.

When you are prepared to address the tremendous difference between the situation of Singapore, a city-state under totalitarian rule operating on the Confucian cultural pattern, and the United States of America, a continental-based imperial power, under more or less democratic rule operating on the fading principles of the Enlightenment, we may be able to press this conversation further. Until then, there is no point to it any longer.

"The trouble with our time is that the future is not what it used to be."

[Nederland]

137. You run from the argument, Sir

Just answer the question. It is a simple thing...

[Raineyb]

90. Loans? So you think on top of the illness and the expenses needed to care for that

that people should have to go into hock?

What the hell is wrong with you? No not all health care is emergency care but when you don't have the money to pay for a doctor's visit that's when you end up taking care of your medical needs.

I think you are on the wrong board. Free Republic is that way ----->

You talk like a Republican and they don't give a shit if people die either.

[Nederland]

92. Read post #64

It better explains what I am proposing.

[Raineyb]

94. What you're proposing does not work and frankly is rather

monstrous. It also treats health care like a car when it should be treated like part of the commons. It's just wrong no matter how you parse it.

[Nederland]

99. It does work

It works in Singapore, it could work here.

http://business.theatlantic.com/2009/06/in_health_care_do_we_all_lose_to_singapore.php

[Zoeisright]

49. Response

Your responses are heartless and cruel.

[elehhhhna]

55. Yeah. That's why all Europeans are dead now. Not enough HC resouces to go around...

when everyone's covered.

Quit now while you're behind.

[Nederland]

58. Not sure what you are talking about

I don't recall saying that Europeans are all dead. I better re-read my OP.

[elehhhhna]

63. honey, you don't even know what YOU'RE talking about.

lol.

[Nederland]

72. Oh but I do

I'm talking about health care.

[Raineyb]

115. No you're not. You're talking about making sure people can't afford it.

It's the opposite of trying to solve the problem we have in this country.

[phantom power]

3. The countries that have it seem to like it plenty.

:shrug:

[Nederland]

10. Yes they do

But only because they are ignoring the coming fiscal reality. From 2000 to 2005, per capita health-care spending in single payer Canada grew by 33 percent, in France by 37 percent, and in the U.K. by 47 percent. During the same period in the US, per capita spending increased 40 percent. Obviously both our ridiculous system and their ridiculous systems are experiencing an unsustainable rates of growth. Growth that exists because in both systems, patients do not care about costs.

[phantom power]

26. Interesting. Still, a single-payer scenario has its own feedback facilities...

For example, Canadians still do pay for their health-care, they just do it via taxes. So, Canadian voters are exposed to those increasing costs, and they have the opportunity for input into what gets done about it. Or, the Candian govt can directly influence what it chooses to pay for, and how much.

One thing about the "individualized, market-based" scenario that is a real problem: spending decisions about health care deeply violate the "ideal-consumer" model, in at least three very important ways:

1) In many cases, there is not time to make a rational cost/benefit decision. For example, suppose I've got a racing heartbeat and a left arm that feels funny. Do I (a) call the ambulance (a huge expense) (b) drive myself to emergency room, or (c) do nothing? How much time do I have to carefully think about it? BTW, this actually happened to me one time. It turned out to be dehydration and a fever, so technically (c) was the answer: lying down with a few glasses of water would have fixed my problem. However, I went to the emergency room. Why? Because it was presenting like a potential M.I.

2) Making rational cost/benefit decisions requires medical expertise.

3) Even in the situations where there is proper time and information for a rational decision, the fundamental cost/benefit relations in matters of health are deeply skewed. What amount of money will I pay to preserve my health? Or the health of my wife, or child? It's not the same as saying something like "well, I'll drive this old car for a few more years because that's the fiscally sound decision. Or ride the bus, or walk." There is no competitive alternative to being healthy, or remaining alive period.

[Nederland]

36. Response

1) In many cases, there is not time to make a rational cost/benefit decision.

True, but like you say, the percentages are rather low. How many times have you been to a doctor or hospital over your entire life so far? 20 times? If people are able to make rational cost/benefit decisions 95% of the time I think we should let them do exactly that.

2) Making rational cost/benefit decisions requires medical expertise.

True, and you should be able to get that by consulting with doctors and medical professionals. Not sure I see your point...

3) Even in the situations where there is proper time and information for a rational decision, the fundamental cost/benefit relations in matters of health are deeply skewed.

This is the real kicker. At some point we have to deal better with the reality that no matter how much money we spend, we all die.

[T Wolf]

5. There needs to be some responsibility on the part of the patient. BUT, once profit is taken out of

the monetary equation, the decision can be made on the basis of sound, MEDICAL, principles and guidelines.

We can at least hope that the decision criteria have the interests of the patient high on the list. With corporate control, that is not possible.

As to being removed from the cost consequences - some of us believe that everyone should get the same level and quality of care.

As with everything, the devil is in the details.

Should the plan (whatever it is) cover your infertility issues? That is a debate that can occur.

Should the plan cover cosmetic surgery, e.g., a nose job, for vanity?

Should the plan cover a nose job as part of facial reconstruction after a car accident?

These questions and terms can be debated (and voted on, if necessary).

But, the income of the patient or their "worthiness" to society should not enter into the decision, IMO.

I'm for letting the doctor and the patient decide, within the guidelines that are set up.

[Nederland]

7. You can never remove money from the equation

It simply cannot be done.

I know you said "profit", not money, but that isn't as much money as you think it is. If you confiscated all the profits of all the famously greedy health-insurance companies it would pay for only four days of health care for all Americans. Add in the profits of the 10 biggest rapacious U.S. drug companies and you add another 7 days.

Corporate profits are a problem, but eliminating them doesn't solve the problem.

[The Magistrate]

12. Profit, Sir, is Hardly the Sum Of It

Insurance companies pay out only four fifths of premium receipts on claims. This is greatly in excess of your 'four days' figure.

[Nederland]

29. Very true

Would you agree that demand for any product that saves your life and costs nothing is infinite?

There is a reason why insurance companies act the way they do.

[The Magistrate]

32. Demand For That, Sir, is Infinite Whatever It Costs

That is the root of the problem of treating medical care as an ordinary item of the marketplace.

[Nederland]

37. Exactly

But the point of the OP is that both our system and single payer system pretend like that problem does not exist. Hard decisions can be made by individuals themselves or someone else. In our system, hard cost/benefit decisions are made by insurance companies. In single payer systems, hard cost/benefit decisions are made by government. I propose that we let hard cost/benefit decisions be made by individuals. In the end, I suspect some people would be more comfortable not having to make those decisions and simply bitch about the decisions other people have made for them. We can give them that option, but personally, I wish I at least had the option to chose.

[The Magistrate]

41. There Is No Point To This Line, Sir

The fact of the matter is that very few people have the money to pay to any major medical emergency out of their own resources. Most people in a situation requiring medical efforts would simply have the decision taken out of their hands by lack of ready funds and credit. This would not drop costs, as it might if we were discussing the provision of ten penny nails or air fresheners, it would simply reduce the number of people who went into medical practice, and the amount of medical care delivered, resulting in lower life expectancies and poorer health over-all.

The best model for this 'market' is that of regulated utilities, both at the provider's end and at the patient's end, with the latter grouped into a single nation-wide insurers' pool, which can be best administered by the national government, and best funded by regular taxation.

[Nederland]

43. That's just plain wrong

The fact of the matter is that very few people have the money to pay to any major medical emergency out of their own resources.

The simple fact of the matter is that the US spend over 2.2 trillion dollars on health care every year. Where does that money come from? Ultimately it comes from us. Whether it is taxes or insurance money, the money is coming from us. How can you possibly say that we don't have enough money? We are already spending it, I'm just proposing that we spend it differently.

[The Magistrate]

44. Do You Imagine, Sir, That Money is Evenly Distributed Among Some Three Hundred Million Individuals?

It is hard to imagine you do, but anything is possible in an infinite universe....

You seem to be proposing individuals bear individually the costs of treatment; many will not have at their disposal the funds to pay for needed treatments. To them, it will make no difference that, to some other individual, the amount required for that treatment falls into the pocket-change category.

[Nederland]

54. Sorry

I guess I wasn't clear. What I was proposing is something similar to what they have in Singapore.

http://business.theatlantic.com/2009/06/in_health_care_do_we_all_lose_to_singapore.php

[The Magistrate]

61. That Hardly Counts As a Pilot Project, Sir, On the Scale We Are Discussing

The 'mechanism' you suggest in commencing this discussing, that the government loan money to people to pay for medical procedures, anticipating repayment out of taxes, hardly alters the situation from that of a government administered single-payer scheme. The patient does not control the expenditure, merely signs a note under duress, in an emergency in which actual possibilities of repayment will be the furthest thing from his or her mind.

Your idea is premised on the belief that people have sizeable amounts of disposable income they could sequester to pay for future health emergencies. Whatever average figures might suggest, this is nonesense in a great many individual instances, and since the stress on the health of poor people runs perceptibly greater than it does on the well to do, health emergencies will occur disproportionately among that swathe of society which has little if any such sequesterable income, and little prospect of repaying any such loan. No matter how you torture it, it is going to work out to a subsidy, and to a great many people necessarily not being able to pay from their own resources for care they need to preserve or extend their lives, or to end pain or alleviate disability.

[Nederland]

65. See post #64 (nt)

[The Magistrate]

15. If You Are Trying Cold, Sir, Try This: Your Infertility Expenses Are Wholly, Absolutely Optional

Properly speaking, they are not even remotely a part of health care, no more than a tummy-tuck and a set of hair plugs would be.

The fact is that no one in need of medical intervention is a customer in the normal sense of the word. A person in need of medical services is always under duress, facing some combination of pain and threat to life or limb. In such circumstances people do not make 'informed rational market choices' and indeed, in most cases, they are not allowed to to by emergency and medical personnel.

That a government single-payer system would cost money is hardly news, nor an earthshaking revelation. It is something everyone knows. The benefit of such a system is that the costs can be borne out of general revenues, the ordinary receipt of taxes by the national government.

[Carl Skan]

16. The "ordinary receipt of taxes"

is nowhere near covering the current costs of our government, let alone additional obligations.

I have no problem with increasing taxes to the point to cover it, but please don't we have the money to spend.

[The Magistrate]

17. Governments Do Tend To Operate At a Deficit, Sir

That has been the case for long enough it may be counted the normal state of affairs. It should not be much trouble to devise a law which would direct most of the stream of monies now siphoned off into private companies purporting to insure against costs of illness into the Treasury.

[Carl Skan]

20. You're right

If the past few years have taught us anything it's that credit is and always will be available and that spending without regard to whether we can pay for it is the responsible thing to do. There's no way China will ever put an end to the funding of our refusal to face the price of our excesses and wars.

We really have no need for that $250 BILLLION a year we spend on interest alone. I mean seriously, what could we do with that money any way?

And no, not all governments run at an operating deficit. It's a zero sum game. Where do you think the money comes from? The debt fairy?

[The Magistrate]

21. China, Sir, Cannot Wound Us Without Grievous Harm To Itself

"Alliance, n: A union of two states with their hands so deep in one another's pockets they cannot separately plunder a third."

[Carl Skan]

22. Do you realize you have just turned over a billion people into our slaves?

You have decided that they should now continue sending us money forever, with no end in sight, and with no potential of ever getting it back.

Of course, that's no different than what we're doing now so I'm not surprised somebody would assume that China's proper place in this world as as our servants.

[The Magistrate]

23. Not My Problem, Sir: The Structure Of Things Is What It Is

China's government has chosen an export-driven economy, and to maintain it at its present levels, and expand it, they must maintain their customers in a position to make the requisite purchases. Tigers are easier to mount than to dismount....

[Carl Skan]

27. And you Sir, in your extremely well thought out future see no change to that

I swear, as much as that "those who ignore history are doomed to repeat it" quote is repeated it's amazing how so many people fail to believe it.

In this case you don't even need much of a historical perspective, just look at the past few years. You sound no different than the fools that drug us into the current financial crisis.

If you want to avoid facing the responsibility of our actions, sir, please feel welcome to do so. I refuse to ignore the fate of future generations just so we can live more comfortably.

[The Magistrate]

30. What Do You Know Of the Fate Of Future Generations, Sir?

Are you returning from a visit?

It is more than possible to divert the premium stream now going to private companies into the Treasury. It is more than possible to re-arrange government expenditures from a variety of dead-loss items into more useful channels. It is quite possible, with better policies and direction, to revive and increase economic activity in our country.

[Carl Skan]

34. Oh, it is?

Then why isn't it being done?

[The Magistrate]

35. You May Well, Sir, Be Making Your Own Contribution To That

By arguing in favor of inaction and the status quo on this particular field of reform.

[Raineyb]

25. BTW, China itself is adopting a single payer system starting in January if I remember correctly.

Which will make our country even less competitive in the manufacturing sector.

I guess guess for some it's okay for us to pay for China's single payers system (by killing off all our jobs and outsourcing manufacturing there thereby sending our money over there so we won't have any money here to do anything for our citizens) but we can't pay for one here. At least that what the reasoning I'm hearing seems to boil down to.

[Carl Skan]

28. Yes, they're working back that way

after trying a more capitalist approach.

[Zoeisright]

46. THANK you.

I was absolutely appalled at the line of reasoning in the OP.

[cbdo2007]

18. Hey you better knock it off with your smart rationalizing and stuff around here.

I've tried bringing up the "intelligent" approach to fixing health care and it doesn't fly around here.

They only solution at DU is Single Payer with no questions asked. Free for everyone and everyone is covered for anything, no questions asked.

You can take you and your smartness on somewhere else with all these smarts. It's Single Payer or the highway!!

[Laelth]

19. There is much truth in what you say.

The only answer you give, however, is "pay more out of pocket." Force the patient, not the government or the insurance bureaucrat, to make the decision.

Yet, in the same breath, you recognize that humans are incapable of making that decision (and I would say this applies regardless of the cost and regardless of how much may have to paid out of pocket). That's why we have bureaucrats make the decision for us. We're incapable of doing it for ourselves.

But even if I were to agree with your proposal, the new out-of-pocket costs would have to be progressive (based upon a percentage of income) in order to be fair. Otherwise, the rich would get all the coverage they wanted and the poor would be highly disadvantaged.

All in all, I might entertain a proposal like that if it could be made fair and if I actually believed people were capable of making such decisions rationally.

:dem:

-Laelth

[lefthandedlefty]

24. Everytime I have gone to the doctor I was the customer

I paid every dime out of my own pocket.The Dr. charged 800.00 to deliver my son 24 years ago he might have been in the room 10 minutes to catch him when he came out anther Dr. charged me 1200.00 to fix my hernia 10 years ago that took him less than 30 minutes.

[TxRider]

33. I disagree

The real problem is that health care has never been considered a right in in this country.

To many it is still not considered a "right" as it is other countries.

To many the idea of health care for those who cannot afford it should be charity if any, not forcefully taken through taxes.

If we were to establish in the minds of the majority of citizens that health care is as much a right as free speech, privacy or bearing arms this would an easy thing to get done.

[Nederland]

38. How do you pay for a right

...for which demand is infinite?

[Lucy Goosey]

48. That's what's done in a single payer system.

Isn't it?

And demand isn't really infinite. There's a lot of demand, but it isn't infinite. I'm not sick, and so at the moment I'm not consuming any healthcare goods or services other than an annual physical. I'm not demanding all of the medical treatments that exist just because my government (I'm Canadian) pays for them, and if I were demanding scores of unnecessary treatments, I would be refused.

The idea of whether it's a right or not is an interesting one to me. As someone who was born in Canada since the adoption of Medicare here, the idea of having to decide whether to get necessary medical services based on cost is foreign to me, but I don't know that I think of it as a right, per se. I just believe that everyone should have the same access to the health system, regardless of their bank balance or their pre-existing conditions.

Anyway, the example of infertility treatments isn't a good analogy for life-saving treatments. When someone has cancer, and the oncologists say they need chemo to have a chance at beating it, the choice is really very different from deciding whether or not to get a $500 genetic test. For what it's worth, infertility treatments aren't covered by medicare here (at least in my province), because they aren't seen as medically necessary, in terms of being life-saving, life-extending or illness-preventing. The supplemental coverage that I buy through my work (for $7 a month) has some coverage for infertility, but not the public system.

[Nederland]

71. You are correct

Demand is not infinite, but it does far outstrip supply. As a result, prices rise. But unlike a normal market, where rising prices results in lower demand, in single payer systems (and our idiotic system for that matter) people aren't directly paying for services, so demand doesn't change. All that happens is prices continue to rise. Which is precisely what we've see happening all over the world.

[Lucy Goosey]

74. Supply doesn't "far outstrip" demand in Canada

And Government regulation helps control costs. I realize that more regulation doesn't appeal to Americans, generally, but it works really well here.

[Nederland]

76. Sure it does

Otherwise you wouldn't have this problem:


A typical Canadian seeking surgical or other therapeutic treatment had to wait 18.3 weeks in 2007, an all-time high, according to new research published Monday by independent research organization the Fraser Institute.

"Despite government promises and the billions of dollars funneled into the Canadian health-care system, the average patient waited more than 18 weeks in 2007 between seeing their family doctor and receiving the surgery or treatment they required," said Nadeem Esmail, director of Health System Performance Studies at the Fraser Institute and co-author of the 17th annual edition of Waiting Your Turn: Hospital Waiting Lists in Canada.


http://www.cbc.ca/health/story/2007/10/15/waittimes-fraser.html

[Lucy Goosey]

80. The Fraser Institute is a right wing think tank,

and quotes and studies from them are highly biased. And even if it were true, wait lists for one particular service does not mean that demand "far outstrips" supply.

[Nederland]

86. Their data comes from the government itself (nt)

If you think it's wrong, prove it with a link to correct numbers.

[The Magistrate]

82. The Study, Sir, Seems To Mix Apples And Oranges

It blends procedures that are wholly elective with procedures that are aimed at chronic but not life threatening conditions, and seems to omit completely procedures that have some emergency character. It does not seem well designed as a diagnostic, but rather well designed to support an ideological view.

[Nederland]

91. Fair enough, Sir

Perhaps you will accept this evidence:


Government is investing $5 million to improve access to cardiac care, the first in a series of targeted investments designed to reduce surgical wait lists, Premier Gordon Campbell announced today.

“We understand the stress and anxiety patients and their families experience as they wait for the phone call to tell them their heart surgery is finally going to happen,” said Campbell. “As a result of all the hard work our health authorities, doctors, nurses and other health care providers have done to rebuild our health system, today we are able to make a real difference in the lives of these patients.”

More money for cardiac care will go to the Provincial Health Services Authority (PHSA), which works with the other health authorities to ensure all B.C. residents have access to high-quality specialized health care services such as cardiac surgery. A provincewide cardiac service means that whether a patient lives in Vanderhoof or Vancouver, they will receive equitable access to specialized medical care.

Right now, more than half of all cardiac patients receive surgery on an immediate basis, without any time on a wait list. This strong system for cardiac care in British Columbia will be supplemented with an additional investment of $3 million to add an estimated 160 extra open-heart surgeries in 2004/05 – a five per cent increase. Campbell said this additional investment will mean the vast majority of even the lowest risk patients requiring cardiac surgery will not wait longer than three months for the care they need.


http://www2.news.gov.bc.ca/nrm_news_releases/2004HSER0055-000652.htm

Note that this is a press release that comes from the Ministry of Health itself, so claims of right wing bias do not apply. In this press release, the government admits that a shortage exists, and for this reason has allocated 5 million dollars to correct the problem. It is nice that they are trying to correct the problem, but it's a bit too late for those who died while on a waiting list, don't you think?

[The Magistrate]

103. What Do You Imagine This Proves, Sir?

People in emergency condition are treated immediately, people who are not in emergency condition wait. That is the same everywhere. Doubtless in some instances misfortune occurs in the interim; perhaps the situation was more serious than the doctor supposed, or the whimsey of the universe just got in early innings on something that might as easily have gone for a decade without incident. That the Canadian authorities are responding to the desires of their constituents for improvement is commendable, but hardly indicates some great problem or a prevailing condition of great risk.

Age-adjusted death rates from cardio-vascular disease in Canada seem to run about 230 per hundred thousand, while in the United States, the figure is about 275 per hundred thousand.

[Nederland]

111. I imagine it proves that shortages of supply have existed in Canada, Sir (nt)

[The Magistrate]

113. They Exist Here, Sir: They Exist Everywhere, And Must, Given The Nature Of The Demand

The only differences are in the means by which the deficit of supply is regulated. Here, it is by ability to pay, which in practice hinges on wealth, or condition of employment, or age, with those employed by large concerns, and those old enough or young enough for government largesse, getting a better shot than those of working age who are employed by lesser concerns, or more callous ones. And, of course, any sustained illness means losing one's employment, and likely going to back of the line in the midst of illness. In Canada, it is done by assessment of the degree of danger the patient is in at present, and where this is not acute, by order of application. The outcomes of the system indicate which may be judged superior in tending the health of the populace. Figures for cardio-vascular disease were given above, so such a judgement can be made on this segment of over-all health.

[Nederland]

118. Then we are in agreement, Sir

I was merely responding to the poster who claimed that demand did not far outstrip supply in Canada. It was a simple objection, nothing more.

[The Magistrate]

119. Not Really, Sir, Because Your Comments Go Beyond That

You have presented the thing in a manner suggesting this stems in Canada from its program of government administration of health care, in a way that makes its system lethal to patients, and that does not happen in a private system. The fact is that more people die of cardio-vascular disease in the United States through lack of timely medical intervention than do in Canada. A person who has undiagnosed cardio-vascular illness, because he or she was unable to afford check-ups and tests, dies just as dead as one who has had a diagnosis of symptoms deemed not immediately dangerous, yet has a fatal heart attack before a scheduled surgery.

[Nederland]

122. If I did suggest that, it was unintentional, Sir

Or perhaps an ill conceived overreach in an effort to make my point. In any case, I don't find any fault in anything you've written here. The US system sucks and the Canadian system is better. I merely believe that the Singapore model is better still. And that, Sir, is our main point of contention.

[The Magistrate]

124. Fair Enough, Sir

We are not ever going to agree on that, but no need to split the stream....

[TxRider]

50. Well..

I can't see demand being infinite, nor supply.

The basic issue is that opponents do not believe the poor homeless guy has a right to healthcare, paid for with their dollars.

Or that a cancer victim has a right to all modern medicine has to offer if that person cannot afford it.

Change that belief and single payers is easy. Trying to force it on people without that belief, especially when they may be in the majority, is going to be quite difficult.

Medicare was passed as a moral issue, a charitable issue. It was widely proposed that old people who had worked hard all their lives deserved health care paid for by all. And it was quite a tough battle.

[Zoeisright]

57. And I hope that your father

recovers from his cancer and lives many more years.

[Nederland]

59. Thank you (nt)

[Zoeisright]

60. You're welcome. Cancer is very hard.

Take care of yourself too. It's easy to neglect yourself when worrying about someone else.

[lumberjack_jeff]

98. Demand is infinite?

How many heart bypasses do you want this month?

[Nederland]

106. You're confusing two different concepts

And I concede that I was not specific enough in my post. There is unit demand and there is monetary demand.

The number of heart bypasses a person demands is limited.

The amount they will pay for one is not.

[lumberjack_jeff]

131. Demand may be inelastic, but it is not infinite. n/t

[Greyhound]

69. Another argument from the spokesman for the "I've got mine, fuck you" faction.

Any single payer system would not operate in a vacuum and one of the prime forces behind skyrocketing costs is the profit motive driven by the insurance companies that set the standards for "acceptable margins" in the industry.

Your argument is akin to the "it takes $400M to make the first pill" bullshit that the pharmaceutical industry (the most profitable industry on earth) keeps trying to feed us.

[Nederland]

73. Did you even read the whole post?

I'm calling the existing system idiotic and calling for change.

[Odin2005]

89. Healthcare is a right, not a commodity. You do what is necessary and find a way to pay for it.

If that pisses off the sociopathic bean-counters moaning about "efficiency" then fuck the damn bean-counters.

Utilitarian ethical arguments are BS.

[Cleita]

97. This OP

surfaces every few years with this type of BS. Years ago it was about Social Security. Now it's about health care.

[Nederland]

104. I never claimed that Health Care is a commodity

And I am perfectly willing to state flat out that it is not one. As a result, I don't understand your objection.

[Raineyb]

117. If you are willing to state that it's not a commodity why do you insist on treating it like one

because that's exactly what your scheme does.

[Cleita]

96. You again. Remember when you said we shouldn't have Social Security either

years ago? Actually, put your money where your mouth is and refuse your insurance and pay for everything out of pocket so you can be forced to make hard choices. But don't force your right wing ideas on everyone else.

[Kaleva]

102. Rec'd for being different

Altough I don't know if it's that much different. There has been discussions about insurance companies offering supplemental insurance for treatments and procedures not covered under a basic single payer plan.

[Kaleva]

108. An example of not having to pay out of pocket

Earlier this week, my wife fell and hurt her lower back. I took her to the ER and the doc on call told her she pulled some muscles and gave her a shot for the pain. He also gave her instructions on applying an ice pack to her lower back every two hours and to stay in bed as much as possible. The next day, still feeling the pain, she called her regular doctor's office and made an appointment for later in the afternoon to see him. I drove her over there. Her doctor checked her over briefly and instructed her to continue to follow the other doctors orders until the pain subsided. My wife wanted a test done to make sure there was no damage to her back but the doctor refused to do so, saying it wasn't needed and costs about $1800.00. My wife told him that her insurance would cover the entire bill (she has excellent coverage) but he still wouldn't do it. My wife was one mad woman as we left but her doctor was correct and she's feeling fine now.

I give kudos to my wife's doctor for sticking to his guns and not running unnecessary tests that would have paid for by the premiums others pay. But don't ell my wife that lest she cut my testicles off as she's still upset.

[DeadEyeDyck]

120. Good post but I got dizzy reading it

Here it is, simple as I can make it.

If I go to the doctor and it costs more than I pay in to my insurance, where is the money coming from. I know the answer but if we put that on a bug scale, it is still an answer I need. I am young and healthy and only go to the MD for my annual physical and flu shot. But others live in the waiting room.

Surely they are not paying to cover themselves.

[Fozzledick]

125. Excuse me, why are you ignoring the elephant standing on your foot?

The real problem with health care in this country isn't third party payment per se, which works fine in every other developed country on this planet, it's the roughly 50% surcharge created by the private insurance system. This includes not only the profits and excessive operating expenses of the insurance companies themselves, but also the totally wasteful bureaucracy and overhead doctors and hospitals are forced to pay for just to deal with the insurance companies' constant attempts to deny payment for legitimate claims.

This is the reason that less than 2/3 of the money we're now spending on "health care" goes for actual care, as opposed to 97% in Canada which is the most obvious case for comparison not because of their geographical proximity but rather because their practice of medicine most closely resembles ours. The amount spent on patient care in both countries is approximately the same, but the private insurance system leaves us with more than ten times the administrative overhead cost, worse outcomes due to denial of coverage, and far worse patient satisfaction with overall care delivery.

The gross discrepancy between individual and insurance prices is also a direct result of insurance companies gaming the system. When insurance companies demand a 50% discount for their continued business, hospitals simply double their base prices to adjust, and then wind up charging the artificially inflated price to the uninsured. To the extent that they are forced to lower their spending to what the insurance companies are willing to pay the result is degradation of the quality of care to the minimum they can legally get away with.

[Kaleva]

129. Medicare has it's own cost problems

There has been some threads here discussing it. Such as why approx. 3 times is spent on the average medicare patient in certain regions of the nation compared to others even though the measurable quality of care is about the same.

I'm a heating contractor and my profit margin on a furnace replacement job would be much greater if I convince the customer to purchase a unit that has all the bells and whistles on it compared to just a basic furnace even though the time to do the job would be about the same for either. In many cases, the higher priced furnace won't provide better heating for the customer but I'd make many hundreds more. There have been a few situations where I have recommended the higher end model because of the particulars of the situation but those instances are few. Sometimes a customer has insisted on the higher priced furnace even though I tried to explain to them that they'll never see a pay back on the cost difference.

[Fozzledick]

132. Do you have to get prior approval from an insurance company for each furnace you deliver?

Have you had to hire three full-time clerks just to handle the nit-picking paperwork required to receive payment from an insurance company for everything you do? Do you have to spend a good portion of your working time personally arguing with insurance company clerks over legitimate bills for furnaces you've already installed but that they refuse to pay in the cynical hope that you'll give up trying to collect? Do your customers have to deal with you through an insurance company that charges them a 25% surcharge on top of your price? Does that company require you to give them a discount price that eliminates most of your profit, and sometimes is actually less than your own costs, or else they won't allow their captive customers to buy from you?

That's the kind of nonsense that the private insurance system has imposed on medical care in this country. Whatever inefficiencies exist in the care delivery system itself are minor compared to the net 50% additional cost added by private insurance. And BTW, I speak from experience as a systems analyst and applications programmer for a critical care hospital and a service company specializing in medical office billing.

[Mind_your_head]

128. Bullshit. What insurance company is paying you to post this?

It's soooooo obvious.

[supernova]

136. By your own logic, you don't deserve fertility treatments

You must cease them immediately because those resource dollars can be used more productively on a healthier couple capable of having children.

Go on, I dare you to tell your wife you don't deserve fertility treatments.