Massachusetts makes health insurance mandatory

[Diceman]

Apparently, Massachusetts will require everyone (http://www.kpho.com/Global/story.asp?S=4729080) to have health insurance. From what I heard on the news this morning, they're going to offer insurance companies "incentives" to offer insurance to low-income families. According to the article, anyone who doesn't have health insurance is going to face tax penalties.

I know that lack of health insurance is a big problem in this country, but I'm not sure I like the idea of a law that says "buy health insurance...or else."

[JustAnotherGeek]

Can we just call it a socialized plan, yet?

I don't want to get into a debate about socialized vs. non medical systems, but this is horrible. The system needs revamping, but not this way.

Ick. :pukey:

[JustAnotherGeek]

Ick. :pukey:
:crap:

:smack:

[phall0106]

Oh, gee, this should work really well. (insert sarcasm smilie here) Lessee, it worked well with requiring car insurance to be mandatory...oh, wait that doesn't work too well, as I was hit by an uninsured driver a few years ago. And, if it's offered, but a consumer doesn't buy it, they'll be penalized (taxes)? Hmmm...so if a couple who have two children are both working, making minimum wage, and paying daycare, rent, buying food, trying to keep their POS junker car running (and buying the state minimimum required car insurance) so they can get back and forth to work, and living sometimes not from paycheck to paycheck, and can't afford to buy new shoes for the kids, then they'll be penalized for not buying health insurance through their employer? Holy, moly, what a concept. :smack:

Since this isn't the Pit, I'll stop there. But this is stupid, stupid, stupid. Don't they think that if people could afford to buy health insurance, they would?

[carnivorousplant]

Seems like a windfall for the insurance companies to me.
I've wondered if my auto insurance wold cost less if it wasn't required. :)

A better approach may be to provide insurance for those who don't have it rather than fine them. Fine companies that don't provide insurance for their workers and pay part of the premiums out of that.

[Sal Ammoniac]

It's actually difficult to figure out how much you need to make before you can no longer get subsidized insurance. I think the figure is high-ish. I was told by an activist pushing the legislation that it was in the $70,000 range, but I don't know if that's true anymore.

I'm feeling pretty conflicted about this. One the one hand, it's great to get universal(ish) coverage, but the approach taken basically negates one of the great advantages of universal coverage -- namely, administrative efficiency. With this law, we've just added new patches to what's already an incredible (and incredibly costly) patchwork -- new programs, new administrative overhead, changes to the tax code, etc. The administrative burden for hospitals, not to mention individuals, has been increased, even though hospitals benefit from not having to provide "free" care as much.

And phall0106, presumably the people you mention will be getting highly subsidized, if not free coverage. And while it may suck, it probably sucks less than getting forced into bankruptcy by medical bills.

[Sal Ammoniac]

Actually, one other thing I should mention. This is very much an "art of the possible" sort of deal. The activists weren't wild about it, but their line of thinking goes like this: once we establish universal care as the basic proposition, and introduce the notion that businesses will need to assume at least some responsibility for healthcare, then it becomes easier to talk later about a more rationalized and more efficient system.

[phall0106]

And phall0106, presumably the people you mention will be getting highly subsidized, if not free coverage. And while it may suck, it probably sucks less than getting forced into bankruptcy by medical bills.

A few years ago, I was working for a small nonprofit organization. I was making less than $32,000 a year, and although I had three children, I did not qualify for subsidized health coverage. (The kids did qualify for subsidized health coverage through a state program--which had a monthly co-payment of $49 per child.) I was barely making ends meet, and could not afford the extra $147 a month on top of child care (thank goodness it was only afterschool care at that point) and all the other expenses related to keeping a family clothed, housed and fed. And, yes, my employer did offer health insurance (for me and my family), but it was almost $300 a month in payments.

Just because subsidized health care is available doesn't mean that a family can afford it.

[Sal Ammoniac]

It's a valid point, though I do think they upped the subsidies to help in situations like yours. But your general point is correct -- this is an ass-backwards way of going about things. The best that can be said is that it's better than nothing. And I hope Massachusetts will inspire other states to do something saner.

[UncleBeer]

The activists weren't wild about it, but their line of thinking goes like this: once we establish universal care as the basic proposition, and introduce the notion that businesses will need to assume at least some responsibility for healthcare, then it becomes easier to talk later about a more rationalized and more efficient system.
Or death by a thousand cuts.

[Sal Ammoniac]

How do you mean?

[UncleBeer]

If society thinks universal health care is a good idea (meaning there's been a democratic vote on the issue, rather than a bunch of chickenshit lawmakers passing a law which panders to both the insurance industry lobby and a handful of uninsured constituents), then the just thing to do is levy a tax and have the government provide a universal level of health insurance (or health care) for everyone in their state. Passing legislation which foists responsibilities of the state off on "business," is reprehensible. And what I mean by a "thousand cuts," is the incremental manner in which these guys are apparently trying to force their will. We can get this much today; tomorrow we'll "refine" it; next week we'll require some additional benefits; come 2009, we'll mandate dental, and a drug plan, and life insurance, etc. This, I predict now, will all be done under the guise of making "a more rationalized and more efficient system." Continually adding functions and responsibilities which are rightly the duty of the state to "business" is inevitably gonna kill some of them. And the more revisions the plan gets, the more businesses will fall away under the burden.

[Sal Ammoniac]

Well, if you're going to have a universal care system, someone has to pay for it, and whether it's individuals or businesses is really the same to me. Of course, if individuals are to pay, then they'll need higher wages, so it comes to the same for business. Here's what I think is the best solution, just because it takes advantage of many features of the existing system: let everyone in the state of Massachusetts choose an HMO, and fund the whole thing out of payroll taxes. Have a sliding scale such that small businesses only pay a portion of the levy. If you're a one-man band, you'd pay 10% of the levy, let's say. Call it $500 annually.

The fact is, most bigger business are already paying for healthcare for their employees. By letting them pay a simple tax per employee to the state, they would get entirely out of the business of administering health plans and negotiating with the HMOs, not to mention their unions. That represents big savings for business. And the administrative efficiency of having a single payer (the state), would probably mean you could insure everybody in the state without adding a single dollar beyond what we're already paying. The HMOs would act as intermediaries, enrolling individuals, negotiating rates with hospitals, and paying claims -- in other words, doing what they do now, only with vastly greater efficiency, because they wouldn't have to negotiate separate deals with thousands of different parties.

And with vastly increased efficiency on the payor side, you could then devote some attention to finding efficiencies in coding, billing, information technology, medical practice, etc.

So that's my plan. And I consider it a pro-business plan, because business would save money overall, and have a (slightly) more motivated workforce. Plus you'd see more innovation and entrepreneurship. There are probably lots of people who'd strike out on their own, but who are afraid of the costs of providing their own coverage, particularly if they have families.

[UncleBeer]

Here's what I think is the best solution, just because it takes advantage of many features of the existing system: let everyone in the state of Massachusetts choose an HMO, and fund the whole thing out of payroll taxes. Have a sliding scale such that small businesses only pay a portion of the levy. If you're a one-man band, you'd pay 10% of the levy, let's say. Call it $500 annually.

Which leaves larger businesses stuck subsidizing everyone else. And still does nothing to prevent lawmakers from their constant meddling.

[Sal Ammoniac]

Sure, but if they can subsidize everyone else, and save money over what they're currently spending, why wouldn't they go for it?

And as for the Massachusetts lawmakers and their meddling... but you don't even live in Massachusetts, do you?

[sleestak]

Well, if you're going to have a universal care system, someone has to pay for it, and whether it's individuals or businesses is really the same to me. Of course, if individuals are to pay, then they'll need higher wages, so it comes to the same for business. Here's what I think is the best solution, just because it takes advantage of many features of the existing system: let everyone in the state of Massachusetts choose an HMO, and fund the whole thing out of payroll taxes. Have a sliding scale such that small businesses only pay a portion of the levy. If you're a one-man band, you'd pay 10% of the levy, let's say. Call it $500 annually.

The fact is, most bigger business are already paying for healthcare for their employees. By letting them pay a simple tax per employee to the state, they would get entirely out of the business of administering health plans and negotiating with the HMOs, not to mention their unions. That represents big savings for business. And the administrative efficiency of having a single payer (the state), would probably mean you could insure everybody in the state without adding a single dollar beyond what we're already paying. The HMOs would act as intermediaries, enrolling individuals, negotiating rates with hospitals, and paying claims -- in other words, doing what they do now, only with vastly greater efficiency, because they wouldn't have to negotiate separate deals with thousands of different parties.

And with vastly increased efficiency on the payor side, you could then devote some attention to finding efficiencies in coding, billing, information technology, medical practice, etc.

So that's my plan. And I consider it a pro-business plan, because business would save money overall, and have a (slightly) more motivated workforce. Plus you'd see more innovation and entrepreneurship. There are probably lots of people who'd strike out on their own, but who are afraid of the costs of providing their own coverage, particularly if they have families.

What about co-pays, limits on benefits, deductibles and prescriptions?

Presently my employer offers a great health plan. It doesn't cost all that much (the company pays a lot towards the insurance) and has low co-pays and deductibles, high limits and cheap perscriptions. Do all the copays go away? What about limits and perscriptions? Do deductibles go away?

I highly doubt that a government plan would cost the same as or less than what I have now and offer the same quality coverage. I know that many people are in the same place that I am. (The last two companies I worked for had great insurance plans, one of those business employed thousands of people)

Also, how do you stop government program bloat? Government programs tend to expand over time and get big and inefficient.

Slee

[carnivorousplant]

And as for the Massachusetts lawmakers and their meddling...

That's everywhere.
There is a proposed Constitutional amendment to set a minimum wage in AR; the legislature has a bill going to set it lower so they can kill the amendment.
They are also voting to lower the 3.3% (!) teacher raise.

[Diceman]

I asked my boss about this story. He says that he pays $500 per employee per month for health care (It's a standard Blue Cross plan, with a $500 deductable.) If I remember the news story correctly, businesses in Massachusetts can pay the state $275 per employee per month to not provide health care. According to my boss, $275 can buy a rock-bottom health plan, the kind with a very high deductable and no choice in which doctor you see. Do you see where I'm going here? Nearly every business in Massachusetts is going to cancel its health care, because it's much cheaper to just pay the state. The burden is going to get shifted to the employees, and the quality of health care is going to suffer, because no matter how efficient the system might be (and we all know the joke about "government efficiency" being an oxymoron), $275 doesn't buy as much health care as $500 does. TANSTAAFL.

Mind you, not every business can afford even the $275 payment. Lots of business are just going to close up.

[dbuzman]

"Poor people would be offered free or heavily subsidized coverage. Those who can afford to buy it but refuse to, would face tax penalties."

So it may not be that bad. The only ones who will be penalized will be those who can afford it but don't buy it. And if you can't afford it you will get it free or or really cheap. Assuming Mass. doesn't screw it up in the implementation phase and it works the way they say it will.

So all y'all lighten up a bit and wait and see how they handle it. According to the arcticle most of your complaints about it are not valid.

[aruvqan]

"Poor people would be offered free or heavily subsidized coverage. Those who can afford to buy it but refuse to, would face tax penalties."

So it may not be that bad. The only ones who will be penalized will be those who can afford it but don't buy it. And if you can't afford it you will get it free or or really cheap. Assuming Mass. doesn't screw it up in the implementation phase and it works the way they say it will.

So all y'all lighten up a bit and wait and see how they handle it. According to the arcticle most of your complaints about it are not valid.

But who determines what the definition of poor is ... before I got a job, all mrAru and I had was his navy retirement, and a $34k a year job. Our mortgage is just under $1k a month, then there is the car, taxes, insurance, housing insurance, electricity, fuel oil for heat and hot water ... the only *luxury* we had was cable and internet access from charter communications. Most months we had nothing left at all in the bank, some months we had to pay partial bills [oil heat in the winter with the damn oil prices going crazy never helped matters, thank god we could heat much of the time with wood]

Most communities 34K doesnt qualify as poor ... but sure as shit we certainly didnt have any money for anything extra. To put it in perspective, I didnt have any new clothing for 3 years, it took me 3 months to save up the $50US for a pair of work pants to give me an 'interview' outfit, which finally gave me more than 2 work outfits when I just got my job last month.

[Sal Ammoniac]

Diceman, as regards the $275 charge, the businesses affected have to be of a certain size; there's a small-business exemption. Mainly the charge is targeted at Wal-Mart and McDonalds, which are said to be the major abusers -- i.e., large employers who typically don't offer affordable healthcare, but whose employees are often users of so-called "free care." It's an open question whether other businesses will opt out of providing insurance, and choose to pay the state fee instead. I suspect that for most businesses wanting employees of a certain caliber, axing the health plan is not a winning strategy. Also, there may be union contracts that effectively prohibit companies from doing that.

Sleestak, to answer your questions, in my scheme, copays and deductibles would go away. These are, after all, just a tax under another name, and for the sake of efficiency, I'm proposing one source of taxation, rather than myriad sources. The minimum benefit level would be mandated (and could be modeled on what HMOs offer now as a minimum benefit level), and prescriptions would be covered, same as today.

I know people like to complain about government inefficiency and bloat, but in my proposal, the government will do little more than collect tax money and use it to pay the HMOs for their enrollees. The HMOs (which are amost all nonprofit in Massachusetts, incidentally) will continue to do what they're trying to doing now -- manage healthcare utilization, provide customer service, efficiently process claims, etc.

All right, this is a hobbyhorse of mine. My talking up my proposal is my way of saying that no, Massachusetts didn't quite get it right this time. But even at that, Massachusetts at least made an effort, which is more than most states can say.

[missbunny]

If I remember the news story correctly, businesses in Massachusetts can pay the state $275 per employee per month to not provide health care. According to my boss, $275 can buy a rock-bottom health plan, the kind with a very high deductable and no choice in which doctor you see. Do you see where I'm going here? Nearly every business in Massachusetts is going to cancel its health care, because it's much cheaper to just pay the state.

It's even worse than that. Employers who don't provide insurance would only pay $295 (not $275) per employee PER YEAR - not per month.

Now why would any company who doesn't already provide insurance jump to do it, since they can avoid doing it by paying a fine of $295 per person? Meanwhile the employee will have to find his own coverage (for far more than $295 per year) or lose his state income tax exemption.

[crazyjoe]

Sleestak, to answer your questions, in my scheme, copays and deductibles would go away. These are, after all, just a tax under another name, and for the sake of efficiency, I'm proposing one source of taxation, rather than myriad sources. The minimum benefit level would be mandated (and could be modeled on what HMOs offer now as a minimum benefit level), and prescriptions would be covered, same as today.


Sal, I say this not to be mean, but this simply won't work. People will vastly overuse coverage if you take away the decuctibles and co-pays. They will visit the doc for the common cold "just to check to see if it's something bad."

I used to work in the healthcare IT industry, and we used to see this sort of usage problem come up when employers dropped deductibles below a certain amount. You'd get lonely older folks going to the doctor just for human contact (while I admit this is sad and awful, I don't think having them use the doctor's office for a social call is a good idea). They simply must be set at a certain rate to discourage people from, for instance, going to the emergency room instead of to their local doctor. I have stepped-up copays on my health plan where I pay 20 for an office visit, 50 for urgent care, and 100 for ER visits (unless admitted). You have to have those sorts of disincentives.

[Sal Ammoniac]

Crazyjoe, this effect has been studied, and been found to be a negligible factor in overall healthcare utilization. Don't have any good cites handy, but maybe somebody else does. Also, you could hypothesize that the effect goes the other way, namely that people defer getting necessary health care because of copays or deductibles, and so end up as more expensive cases.

That said, I don't have a hugely strong feeling one way or the other about copays or deductibles, and I don't think my proposal stands or falls on that relatively minor question.

[UncleBeer]

Sure, but if they can subsidize everyone else, and save money over what they're currently spending, why wouldn't they go for it?
Maybe that's correct, but we're operating here entirely on your suppositions. I wanna see the actual costs of the plan laid out. You simply saying "they'll save money" doesn't necesarrily make it so.

And as for the Massachusetts lawmakers and their meddling... but you don't even live in Massachusetts, do you?
Nope, I don't. I live in a state where the guy administrating some investments for the state's unemployment insurance has absconded with many millions of dollars. So, I real likely to trust any state health insurance administrator to behave honorably either. Power and money is to dishonest politicians like shit and honey to flies.

[Barbarian]

crazyjoe, your proposition is full of crap. It's a typical American attitude, but it just ain't so, as anyone who has experience health care in countries with universal health care can tell you.

Emergency rooms and doctor's offices are not clogged with healthy bored people. They're filled with sick and injured people. And when you hike co-payments, all you do is discourage people from getting annual physicals or seeing the doctor when they have a minor affliction-- and instead end up having seizures at work and spending 3 days in the ICU.

The ovewhelming majority of people who use health care (that is, everybody) are pretty damn responsible with it. There are probably, as a percentage, more doctors with fraudulent billing practices than patients showing up to say hi.

Sal Ammoniac points out that many major businesses currently pay for health care for their employees, but the trend in the U.S. is to remove health care coverage. Some of those are ailing companies (like GM), but some are healthy vibrant companies. Heck, my union is in the process of negotiating a new contract, and my company no longer wants to cover health care. In fact, the company violated the terms of our contract (which is still in effect until we negotiate a new one) and stopped making health care payments on behalf of employees months ago (the union is picking up the slack, and has filed a grievance with the national labor relations board)

[Sal Ammoniac]

Maybe that's correct, but we're operating here entirely on your suppositions. I wanna see the actual costs of the plan laid out. You simply saying "they'll save money" doesn't necesarrily make it so.
It's a fair point. Let's make the following assumptions for the state of Massachusetts: a non-Medicare population of around 5.4 million; a working population of 3 million persons; a $400 a month individual cost for a basic HMO plan (see some figures here (http://www.mass.gov/doi/Consumer/css_health_plans05_12.html)); and existing governmental health insurance expenditures of nearly $8 billion. With these assumptions, by my back-of-the-envelope reckoning, the standard business levy would be around $6,000 annually.

By contrast, a Brandeis University site (http://my.brandeis.edu/news/item?news_item_id=103953&show_release_date=1) indicates that "the average annual healthcare cost per employee is $7,999."

Now, bear in mind that many current hospital costs -- for free care, bad debt, etc. -- are shifted onto the insurance companies, such that the posited $400 monthly cost for insurance is probably higher than it would be in a system with universal coverage. Plus, with universal coverage, you could create huge administrative efficiencies through the imposition of a single medical coding system and standardized electronic claim forms.

Bear in mind that these are quick-and-dirty numbers. The actual analysis would take a hell of a lot of work. But it does suggest that most businesses would pay no more than they currently do, and some would pay less. And if you could achieve significant administrative efficiencies, they could pay a lot less.

[Cerowyn]

The Canadian health care model is essentially what Uncle Beer is proposing: the government runs a health insurance plan (called funnily enough, in Ontario for instance, the Ontario Health Insurance Plan) to which all citizens are insureds. For those that are employed, their employer pays the premium (by law). For those that are unemployed, the government contributes on their behalf. When I go to the doctor, I present my insurance card. The only time I ever see a bill is on the rare occasion that the insurance people send me a "verification" letter that basically asks me to confirm that I received the services they are being billed for (just auditing, I presume).

It ain't perfect, and it's not run as well as it could be. But it works for the most part.

[SkipMagic]

Off to GD.

[Magiver]

A few years ago, I was working for a small nonprofit organization. I was making less than $32,000 a year, and although I had three children, I did not qualify for subsidized health coverage. (The kids did qualify for subsidized health coverage through a state program--which had a monthly co-payment of $49 per child.) I was barely making ends meet, and could not afford the extra $147 a month on top of child care (thank goodness it was only afterschool care at that point) and all the other expenses related to keeping a family clothed, housed and fed. And, yes, my employer did offer health insurance (for me and my family), but it was almost $300 a month in payments.

Just because subsidized health care is available doesn't mean that a family can afford it. The earned income credit (in addition to any other tax rebates) would have provided you with between $692 and $1114 depending on your marital status. It doesn’t cover the whole $1764 cost but it puts a healthy dent in it by itself. Additional tax credits should cover the rest. Doesn't matter how you slice the pie, if you come up short at the end of the day it's still a negative on the balance sheet.

I think it's great that MA has decided to try this. They can be the guinea pigs for the rest of the states. Since it took 2 years to legislate I’ll assume it has the voters approval.

[WillMagic]

Apparently, Massachusetts will require everyone (http://www.kpho.com/Global/story.asp?S=4729080) to have health insurance. From what I heard on the news this morning, they're going to offer insurance companies "incentives" to offer insurance to low-income families. According to the article, anyone who doesn't have health insurance is going to face tax penalties.

I know that lack of health insurance is a big problem in this country, but I'm not sure I like the idea of a law that says "buy health insurance...or else."

Yay for artificially stimulating demand via government fiat, which will lead to increased health care prices for all! Yay!

This is all so silly. The reason that health insurance is sooo expensive is because of government regulations in the first place. Governments force insurance companies to cover alcoholism, marriage counseling, etc., which forces the price of health insurance up needlessly. When people then make the rational decision to forgo the overpriced health insurance, the government then steps in and mandates they buy it! Great!

Get the government out of health care. Completely. For everyone's sake. Well, everyone except the HMO's, as they benefit the most from government interventions.

[Sal Ammoniac]

The reason that health insurance is sooo expensive is because of government regulations in the first place. Governments force insurance companies to cover alcoholism, marriage counseling, etc., which forces the price of health insurance up needlessly.
I'll believe you when you can give me a cite about how much it costs the health system when the government forces insurance companies "to cover alcoholism, marriage counseling, etc."

[Sal Ammoniac]

Oh, and you can also give me a cite that shows where countries that have no government involvement in healthcare have better health systems that countries that do.

[UncleBeer]

The Canadian health care model is essentially what Uncle Beer is proposing: the government runs a health insurance plan (called funnily enough, in Ontario for instance, the Ontario Health Insurance Plan) to which all citizens are insureds. For those that are employed, their employer pays the premium (by law). For those that are unemployed, the government contributes on their behalf.

Hmmm. Perhaps I wasn't clear enough then; that isn't what I was proposing at all. Here, in a two-paragraph nutshell is what I believe to be a fair universal healthcare plan:

The general populace is given an opportunity to vote on the desirability of universal healthcare, rather than something legislated by your elected representatives. This issue is too important, and potentially too expensive, to be left entirely up to lawmakers who're subject to all sorts of undue influence. If the majority of the voters disagree that universal healthcare is desirable, the issue is dropped. If they agree, then a plan is developed thru which every resident of the state is supplied with an identical level of coverage. This plan is put together, in several distinct pieces probably (like general care, catastrophic care, prescription plans, vision & dental care, hospice, in-home assistance, maybe even life insurance), by an independent, bi-partisan commission directly elected by the state's residents. Residents would again have an opportunity to vote on each individual piece of the healthcare plan as the commission crafts it; simple majority vote would signify approval or disapproval of each piece. The regulations authorizing the formation of the commission would also describe the limits by which the plan could be changed in the future through commission-only actions; modifications to the plan outside that scope would again require a vote of the state's residents. All residents are then required to enroll in each portion of the plan approved by the voters unless they specifically opt out by filing whatever form is provided for such. Those persons opting out must pay out of pocket for any services for which they have declined coverage. Enrollments are automatic from year-to-year and would be identical to your coverage(s) from the previous year.

This coverage is then paid for thru a progressive tax (similar to the income tax) levied specfically and only for this purpose and collected thru payroll, unemployment, social security, etc. dedcutions. These payments are tax-decuctible - both federal and state. In the case of minors, or other dependents, the persons your tax payments insure, are identical to the persons claimed on your state (or federal if the enacting state doesn't happen to have an income tax) income tax return. The accounting of all this could be incorporated in your usual tax filings without too much difficulty. Employers would pay no portion of the costs of this plan directly; the responsibility for funding will be entirely upon the individual citizens of that state.

It is only in this manner that the citizens can be certain they're getting the coverage they need and how much it is costing them. It also make the state accountable for their expenditures.

[Sal Ammoniac]

Employers would pay no portion of the costs of this plan directly; the responsibility for funding will be entirely upon the individual citizens of that state.
I don't have much problem with your proposal, except perhaps that it's a little cumbersome. I think it's actually a moot point whether employers and individuals pay. If individuals are to pay, they're going to have to be paid a little more, presumably out of the money employers save by not offering a health benefit. It's the same money in the end, and how you feel about whether employers or employees pay is, I suspect, ideological.

[crazyjoe]

crazyjoe, your proposition is full of crap. It's a typical American attitude, but it just ain't so, as anyone who has experience health care in countries with universal health care can tell you.


Really? And you base this on what set of statistics? I might not be able to cite mine (proprietary company info that I no longer have access to) but I did work in the industry and I did see this sort of thing happening. I know that in countries with universal healthcare, lines and waiting a long time are not uncommon things. Here, depending on your doc, you can usually get in the same day if you need to see one for a cold.

I find it odd that you might think that American health care consumers have no need to change their ways of thinking, that they will magically change if they switch to universal health care.


Emergency rooms and doctor's offices are not clogged with healthy bored people. They're filled with sick and injured people. And when you hike co-payments, all you do is discourage people from getting annual physicals or seeing the doctor when they have a minor affliction-- and instead end up having seizures at work and spending 3 days in the ICU.


This is only partly true. I have stupid moron friends who were taking their newborn to the ER every couple of weeks for things like "she's constipated" or "she bumped her head." Her copays for ER visits obviously were not high enough.

My copays for drugs are to the point where I always ask the doc for the older, more established drugs that are likley to have generic substitutions. Because I know how much drugs can cost me at the counter, I don't take the most newfangled drugs out there when plain old amoxicillin will work just fine. But if your co-pay is, like my dad's, 5 bucks per script, you don't have any incentive to educate yourself about cost.


The ovewhelming majority of people who use health care (that is, everybody) are pretty damn responsible with it.


Maybe in your country. Here in America we need a major culture shift in order for this to happen. You're not going to get this culture shift just by switching to national health care.

[swissmtndog]

The general populace is given an opportunity to vote on the desirability of universal healthcare, rather than something legislated by your elected representatives.

I think the chance of UHC passing would be very small, once your average Joe understands his effective price tag. Your average Joe wants the other guy to pay just as much, if not more, than the undue influences on the lawmakers you refer to.

[Diceman]

It's even worse than that. Employers who don't provide insurance would only pay $295 (not $275) per employee PER YEAR - not per month.

Now why would any company who doesn't already provide insurance jump to do it, since they can avoid doing it by paying a fine of $295 per person? Meanwhile the employee will have to find his own coverage (for far more than $295 per year) or lose his state income tax exemption.
It's $295 per year ?! Holy shit, that's only 24 bucks per month! Someone is going to have to fork over a ton of money to fund this program, and if it ain't the businesses, then it's going to be either the state of Massachusetts (by raising taxes) or the people themselves.

[WillMagic]

I'll believe you when you can give me a cite about how much it costs the health system when the government forces insurance companies "to cover alcoholism, marriage counseling, etc."

It can be explained logically.

Say you are a 25-year-old healthy, single male, looking for cheap health insurance. You don't drink...period. Now, when looking at various plans, it would make sense to purchase a plan that didn't cover alcoholism, right? Alcoholism coverage costs some nonzero amount of money. So, in a free market, you could look for a plan specifically tailored to your needs, and that plan would save you money.

But when the government steps in and mandates that all insurance policies cover alcoholism...the costs of alcoholism coverage don't just disappear. They are passed on to the consumer. And for our sober 25-year-old, those costs are a complete waste of money. He is forced to either subsidize other people's alcoholism treatment or forgo health insurance entirely...an entirely inefficient result.

For more, you can read http://www.lewrockwell.com/hoppe/uncertainty-insurance.html (this) great piece by Hans Hoppe.


Oh, and you can also give me a cite that shows where countries that have no government involvement in healthcare have better health systems that countries that do.

Obviously there is no cite on this, because every first-world government is heavily involved in health care provision, so there is no possibility for a study. And comparing American healthcare to Somalian health care is obviously comparing apples and oranges, as the lack of regulations in the Somalian health care industry is obviously overwhelmed by the lack of wealth in that country.

[Kimstu]

Someone is going to have to fork over a ton of money to fund this program, and if it ain't the businesses, then it's going to be either the state of Massachusetts (by raising taxes) or the people themselves.

That's the opinion of a couple of Massachusetts doctors who wrote this article (http://www.tompaine.com/articles/2006/04/07/massachusetts_mistake.php) criticizing the MA plan and recommending a single-payer program instead:

What’s wrong with this picture? First, the politicians assumed that only about 500,000 people in Massachusetts are uninsured. The Census Bureau says that 748,000 are uninsured. Why the difference? The 500,000 figure comes from a phone survey conducted in English and Spanish. Anyone without a phone or who speaks another language is counted as insured. The 748,000 figure comes from a door-to-door survey carried out in many languages (including Portuguese and Haitian Creole, common languages in Massachusetts). In sum, the reform plan wishes away 248,000 uninsured people who don’t have phones or don’t speak English or Spanish. It provides no funding or means to get them coverage.

Second, the linchpin of the plan is the false assumption that uninsured people will be able to find affordable health plans. A typical group policy in Massachusetts costs about $4500 annually for an individual and more than $11,000 for family coverage. A wealthy uninsured person could afford that—but few of the uninsured are wealthy. A 25-year-old fitness instructor can find a cheaper plan—but few of the uninsured are young and healthy. According to Census Bureau figures, only 12.4% of the 748,000 uninsured in Massachusetts are both young enough to qualify for low-premium plans (under age 35) and affluent enough (incomes greater than 499% of poverty) to readily afford them. Yet even this 12.4% figure may be too high if insurers are allowed to charge higher premiums for persons with health problems—only half of uninsured persons in those age and income categories report that they are in “excellent health.” [...]

Predictably, rising costs will force more and more employers to drop coverage, while state coffers will be drained by the continuing cost increases in Medicaid. Moreover, when the next recession hits, tax revenues will fall just as a flood of newly unemployed people join the Medicaid program or apply for the insurance subsidies promised in the reform legislation. The program is simply not sustainable over the long—or even medium—term. [...]

Overall, Massachusetts residents will spend $13.3 billion on health care bureaucracy this year—nearly one third of our total health bill. If we cut bureaucracy to Canada’s levels we could save $9.4 billion annually, enough to cover all of the 748,000 uninsured in Massachusetts and to improve coverage for the rest of us.

Study after study—by the Congressional Budget Office, the General Accounting Office and even the Massachusetts Medical Society—have confirmed that single payer is the only route to affordable universal coverage. [...]

But single payer national health insurance threatens the multi-million dollar paychecks of insurance executives, and the outrageous profits of drug companies and medical entrepreneurs.

[Accidental Yuppie]

Many people do not have an employer to buy health insurance for them and this makes affordable insurance difficult to find if they make any money at all. There are subsidized programs but they cut off at a fairly low income threshold, about $50,000.00 for a family of 4, less for individuals and couples.

The MONTHLY local rates for individual Blue Cross in my region are
Individual crappy HMO plan $625.00
Individual good POS plan $1100.00

Family of 4 crappy HMO plan $1850.00 a month
Family of 4 good POS plan $3300.00

See the problem here? People who get insurance through their employers don't know how good they have it, even if they have to pay the whole cost.

Unfortunately, one of the reasons insurance is so expensive is that health care is expensive. The drugs used to keep a typical advanced cancer patient alive for one more month can easily top $20,000.00 and medical advances have made cancer and AIDS long term chronic illnesses in many cases.

While the price of some of the drugs is justified, most of them are outrageously expensive. This is in large part due to a well-meaning but misguided piece of legislation requiring insurance companies to provide neccessary drugs regardless of cost.

http://www.iht.com/articles/2006/03/12/business/web.0312berenson.php

is the story of how the makers of a decades old anticancer drug just increased the price from about $75 a tube to about $500, just because they could. They probably felt the insurance companies weren't paying enough for a drug that treats CANCER, but it was a real problem for the uninsured that needed the drug.

Still, I am against socialized medicine, the system is broke in large part because of stuff like this which legislates against the free markets. I have spoken with seriously ill people in Canada and the UK, and I am amazed at the way these governments ration health care.....waits of 6 to 8 weeks for a CAT scan, which you can usually get if needed in a few days in the US system. The patients in these countries seem to accept the reasoning that there aren't enough machines and doctors, but the reason that there aren't enough is that the government won't buy more.

Barbara

[kanicbird]

A personal level unfunded mandate, gov't is not God, it just can't say 'You shall do this' and expect it to happen, it appears even God has trouble enforcing these.

Hmmm...so if a couple who have two children are both working, making minimum wage, and paying daycare, rent, buying food, trying to keep their POS junker car running (and buying the state minimimum required car insurance) so they can get back and forth to work, and living sometimes not from paycheck to paycheck, and can't afford to buy new shoes for the kids, then they'll be penalized for not buying health insurance through their employer?

I'd like to know the number of couples who both make minimum wage, If taken over a few months I'd bet this number drops to zero. Also how can a coulbe making min wage afford daycare, it would be cheaper for one parent to stay home.

[Barbarian]

Really? And you base this on what set of statistics? I might not be able to cite mine (proprietary company info that I no longer have access to) but I did work in the industry and I did see this sort of thing happening. I know that in countries with universal healthcare, lines and waiting a long time are not uncommon things. Here, depending on your doc, you can usually get in the same day if you need to see one for a cold.

I find it odd that you might think that American health care consumers have no need to change their ways of thinking, that they will magically change if they switch to universal health care.


Malcolm Gladwell has a good article about what he calls moral hazard (http://www.gladwell.com/2005/2005_08_29_a_hazard.html) and its effect on health care.

Canada only implemented universal health care in the 60s. Sorry that you think Americans are more likely to abuse the system. But I think you're wrong. One great demonstration is to look at uber-rich people who think nothing of a co-pay. How often do they abuse seeing a doctor? Probably not that often.

Having used the Canadian health care system, and knowing plenty of doctors, I can tell you that any Canadian shortages in care aren't due to abuse/overuse by patients. Health care in Canada is a provincial matter, and the provinces have historically been less willing to spend money on equipment than health care practitioners in the U.S. As a result Canada does have longer wait times for hip replacements, MRIs, etc... because the facilities are overbooked. Canada has 151 MRI machines. The U.S., with 10 times the population, has about 5500 MRI scanners. cite (http://www.cihi.ca/cihiweb/dispPage.jsp?cw_page=media_13jan2005_e)

Any queues aren't because people who think they have hip problems are clogging up the queue. They can't. The first step for any procedure in Canada is to see your GP, if you have one. The GP then refers you to a specialist, and so on and so forth. (And right now, many provinces are working on universally accessible wait time lists so patients and doctors can figure out how to minimize wait times.)

About 1/3 of Canucks don't have a primary care physician, because fewer doctors are setting themselves up in family practices. There have been times I've had a family doctor, and times (because of moving and whatnot) that I haven't. Every time I've been sick enough to see a doctor I have always been able to see a doctor that day -- and if I've gone to a clinic, I don't even have to make an appointment. I have never even heard of someone who has had to wait to see a doctor for a basic emergency (as a journalist, it's my job to know*). Nurses do triage when you come in the door, and if it's serious, you'll be moved to the front of the line. The only restriction is facilities, operating rooms, and doctors. Canada doesn't have enough -- but that's a problem that can easily be fixed.



This is only partly true. I have stupid moron friends who were taking their newborn to the ER every couple of weeks for things like "she's constipated" or "she bumped her head." Her copays for ER visits obviously were not high enough.

Spoken like an insurance agent who wants to minimize costs. But I'd rather have a medical professional determine if your friends were wasting time, since the U.S. ranks [url=http://www.cdc.gov/omh/AMH/factsheets/infant.htm]fairly high[/i] on the infant mortality scale. A kid who hasn't pooped in a week may or may not be sick; that bump on the noggin could be normal, or could be something more serious. But the reality is that laypeople don't know how serious any medical complaint is-- that's why they see doctors.

*If you fall a break a hip between Christmas and New Year's, you will have to wait for surgery, because odds are only one or two doctors are doing surgery that week. But you're not waiting because of any patient abuse problem with universal health care. You're waiting because there aren't enough trained doctors working. Different problem, but you end up waiting three days in the hospital.

[Sal Ammoniac]

Say you are a 25-year-old healthy, single male, looking for cheap health insurance. You don't drink...period. Now, when looking at various plans, it would make sense to purchase a plan that didn't cover alcoholism, right? Alcoholism coverage costs some nonzero amount of money. So, in a free market, you could look for a plan specifically tailored to your needs, and that plan would save you money.

This assumes that people know, to a nicety, exactly what healthcare they will need in the near future. They don't -- that's just the problem. Even to take your example, it's not unheard of for a non-drinking 25-year-old to start drinking, and suddenly find himself unable to stop. What then, in your example? Is he to pay for his alcoholism treatment out of pocket? Or maybe he tries to change plans, but finds he has a "preexisting condition" for which he's unable to get insurance.

The other problem is that there is not, currently, an IT infrastructure that well supports this profusion of tailored plans. The inevitable result would be people showing up at the hospital to get care, and not knowing what care they're entitled to. The hospital has no way of knowing either, so they either have to chance it, or call the insurer to find out. This, by the way, is real-world problem today, one that I have encountered personally. Your proposal would make it more severe, and probably result in more uncollected bills for the hospital. And by the way, hospitals in Massachusetts at least are not operating on fat margins. With any significant increase in bad debt, they're at risk of having to shut their doors.

The problem with free-market approaches generally is that they push a lot of the risk onto individuals. You go with a low-cost plan, or a low-cost drug, or a low-cost provider, and you're taking a big gamble. It may work out for you, but boy, the penalties when it doesn't are severe.

[WillMagic]

This assumes that people know, to a nicety, exactly what healthcare they will need in the near future. They don't -- that's just the problem. Even to take your example, it's not unheard of for a non-drinking 25-year-old to start drinking, and suddenly find himself unable to stop. What then, in your example? Is he to pay for his alcoholism treatment out of pocket? Or maybe he tries to change plans, but finds he has a "preexisting condition" for which he's unable to get insurance.

Wow. So because of this hypothetical, people shouldn't even have the OPTION to forgo alcoholism coverage? Even though it is an entirely voluntary choice to drink?

Obviously people don't know exactly what health care they will need in the future...that's why there is insurance in the first place. However, when it comes to ailments that are in a real sense voluntary (alcoholism, drug addiction, marriage counseling et al.) there are going to be people who know they are highly unlikely to need coverage. So why should they be forced to pay for it? How is that not a gross violation of liberty?

The other problem is that there is not, currently, an IT infrastructure that well supports this profusion of tailored plans. The inevitable result would be people showing up at the hospital to get care, and not knowing what care they're entitled to. The hospital has no way of knowing either, so they either have to chance it, or call the insurer to find out. This, by the way, is real-world problem today, one that I have encountered personally. Your proposal would make it more severe, and probably result in more uncollected bills for the hospital. And by the way, hospitals in Massachusetts at least are not operating on fat margins. With any significant increase in bad debt, they're at risk of having to shut their doors.

Well then the hospital needs to start running its business better. This seems like an extremely minor quibble. If a hospital is really going to go out of business because they can't get their administration together, then let it go...it's a poorly ran hospital anyway and will probably be replaced by a hospital that can get its shit together.

I mean, this is a nonzero cost, certainly, but are you really going to argue that everyone should be forced, BY GOVERNMENT, to pay for coverage they don't want and have no use for just so hospitals can save?

The problem with free-market approaches generally is that they push a lot of the risk onto individuals. You go with a low-cost plan, or a low-cost drug, or a low-cost provider, and you're taking a big gamble. It may work out for you, but boy, the penalties when it doesn't are severe.

Sure, but people willingly assume that risk when they get to make their own choices. Every person has a different needs, different wants, different values. Free-market approaches allow people to, GOD FORBID, make their own decisions and spend their money in the manner of their pleasing. And arguing that they shouldn't be allowed to do so is arguing for totalitarianism.

[Sal Ammoniac]

Well then the hospital needs to start running its business better. This seems like an extremely minor quibble. If a hospital is really going to go out of business because they can't get their administration together, then let it go...it's a poorly ran hospital anyway and will probably be replaced by a hospital that can get its shit together.
No question that hospitals need to run their business better. But to do so, they need to make huge IT investments, and they usually don't have the money because their margins are so low. And I can assure you this is not a minor quibble. It is an important fact of life for the hospital industry. It's fine to say, "Oh, just let them fail," but tell that to a community that's looking at losing the only emergency room for miles around.

But I'm curious how far you are willing to take the fair-market gospel when it comes to healthcare. Are you willing to let anybody practice medicine, regardless of training or licensure? Because that would certain bring the cost down, and be respectful of patient choice, and the willingness of individuals to assume risk.

And you didn't answer my question about what happens when people forego a certain kind of coverage, only to find they need it after all.

[WillMagic]

No question that hospitals need to run their business better. But to do so, they need to make huge IT investments, and they usually don't have the money because their margins are so low. And I can assure you this is not a minor quibble. It is an important fact of life for the hospital industry. It's fine to say, "Oh, just let them fail," but tell that to a community that's looking at losing the only emergency room for miles around.

Huge investments? Isn't this kind of a one time thing? You make an IT investment and you don't have to make another one?

But anyway, my main point is this: if people demand choice in their health care, and a hospital is unable to supply that choice and consequently people stop patronizing that hospital, then I think it's for the best, and I don't think the government should step in to stop it.

But I'm curious how far you are willing to take the fair-market gospel when it comes to healthcare. Are you willing to let anybody practice medicine, regardless of training or licensure?

I bet you aren't expecting this answer. Yes. I am. That's not to say I would end liability, or that a doctor that performs malpractice or other fraud shouldn't be sued.

Because that would certain bring the cost down, and be respectful of patient choice, and the willingness of individuals to assume risk.

You're right! It's a great idea. Also it means that the small community hospital that couldn't compete because of some IT expenses will be replaced quickly by one that can.

And you didn't answer my question about what happens when people forego a certain kind of coverage, only to find they need it after all.

Obviously they have to pay for it out of pocket. Or, they can look for charity, if their situations warrant it.

I noticed you snipped the other parts of my argument. Any comment on those, or are you just going to concede those points? You know, that mandating insurance coverage of alcoholism etc. is vastly inefficient as well as being a gross violation of liberty?

[Sal Ammoniac]

Huge investments? Isn't this kind of a one time thing? You make an IT investment and you don't have to make another one?
People outside the industry are staggered by the cost of the IT investments required in healthcare. If you're going to build an IT system to verify in real-time the insurance coverage of every one of 300 million Americans who might want to walk through your doors on any given moment, you need to connect it to your billing system, which you need to connect to your medical coding system, which you need to connect to... etc., etc. You're often dealing with legacy systems, many of them proprietary, and most of which need to be up 24/7. Believe me, it's very expensive, which is why community hospitals -- and even big academic hospitals -- haven't done it.


I noticed you snipped the other parts of my argument. Any comment on those, or are you just going to concede those points? You know, that mandating insurance coverage of alcoholism etc. is vastly inefficient as well as being a gross violation of liberty?
I'll concede that mandatory alcoholism coverage is a teensy-weensy violation of liberty. What I don't see is where it's "vastly inefficient" or makes our insurance system "sooo expensive," particularly compared with all the other factors that do make our insurance system expensive and inefficient.

As for the rest the argument, you get points for consistency, but allow me to say that I have no interest -- and I doubt many other people do, either -- in living in the libertarian dystopia you propose.

[bizzwire]

Actually, one other thing I should mention. This is very much an "art of the possible" sort of deal. The activists weren't wild about it, but their line of thinking goes like this: once we establish universal care as the basic proposition, and introduce the notion that businesses will need to assume at least some responsibility for healthcare, then it becomes easier to talk later about a more rationalized and more efficient system.

The Governor of Massachusetts was on NPR today, talking about it, and as far as he is concerned, you couldn't be farther from the truth. To condense his argument, if an uninsured person shows up at the hospital and is treated, their medical care is not free: somebody pays. That somebody are those people who pay insurance premiums. The goal of this plan is that everybody pays.

[clairobscur]

I know that in countries with universal healthcare, lines and waiting a long time are not uncommon things. Here, depending on your doc, you can usually get in the same day if you need to see one for a cold.
.


Here too. As I say times and again, waiting lists exist in *some* countries with a public healthcare system (and it happens to be the countries american people are the most familiar with : Canada and the UK). It's not a unavoidable consequence of a public healthcare system.


Besides, as usual, without such a system, you can indeed see a doctor on the same day providing that you have enough money to pay him this day.