No. It’s exactly the opposite. It’s precisely and literally the other way around.
That fact has frequently been noted by the eminent health care economist Uwe Reinhardt, and has come to be known as Reinhardt’s Law, or sometimes Reinhardt’s irony or paradox. Simply stated, in single payer systems or their functional equivalent, cost control is achieved up front through a negotiated, uniform, and transparent fee schedule, and there is explicitly no meddling at the clinical level between doctor and patient. Whereas with private insurance, every claim is individually adjudicated, so meddling with the doctor’s clinical discretion is inherently baked into the system; the intrusion of insurance bureaucracy into clinical decision-making is pretty much the hallmark of US health care. The irony is that physicians opposed to “government involvement” in health care have pretty much brought this situation on themselves; by insisting on their economic freedom from single-payer regulation of their fees, they have sacrificed their clinical freedom to insurance bureaucrats.
From a paper on physician autonomy [PDF]:
It is Reinhardt’s assertion that the absence in the United States of an overall program of budgetary control over medical expenditures, as is characteristic of the prominent European systems, results in unparalleled micro-management at the clinical level to achieve cost control unattainable on a larger scale. He writes that “…if the bureaucrats cannot somehow impose upon the healers an overall budget constraint ex ante, then they will sooner or later be driven to control their outlays on an ongoing basis, by monitoring each and every transaction for which they pay – that is, by second guessing both the providers’ clinical and pricing decisions” (Reinhardt, 1988). This appropriation of the clinical dimension of autonomy would be regarded as intolerable by physicians in other medical care systems. He suggests that “European and Canadian physicians would be appalled at the numerous intrusions into clinical decisions now routinely made by these external monitors in the United States. They probably would rise up in arms over that loss in clinical autonomy” (Reinhardt, 1988).
It seems problematic that physicians in the United States would willingly and knowingly sacrifice the clinical element of autonomy that Freidson considered to be the more consequential element of his two-part definition of autonomy. Clinical autonomy, after all, constitutes the primacy of the physician in the health care division of labor and is the basis on which arguments for political and economic autonomy are formed. Reinhardt’s answer to this seeming paradox is that physicians in the United States have traded off clinical autonomy “in their tenacious fight to preserve the individual physician’s right to price his or her services as they see fit” (Reinhard~ 1988). This observation has been distilled into a formula referred to as Reinhardt’s “Law” or “Irony.” Reinhardt has summarized his law as follows: “In modern health care systems, the preservation of the healers’ economic freedom appears to come at the price of their clinical freedom” (Reinhardt, 1988). The application of Reinhardt’s Law to the late-20th-century United States scene would appear to indicate a priority on the part of physicians to pursue economic betterment at the expense of clinical autonomy.
I think a lot of people have come up with convoluted rationalizations for why the status quo is justified. Who wants to accept that they’ve been exploited by a system that robs us of money, time, energy, and dignity? If you’re a red-blooded American capitalist, that’s a bitter pill to swallow. It violates everything that we’ve been taught to believe about the free market. Better to pretend that the hoops we jump through are necessary evils rather than evil evils.
As a Tricare recipient for the last 16 years, my family and I are living the “nightmare” of socialized medicine. And oh, let me tell you how fucking “scary” it is. Every time I need a physical, I just pick up the phone and schedule an appointment with the clinic. And when I turn up at the receptionist desk, all I have to do is show them my ID; I don’t have to have any tedious conversation about HMOs, PPOs, or any other unintelligible acronyms that I no patience to keep up with. When I need a diagnostic procedure, I don’t have to wonder whether it’s covered by my policy or if I need to get some special approval; if the goddamn doctor says I need it, then I need it. And when I need meds, the docs prescribes them to me and I pick them up at the pharmacy downstairs. And I don’t have to pay a dime for any of it. Not even a $30 copay that…does what exactly? Why don’t people see how crazy it is that they are getting charged chicken shit co-pays for something they are already shelling our expensive premiums for?
When I see people acting as though this “nightmare” is worse than anything you can get from private insurance, I feel like slapping them.
I would guess that makes you active or retired military, or the spouse of one? If thats the case, thank you for all the bullshit you go through for me and my family. Our family respects that sacrifice.
I have a question though. Everyone I have talked to on Tricare or general VA benefits are really happy with their care, but the only gripe is that they have to go to the VA which usually isn’t in a place around them.
There seems to be a lot of negative stuff about the VA in the news. Is some of the negative stuff anything you have experienced (if that applies to you at all)?
I live in the national capital region, where there is no shortage of military treatment facilities. But Tricare recipients can receive care outside MTF if they live far away from one. I don’t know a lot about VA hospitals.
The finance companies that Kip down at the country club invests in would stop paying out the dividends on which he has come to depend. Fewer items would be pawned or sold on Ebay in desperation, slowing the churn of older manufactured goods through society. And all of these economic activities on which the privileged have come to depend would be derided by progressives & labor union members as “the bad old days to which we refuse to return.” Can you imagine?!
This is just a fantasy, designed to support the idée fixe that gouvernement health care is run by bureaucrats. It’s not, at least in the Canadian system. (I’m not claiming any particular virtue about the Canadian system. I’m just mentioning it because it’s the UHC system I lived with all my life and am familiar with. )
Doctors are independent contractors. The Medicare system assumes that doctors can. E relied on to give the appropriate treatment that their professional judgment requires. They give that treatment, then get paid. Y the system. They don’t have to go to a bureaucrat to get père-clearance for a particular treatment and they don’t have their treatment choices scrutinized afterwards and claims denied. That’s the significant features of the American private insurance model, designed to cut costs. I guess since that’s how your system operate, you just assume that gouvernement run health funding systems run the same way. They don’t.
Right. This is an issue that’s been well studied, as I described up in my post #201. The clinical autonomy of doctors is in fact an important consequence of the health care systems in Europe and Canada and elsewhere in the world, and the subservience of doctors to insurance bureaucrats is in fact an important consequence of the American health care system. These are fundamental consequences of the way those systems are structured and the way they control costs. The civilized UHC systems do it by negotiating reasonable fee structures for all medical providers and then leaving the doctors alone to do their work according to their professional judgment; the US system does it by scrutinizing every single claim and trying to second-guess the doctor’s judgment wherever possible, a system that is barbaric and constitutes unconscionable interference in medical practice. But in return for being barbaric and counterproductive, at least the US system costs twice as much as it needs to!
To further point out the difference, it’s instructive to look at the differences between the UHC system in Canada, which usually doesn’t cover dental care, and the private insurance a lot of people use to cover dental care.
I get my dental care insurance via work, so it’s actually quite similar to how all medical insurance works in the US.
For all non-dental care I’ve ever received, I’ve never had a bureaucrat try to refuse to cover the procedure. There was one operation I had, where they did have to make a decision about putting me on a wait list* for having it done in Toronto, or paying for me to travel to the US to have it done. They eventually paid for the US option, which was the one my doctor preferred.
Compare that to my dental plan. Routine coverage is pretty automatic, but the first time I had to have a crown put in, they initially denied coverage for it. My dentist spent some time arguing with them, and I eventually had it done on my own dime, and then re-submitted the claim as a fait accompli. They eventually did pay the 75% or so that they were supposed to cover, but had I not had the money to pay for the crown upfront, I might have been completely out of luck. I’m now currently waiting to hear if they’ll cover another crown that I need.
Seems like a bit of a difference to me.
*As for the wait list, not long after, they added more money to cut down on the list, so that within a year, it was no longer necessary to send people out of country for this sort of procedure. So, in fact, the bureaucrats actually listened to the doctors and changed their policies, not the other way around.
agree with Horatius: the only time I’ve had to fight to get coverage for treatment was the private dental plan, which wasn’t going to provide something at full cost. Never had such an issue with medicare.
Since Medicare payroll taxes pay for all of Medicare I know that my taxes would more than double to pay for the 120 million people that would need to be added to Medicare rolls.
About 160 million are on private insurance now and 50 million are on Medicare that I also pay for via the 2.9% payroll tax. That leaves 120 million that would need to have their premiums paid by us working stiffs.
I expect my taxes would more than double what I pay for in private + Medicare now.
Senator Warren is straight out lying when she claims my “cost” would go down.
How are you accounting for what businesses pay for employee insurance?
Most employer-sponsored health plans are heavily subsidized by the employer, who then takes a tax deduction for the amount paid to the insurance company. Are you ignoring these sums in your calculations, or are they figured in somewhere that you haven’t mentioned?
