In Favor of Nationalized Health Insurance

[Thing_Fish]

OK, I find it hard to believe that this topic hasn’t been debated here before, but my search says nay, so here goes.

I would like to argue that the United States should adopt a national single-payer health insurance plan, specifically modeled on “The Physician’s Plan”, which you can read in full PDF gloryhere , and which is currently before Congress as HR 676, the Conyers/Kucinich US National Health Insurance Act. Under this system, health care would be continued to be delivered mostly by the private sector, but would be paid for by a public agency rather than,as now, largely by a patchwork amalgam of private for-profit insurance companies. Patients would be able to choose which doctor and hospital to use, and doctors would regain their ability to practice medicine without interference from insurance company bureaucrats.

Currently, the U.S. is spending more than twice as much as the rest of the industrialized nations ($7,129 per capita), but still doing poorly in comparison on major health indicators such as life expectancy, infant mortality and immunization rates. Moreover, the other advanced nations provide comprehensive coverage to their entire populations, while the U.S. leaves 46 million completely uninsured and millions more inadequately covered.

Private insurance companies spend $350 billion annually on expenses that have nothing to do with health care; underwriting, billing, marketing, and of course profits and executive pay. In turn, doctors and hospitals must pay for staff members whose only function is to deal with this bureaucracy. The elimination of these companies and recapturing of this wasted money would allow us to fund universal health care without any net increase in money spent on health care. Some tax increases would be necessary, but since nobody would have to pay for insurance premiums anymore, most individuals and businesses would come out ahead.

Under this system, all Americans would be covered for all medically necessary services. Doctors, just as now, could choose to be in private practice and be paid for their services according to a negotiated formulary, or could choose to be employed by a hospital or HMO on a salary basis. Hospitals would be allotted a global sum for operating expenses, which would be determined by regional planning boards responsible for allotting resources in an equitable way.

More details can be found at the website of Physicians for a National Health Plan .

Your thoughts?

[gonzomax]

We have convinced our voters that health care is beyond our means. Note that the neocons deliberately made it that way. Slashing taxes and starting wars will bankrupt us so severely that health care and social security are too expensive for us. It was not an accident. The plan is to eliminate as many services to the poor and middle class as possible.We do love our rich in America don’t we.

[Sal_Ammoniac]

I’m more or less in favor of any scheme but the present one. The one you propose is okay by me, though I would argue that you could continue to use insurance companies as intermediaries. The advantages would be that you could make use of much of the present system, minimizing disruption, and that you leave some market forces at work, in that insurance companies would need to compete for patients, and bargain with providers for the best deal. In fact, the only change from the present system would be that every American would be covered and would get to choose which insurer/HMO to cover them, and that payment of the premiums would come from taxes, as opposed to employers.

[Burton]

And it could be overseen by the Walter Reed administration.

[Thing_Fish]

Sal, I’m not quite sure what you envision… the government would pay premiums directly to insurance companies? I don’t see any advantage to that over what I have proposed…the different insurance companies would still be wasting resources, and doctors would still be burdened by having to keep track of the different paperwork required to get paid by various insurers, who would still find it to be in their financial interest to make that process as confusing and burdensome as possible. The plan I have proposed does leave market forces at work, since doctors would still be competing with each other directly for patients. They would not, however, be able to compete on price, which I feel is a reasonable restriction on the market, since such competition provides an incentive to offer substandard care.

[Thing_Fish]

Burton, not quite sure what to make of your drive-by snarkery. It appears that you are spouting the neocon line that government is inherently incompetent, which becomes a self-fulfilling prophecy when we elect neocons to run government! As long as we continue to do that, it is certainly true that this or any other effort to move towards a more civilized and just society is doomed.

From the PNHP website:
2) There is a lot we can learn from the Walter Reed disgrace. Its operation was outsourced to a Halliburton-connected company in 2002, over the objections of some Army medical personnel and leadership, with a subsequent loss of government employees with institutional experience and a drastic reduction in staff. There was also some hanky-panky with the contracting process when the government employees’ bid for the operations contract came in lower than the Halliburton company’s bid, and the bids were subsequently “recalculated” to make the private company the lowest bidder. Here is a link to an eye-opening article:

“Bush Administration push for privatization may have helped create Walter Reed ‘disaster’”

This article has links to Rep. Waxman’s letter to the Army generals and to the Army Times article that “connects the dots”.

(contributed by Dr. Anne Carroll)

[Burton]

There will be more of that I’m afraid. I don’t think it makes too much difference whether we have a Democratic or Republican administration in charge. I think national health is something to strive for but it won’t be without big problems.

[Thing_Fish]

@Burton

There will be more of that I’m afraid. I don’t think it makes too much difference whether we have a Democratic or Republican administration in charge. I think national health is something to strive for but it won’t be without big problems.

Well, nothing worth striving for ever is! Sorry about the rude tone of the first sentence of my last post.

[Sal_Ammoniac]

[QUOTE=Thing Fish]
Sal, I’m not quite sure what you envision… the government would pay premiums directly to insurance companies?
Yep.

@Thing Fish

I don’t see any advantage to that over what I have proposed…the different insurance companies would still be wasting resources, and doctors would still be burdened by having to keep track of the different paperwork required to get paid by various insurers, who would still find it to be in their financial interest to make that process as confusing and burdensome as possible. The plan I have proposed does leave market forces at work, since doctors would still be competing with each other directly for patients. They would not, however, be able to compete on price, which I feel is a reasonable restriction on the market, since such competition provides an incentive to offer substandard care.

Well, insurance companies don’t purely waste resources. In some ways, they increase the efficient use of resources, often in ways that doctors don’t like (e.g., preauthorization for MRIs). And they do embody some market forces, in that they compete for patients, and force providers to compete on price (and as to whether competition on price provides an incentive to offer substandard care, I don’t agree – and anyway, you don’t solve that problem with fixed rates).

You’re right that having different billing forms and procedures creates a administrative waste, but you can solve that problem by mandating a standardized electronic claims form. Even today, there are electronic clearinghouses that process claims for several different insurers.

The best reason I can think of to continue using insurers as intermediaries is that they’re already doing it. We could have a national health insurance system and 100% coverage in six months, with minimal disruption to most Americans. On the other hand, if you have to expand the existing Medicare bureaucracy to cover everyone, it’ll take a lot longer.

Mind you, either of those solutions would be vastly preferable to what we have now.

[Sal_Ammoniac]

@Burton

And it could be overseen by the Walter Reed administration.

Got a grievance against the Army? Convinced they can’t do anything right?

[BrightNShiny]

I’d prefer to start off with emergency room coverage. Emergency room coverage, I think, makes the most sense economically. First, emergency procedures tend to be pretty expensive. And for indigent/poor people, both private and public organizations are required to treat them. Additionally, in an emergency situation, most people don’t have the ability to competitively shop for services and prices. This creates a bi-lateral monopoly, which can lead to inefficient market pricing. So, anyway, that’s where I’d start. A national emergency health care coverage plan which provides coverage with minimal copays, which regulates prices in such a way that pricing is at an efficient level, and provides a reasonable profit to providers. The Copays should be priced in such a way to discourage people from overuse of the system.

And I’d fund it with the Automated Payment Transaction Tax system which would replace our current tax system. And then I’d get a pony.

[RTFirefly]

I recommend Ezra Klein’s Health of Nations in this month’s American Prospect for a quick summary of how France, Germany, England, and Canada provide a level of health care comparable to ours at half the price, and (unlike us) don’t leave one-sixth of the population without coverage.

Plus he discusses the Veterans’ Administration health care system in America, which covers one of our oldest, sickest groups of people at a lower rate than our average per-capita cost.

Bottom line is, the obstacles to good-quality universal health care here are political and corporate clout, not cost.

We’re the richest country in the world, yet we’re pretty much the only industrialized country that “can’t afford” universal health care. That makes no sense at all. Hell, even countries like Thailand have universal health care now.

And yeah, the waiting period for something, somewhere is always going to be longer than here. There are two questions that should be asked whenever this one comes up:

1. Is the longer wait time for X in the Slobbovian health care system representative of longer waiting times overall, or is the writer who brings up the example cherry-picking the instances that make the U.S. system look best compared to Slobbovia?

2. Are the numbers being skewed by the exclusion of those Americans who, due to costs and poor or nonexistent insurance, are foregoing care that they need? Klein discusses that here:

If you look at waiting times, you’ll see that relatively few Americans wait more than four months for surgery, which helps folks claim that America doesn’t ration care, and makes our system look pretty good on the waiting times metric. Here’s what they don’t tell you: When you look at who foregoes care, the international comparisons reverse themselves. About 23% of Americans report that they didn’t receive care, or get a test due to cost. In Canada, that number is 5.5%.

Worse, the American number is understated, as in order to know you need a surgery or further care, you need to go for an evaluatory visit, and as it happens, many Americans – including 36 percent below average income – aren’t even seeking that.

[Sal_Ammoniac]

@BrightNShiny

I’d prefer to start off with emergency room coverage. Emergency room coverage, I think, makes the most sense economically. First, emergency procedures tend to be pretty expensive. And for indigent/poor people, both private and public organizations are required to treat them. Additionally, in an emergency situation, most people don’t have the ability to competitively shop for services and prices. This creates a bi-lateral monopoly, which can lead to inefficient market pricing. So, anyway, that’s where I’d start.

Why fragment an already fragmented system even further? Your idea would also cripple our nation’s emergency rooms, since they’d be the only locus for getting “free” care. An emergency-room doc is not a PCP, and shouldn’t be treated as one. Emergency rooms are designed to handle short-term acute crises, not manage people’s care.

[BrightNShiny]

@Sal Ammoniac

Why fragment an already fragmented system even further? Your idea would also cripple our nation’s emergency rooms, since they’d be the only locus for getting “free” care. An emergency-room doc is not a PCP, and shouldn’t be treated as one. Emergency rooms are designed to handle short-term acute crises, not manage people’s care.

Don’t people already go to emeregency rooms for “free” care? Aren’t they already trying to use docs as PCPs? That’s why I’d put a co-pay in. If you choose the right prices on co-pays, you can discourage people from seeking unnecessary care. My system fixes one aspect of health care funding. Notice I said that I’d prefer to start with this. If it doesn’t turn out to lower health care costs across the board, then we could discuss additional systems.

And it harldy creates additional fragmentation. Right now, each emergency room system has to figure out a way to deal with unpaid emergency room care. This eliminates that.

But I’ll say this. Any universal health care system is going to run into significant political opposition, and you’d have to phase it in anyway. I think emergency health care is the best place to start, since it’s one of the big drains on the system to begin with.

[Sal_Ammoniac]

@BrightNShiny

Don’t people already go to emeregency rooms for “free” care? Aren’t they already trying to use docs as PCPs? That’s why I’d put a co-pay in. If you choose the right prices on co-pays, you can discourage people from seeking unnecessary care.

I agree that this somewhat characterizes the present system, but it’s really suboptimal. If you’re going to improve the system, you should try push people away from using the emergency room for primary care, rather than reinforcing their tendency to do just that. And trying to manipulate behavior through copays is a double-edged sword. In the worst-case scenario, you make people who really should be going to the emergency room think twice, sometimes with fatal results.

There’s a strong trend in modern medicine to try to restrain costs by keeping certain kinds of people out of the emergency room – heart-failure patients, diabetics, asthmatics, etc. When you get these kinds of patients constantly cycling through your emergency room, that’s when you start paying real money. If you create a system that gives people universal access to the emergency room, regardless of your copay strategy, you’re going to end up undermining one of the most significant cost-containment strategies being pursued today.

I agree that politically, incrementalism might be the right idea, but you have to be careful – if the first increment is a failure, that’ll kill appetite for any additional increments. I’d be concerned that your emergency-room idea would have unacceptable side effects. My idea of incrementalism is for individual states to take the lead. When I proposed earlier that we use the existing insurance companies and HMOs as intermediaries, one of the things I was considering was that it made easier this kind of state-by-state incrementalism. In certain states, you have a few dominant providers, giving you an infrastructure that’s ready to go. You’d only have to switch the payment mechanism, and suddenly you’d have universal healthcare.

[conurepete]

I have not yet seen any good proof that co-pays help people to make better choices. It is hard to even get people to pay attention to their health when not in a health crisis.

[Thing_Fish]

RTFFirefly , thank you for posting the link to that excellent Klein article! **

Sal** , you might be especially interested in its discussion of the German system, which does include some heavily regulated entities analogous to insurance companies. The benefits of this are still not really clear to me, but it still seems to qualify as “a vast improvement over what we have now”. This thread seems to be at some risk of turning into “a bunch of people who basically agree with each other searching for something to argue about”, but I am curious about your assertion that you do not believe that price competition creates an incentive to substandard care, and that fixed prices are not an effective way to deal with this. Perhaps you mean that you feel there are, or could be, sufficient counter-incentives built into the system that this would not practically speaking be a problem, and that if it were to be a problem, better ways of dealing with it than fixed pricing exist?

Although I was not around for the Medicare rollout, my impression is that it was done very quickly and easily, in contrast to the dire predictions that had been made beforehand. I don’t see any reason to believe that implementation of a single-payer system need be a lengthy or complicated process.

It has been pretty amply demonstrated that people in general are not good at distinguishing necessary from unnecessary care, so adding extra financial burdens to seeking care is at least as likely to discourage people from seeking necessary care. Klein addresses this issue in his section on France; here is a New England Journal of Medicine article which looks at this issue in more detail, andhere is a less scholarly examination from Malcolm Gladwell in The New Yorker .

Another serious problem with BrightnShiny 's proposal is that turning people away from emergency rooms on the grounds that they cannot afford the co-pay would be ethically unacceptable.