Most healthcare debates degenerate into people accusing one system or another of having properties (like rationing) that are true for all systems, or attacking policies based on success/failure of systems that don’t implement the policy in a pure form.
So here are the questions:
All healthcare systems need a source of money. Ultimately, this comes from the people. What is the best way to source this - private insurance, public insurance, direct government spending from tax, vouchers, others?
All healthcare systems need a system of rationing available care. What is the best basis for rationing?
All healthcare systems need a reward system for improvements in medical care (new drugs, treatments etc). What is the best way to fund this?
All healthcare systems need to decide whether people who can’t pay get covered, and whether paying extra can buy better healthcare. What should be allowed?
Private insurance has an answer to the first three, but I would argue that their answer necessarily implies that some people don’t get covered, and others buy better healthcare, with side effects that it is possible to pay and still NOT get adequate healthcare. Thus, if you believe in a right to health, the question is how to fairly and effectively make a hybrid government / private system.
Solely government systems need an added mechanism for encouraging private participation in both the research and provision marketplace - this isn’t an automatic necessity, but it seems to be a practical one.
I’d say that private insurance does not have an answer to the first three and the debate goes far beyond just having coverage for all.
Yes private health care funds itself. But it is massively inefficient and monstrously expensive. But we have no other choice today than to accept what they dictate. Market pressures are in no way keeping prices down. Far from it. Prices are rising at a dramatic pace.
Yes private insurance rations health care. But the rationing is premised on nothing more than the insurance company making money. If they can deny you coverage then they will do so because it behooves them, not you. There are stories galore (and studies that show statistically significant amounts of this happening so not all anecdote) of people finding the health insurance they paid for being revoked at the moment they need it.
Yes there are improvements in health care. But where? We got Viagra…lucky us. When we get some medically useful treatment they are staggeringly expensive. IIRC there is a breast cancer drug that costs upwards of $120,000/year to access. Does it need to be so expensive because of costs of development and manufacture? No. While those costs (especially development and approval) can be significant there is no justification for the $10,000/month price tag except that they have a monopoly on the drug and they can charge it.
A public option addresses much of that. It is not there to make a profit. It would not spend a fortune in advertising. It would not pay obscene executive salaries. It would not deny coverage because you forgot to report you had acne once (happened). It would still provide a market for innovation. Come up with a new drug or machine that is really useful? Great…it will get bought. It would however have the leverage to negotiate reasonable rates from providers.
First, thank you for starting this thread, and I hope the partisans don’t hijack it.
As you say, funding comes from the people. The main question in my mind is whether the funding should be distributed equally per person, divided proportionally by income, or divided proportionally by health risk. (Whether the funding paid directly by people or indirectly by employers or government is an implementation issue and not a health care issue.)
Each method has its problems. Each person paying proportionally to their health care risk is medically fair (the largest users of medical care will pay the most), but kind of removes the point of insurance–to spread the cost. Each person paying equally into the system is democratically fair, but puts a larger burden on the poorest people. People paying proportionally to their income is economically fair, but (along with equal per person payments) removes the economic incentive for people to lower their own health care costs.
I think we need a combination of the methods. Most of the cost should be proportional to income, but there needs to be a component proportional to avoidable risks.
I don’t know how our current system allocates resources, other than creating queues. I haven’t heard many complaints about it, so I assume our current allocation system is adequate. The problem of the uninsured not getting access to health care is a failure of the funding system, not an allocation problem.
Our patent system needs overhauled–mostly vastly more examiners to approve or reject patents and tighter enforcement of prior art rules. Our government-funded health care research needs a lot more funding too. There needs to be a larger separation between the development of new medical inventions and their manufacture. Specifically, drug manufacturers should not be in the drug research business.
I think this is not a separate question. It should be answered by the answers for funding and allocation questions.
Whether the health care system is private or public is a distraction. The government will regulate what is allowed or not. Whether the funding is directly from individuals to an insurance organization or indirectly through employer contributions or government taxes is a matter of preference, and doesn’t really change how effective or not the health care system is. Nor does it matter if the insurance organization is private for-profit, private non-profit, or public–that’s an economic matter. The medical effectiveness of the organization is what matters and it’s not clear that any organization has an inherent advantage.
The real questions about health care is what requirements there should be and the incentive structures. The three main parties (patients, insurance, and health care providers) need to each be encouraged to maximize the patients health and minimize costs. This can be done no matter what economic setup is used.
Your complaints are not inherent to private insurance nor are they necessarily solved by public insurance. The only fundamental difference between public and private insurance is who the stockholders are. All the issues you mentioned are determined by government regulations, which can apply to both private and public insurance.
The fundamental difference is one is for-profit and one is not-for-profit (essentially). The for-profit companies make decisions based on what is best for their company and not what is best for the patient. That includes looking for any way possible to deny payments when you need it.
Oh please. It is easy to believe the rhetoric about insurance companies making huge profits, yet the facts do not bear this out. The insurance industry ranks as only the 86th most profitable industry and earn only 3.3% (according to CBS Evening News, 9/10/09).
Windfall profits? You can get more than that with a bank CD.
For-profit insurance companies must make decisions on what’s best for their stockholders. What effect that has on patients depends on the regulatory framework. We could have regulations that allow patients to easily recover damages from a company that did not cover what they should have. That would align the stockholder and patient goals.
What’s to make a public insurance organization provide good service to its customers? The same thing that can make a private company–the regulations.
That’s my point. Arguing about public or private is a distraction. We should be arguing about what the regulations should require of the insurance organizations. And patients and doctors, too.
The problem the politicians are trying to solve is from the last century. It costs too much and won’t work.
The way to solve it is to approach it from this century. My simple plan:
First, there should be a tiered system of care. If you want the best airline seat, you pay for a first class ticket. If you want an expensive meal, you should not expect to get it paying fast food prices. Nobody can argue or complain about that. So, if you want the best health treatment, be prepared to open your wallet. If you cannot afford it, we can make affordable, lesser-quality options available such as the Walmart health clinics.
These low-cost alternatives would not be free. Illegal immigrants may take full advantage of these services as long as they pay (just like everybody else).
Second, everyone needs to take personal responsibility for their own health care. Obama talked to schoolchildren about taking responsibility, so let’s extend that to your health.
If you break your arm playing sports, you should expect to pay to get it fixed. Nobody forced you to play that sport. If you have health problems due to your choices in overeating, why should someone else pay for that?
Let’s use the internet to give the best medical advice to anyone who wants it, free of charge. If you log in regularly, follow the advice, track your exercise, document your improvements in weight and blood pressure, then you earn discounts for health care.
Let’s limit the legal liability of doctors. Again, using the internet, you can learn as much about your condition and possible diagnoses, for no cost. You can learn which hospitals and surgical teams give the best results. If you keep going to Doctor Nick Riviera and are unhappy with the results, why should the courts hand you an unlimited amount of cash?
Based on 2009 profits which saw the economy tank big time. Insurance companies are massive investors. Moreso than the other sectors listed. When the markets went in the shitter so did their profits.
Look at their profits from 2000-2007. That is the trend. Then go 2000-2009 and see if your 3.3% still holds and where they rank then.
It is this massive increase in costs that is at issue. Not that the insurance companies had to cope with a crashing market.
Either insurance companies are bilking us or health care providers are and insurance is passing along the costs. Either way private insurance has woefully failed to keep costs in check (understanding there is always likely to be some small increase if for no other reason than inflation but this goes waaaay past that).
So, poor kid is playing in his local park on the monkey bars and falls off and breaks his arm. His parents cannot afford to pay $500 to get his arm set and cast. Since no one made him play on the monkey bars it is his own fault. His parents simply cannot pay so the kid is fucked?
Assume the kid lives in a rural area and there are no free clinics within 500 miles.
Sorry kid…shoulda been born to parents with more means.
The rest of this idea is a mess too. Self diagnosis via the internet? Double-:eek:
While we’re at it, why not put this kid in the middle of death valley, too? Most people can afford $500. If they can’t, they can find a lower-cost alternative, perhaps a teaching college. Or they can read up on the internet and MacGuyver up their own cast out of stuff from around the house. Either way, I think the kid learns a valuable lesson about staying off the monkey bars.
Kids are kids. Shit happens. Unless you lock them in a closet there is a good chance you will take any given kid to the hospital at some point between age 0-18 for some injury or other.
Hell, shit happens to adults too. Sometimes people just walking seriously twist an ankle or trip and fall that can require medical attention. Their own fault for walking I guess.
You’d also likely just get people lying. “How’d he break his arm?” “Some nut with a baseball bat came out of nowhere and whacked him, no we do not know who it was.”
And you are wrong to assume everyone has $500 lying around. As it happens it is more than that. I looked up costs for setting a broken arm and in 2005 it was $2,523. (cite)
Sorry…lots and lots of people absolutely cannot pull that cash out of their pocket.
Nor can you assume a source of free care is nearby and open. It is a big country. Lots and lots of it is rural. Free clinics are few and far between out there as are Universities.
Since this is an obvious fact to you and I, it should be obvious to the parents. So that means they can plan for this sort of expense.
As for the expense, I mentioned a tiered system. If they can’t afford the $2500 level of care, then how much can they afford?
If the answer is $0, they better start learning how to jury rig stuff.
How is this any different than an unexpected car expense or an unexpected home repair bill? If someone can afford the best mechanic or contractor, it gets fixed well in a timely manner. If someone can afford less, they go with a cut rate service, or perhaps they jury rig a fix for no cost.
An unattended broken arm can cause a life long deformity not to mention a lot of pain at the least.
Cut-rate medical service has a good chance of landing the provider in court for malpractice for sub-standard medical care. No one advertises shitty medical services but at least it is cheap!
And sorry to break it to you but a lot of people whose car breaks down do not get it fixed. Heck, there are people in my city who get their power turned off because they cannot pay the monthly power bill.
You seem to think poor people are able to keep thousands of dollars lying about. I suggest you have no notion of what it is to be poor.
When I was 15 my appendix swelled up like a balloon. Was that my fault, maybe my mom’s fault? She would never have been able to afford the surgery to fix it on her own. How do you propose she “MacGuyver” an appendectomy? Tonsillectomy “open up. snip snip”?
I think we should start a GQ about what can go wrong with an untrained laymen attempting to set a broken bone. Don’t you agree?
I think you will find the people who claim they can afford $0 are magically able to afford more when properly motivated. Say, by a sudden medical condition.
Before answering any of the questions in the OP, we must decide upon the goals of a healthcare system. Is it to provide effective care to all? Is it to reduce the impact of diseases and illness? Is it to maximize profits of providers and insurers?
The second question is how to minimize costs given the answer to the first. Is the cost to be minimized public or private?
Then we have to decide how to weigh the political aspects. We can’t get away from it. Statistically, the larger the pool you have the more accurately you can set rates and predict the cost of medical care. Perhaps insurance is a natural monopoly. If so, perhaps it should be taken over by the government. How you feel about this depends on how you feel about government control. I can see a much better argument for why medical care is not a natural monopoly, since a diversity of expertise and methods is beneficial. Some may argue against that also.
Rationing is also inherently political. Those who feel money is a sign of virtue might be in favor or rationing by dollars, since that would give the virtuous well-to-do more. If you are more numbers based you can support rationing based on medical need.
There is also a factor of value of a life. If you feel any life is infinitely valuable, you’ll be for pouring money into low probability treatments for the very old and ill.
But I think my first point is the real area of contention in this debate. If we all agreed that every person in this country deserved excellent and timely care, including preventative care, we’d only be debating the best way of getting there. I think the little hijack in this thread shows that this assumption is not held by everyone.
It seems nearly everyone in this thread istaking it as a given that the government has the obligation to provide health care if a person cannot pay for it.
Why?
We wouldn’t say that the government must provide a college education. We wouldn’t say that the government must help you find a spouse.
On what basis do we decide that the government is responsible for health care at any level?
Because you won’t die or be crippled without a spouse, and the government does assist with college education. FAFSA, scholarships, and federally backed loans.
Plus the whole public school system to get you to college level in the first place.
Also it makes the country uncompetitive. The economic load for healthcare is a much higher percentage of the GDP, compared to UHC countries, with worse outcomes.
Since healthcare is linked to employers, who have to shoulder this increased burden, this means our dysfunctional healthcare system drives companies, and therefore jobs away.
Right…because people who have had their electricity turned off really actually have a stash of cash. Electricity (or gas or even water) are just one of those luxury things they’d rather go without.
Unwilling to pay the $35 electric bill they doubtless will magic up $2500 when needed.