Universal health care and the poor

Great Debates
141

We don’t really disagree.

I’ve read the paper. It’s got a lot of good ideas in it. Thanks for the link.

However, with public opinion as it is now, I do not think people will accept significant reform. First, we have to come up with a good plan that people of most political ideologies would be willing to accept as a compromise–a plan in which most people could find things they agree with. That means forgetting about a single payer system. (Although a compromise plan might still retain Medicare/Medicaid style programs in some form.)

Then we need to advocate this plan in such a way that it will survive the inevitable attacks of special interest groups and extremists who won’t accept any compromise. This is going to require a serious bipartisan effort.

I absolutely do not think it’s better to do nothing. (Have you really read my posts?) I am saying that we need to proceed with a careful strategy. And I think any strategy that includes either 1) harping on how great a single payer system would be or 2) trying to gradually throw out little fixes to the current system is going to fail.

142

And I agree that Universal Payor is DOA.

That leaves the others.

Mandated coverage (employer/individual coupled with my insurer one-price-for-one-product rule/or both)

expansion of current programs for the uninsured

new programs

or some hybrid of the above.

Which do you like?

143

This is the part that I find hard to believe.

AFAICT, the argument that we would save money is based on the following:
[ul][li]Savings on administrative costs. I used to work IT for a hospital system. Medicare had more paperwork than the insurance companies, not less. I do not see how billing, DRGs, CPT and HCPCS coding, etc., is going to be less onerous dealing with the government. []Savings based on preventative care. No doubt there will be some of this. I suspect, however, that the US experience with free vaccination does not indicate that there is a pent-up demand for preventative care that will save money in the long run. And I don’t see that poor people who are covered by Medicaid are much more diligent about getting preventative care than the uninsured. No doubt there are some. I don’t know if it will amount to significant savings. []Savings based on setting limits. This is the major sticking point I have with universal health care. Extending coverage to the currently uninsured will increase demand, not lessen it, and increased demand tends to increase costs and prices. [/ul]If I could believe the government would set an amount they were going to spend, and then refuse to increase it, I might believe in single payer or universal coverage. But I see how much abuse the HMOs take for refusing to cover things like 48 hour maternity stays, and I find it hard to believe a politician is going to take heat for supporting something expensive, popular, and medically unnecessary. [/li]
Yes, I know what the Canadians and Europeans do. The US has a different culture and different demographics than Canada or Europe. Transplanting their system to us will not work one-for-one. IMO.

I have said it before - the only U.S. system that will save money in the long run is one that can say, “No, we are going to let your grandma or the cute little white kid die. And we are doing it to save money. One more small incremental increase is too much.”

Regards,
Shodan

144

Shodan,

You forget the shifted costs of providing expensive but too late care to the currently uninsured. And you assume universal coverage means single (governmental) payor. It does not.

See http://www.nchc.org/materials/studies/index.shtml for a nonpartisan analysis of the costs compared to doing nothing.

Finally we gotta go with the evidence we got. We do less for a lot more than all the rest (overall). We don’t need to transplant over another system, but we do need to analyze what they’ve done right and apply some of those methods in ways appropriate for our culture.

145

None of this really explains why other countries invariably pay less though. Australia has roughly the same demographics as the US, and they still spend alot less. The idea that they are only saving money by letting people die off is patently false. It can’t be a coincidence that every country with universal access pays less than us.

there would also be savings from price negotiations on some things like pharmaceuticals.

http://cthealth.server101.com/

Administrative expenses will consume at least $399.4 billion out of total health expenditures of $1,660.5 billion in 2003. Streamlining administrative overhead to Canadian levels would save approximately $286.0 billion in 2003

So you combine things like lower admin. costs, lower prescription drug costs, more preventitive care and perhaps a $400 billion annual savings is possible.

146

Do countries with socialized medicine have caps on malpractice lawsuits/insurance? Do they have some limit on the costs of medical school or some form of subsidy to pay for training doctors?

I ask this because my (admittedly limited) understanding of why doctors need to charge as much as they do (obviously, supply and demand is involved as well, but it’s all expensive either to the patient or to his/her insurer, so there’s clearly a limit to how low they can go) is they have a lot of overhead, much of this being a) repaying student loans that got them through med school, and b) malpractice insurance. Is there any significant difference in these expenses between US doctors and Canada or UK or France doctors?

147

Medicare being a pain to deal with does not mean that all other government programs are going to be hard to pain to deal with. Government programs can be good or bad. Just like private companies.

148

This is a whole 'nother debate. The link between malpractice awards and malpractice premiums isn’t nearly as clear as you may think.

149

And even those who, like me, see a clear link, do not feel that tort reform will be the most important item in controlling costs. Mind you, I think it would help. But that is indeed another debate entirely. And I wouldn’t want to tie it to reform because then the lawyers would kill it. I want something that can actually get done!

150

You could flip it and say the same thing. Western governments call it a public health system because it sounds better than socialized medicine. Canadians are still lucky enough to cross the border when their expectations are not met. There are already places south of the border that cater to American’s looking for a better ROI on their medical dollar. If Socialized, sorry… Public Health Care is enacted there will be airliners queuing up for landing rights in Middle and South America.

151

I pretty much answered that in my first post. I think the Austrian plan has a set-up that will make a lot of people happy.

  1. Government mandates universal coverage, and what that coverage has to be. Fees and costs are capped. That makes a lot of the people who like single payer happy.

  2. Policies are through private insurers. Keeping a significant part of the plan privatized will make Republicans, free-market proponents, etc. happy. Also the big insurance companies, who would lobby hard against socializing all health insurance.

  3. Funding through a combination of required employer contributions and taxes. That’ll help mollify the “oh my God our taxes will skyrocket!” crowd. Since many employers already pay large parts of their employees’ health care premiums, at least the companies that do won’t fight it so hard. (Though I’m sure Wal-Mart et al. will throw a fit.)

  4. As far as prescriptions go, our government should institute price controls so that we’re paying prices similar to those in Canada and Europe.

There are more details that need to be worked out, but I think that’s the best rough idea I’ve heard, in that it both solves the problem and is about as palatable as health care reform gets.

152

I am insured, through an act of luck.

To see my GYN for my annual pap smear, I had to wait nearly 3 months. I am still waiting for authorization for a medically necessary surgery that should’ve happened 2 months ago, but the insurance company keeps dragging its heels about approving the claim. So I get to live in pain until they decide to do something about it.

Screw that. That’s not an efficient system. My claim’s been there since March. Why should I have to wait 6 months for an approval for medically necessary procedure?

153

Except that ‘socialised’ is a word with a clear meaning and what people are talking about here isn’t it.

154

I am not sure what you mean by this. Are you talking about saving money thru preventative care?

As I mentioned, I am not as sure as some that there is a pent-up demand for preventative care among the uninsured that will save us money in the long run. I mentioned the free vaccination plan. States with free vaccinations don’t have significantly higher vaccination rates than those without. (I can dig up a cite if you like.) Most of the time, what forces people to get their kids vaccinated is that they won’t let them into school without it. So people aren’t, in this case, pining to get preventative care that will prevent measles and whooping cough. Thus providing taxpayer-funded vaccinations does not result in huge cost savings later. AFAICT.

If this highjacks the discussion into vaccination non-compliance and religious objections and quackery about thimerisol, I will withdraw the comment as I don’t want to change the focus. But it seems to me that, for us to save a lot of money on healthcare by providing universal coverage, then the uninsured would have to be disproportionately eager for preventative care but prevented from getting it by lack of access. And I don’t see that this is the case.

I’m subject to correction, but it seems to me that for a lot of people, preventative care is just not a high priority. This includes stuff like vaccinations, but it also includes diet and exercise and not smoking and wearing seat belts and things of that nature. And I would expect that the class of uninsured includes a certain proportion of people who could afford health care, sort of, if they skimped on something else, but don’t choose to make the sacrifices. Maybe this is a rational, or even unavoidable choice, for them. I don’t know. But I would bet that at least some of them are relying on an expectation of charity care, if worse comes to worse, and I wonder if those folks in particular are going to change their priorities if health care were universally guaranteed.

Certainly it is true that some government programs work better than others. No doubt we would disagree on which those programs are ($200 hammer, anyone? :wink: ), but as a general principle, sometimes government can do it. But Medicare and Medicaid are as close as we got in the US to unversal coverage health care. Medicare covers everyone over 65, and Medicaid covers a lot of poor folks.

And therefore it seems to me to be a good place to ask if the expectations of universal coverage are working out. And it doesn’t seem that they are, at least not as well as proponents of universal care say they should. And Medicare in particular costs a shit load.

Therefore I expect that these are good places to ask, if universal coverage is going to save us a bundle, why doesn’t it seem to do so with Medicare and Medicaid? And if there is something more than we should do so it does save us a lot, why don’t we try it first with Medicare and Medicaid and be sure that it will really work? Medicare seems to be in more impending trouble than Social Security, and I don’t see the political will to do much by way of radical reform of SS. If the proponents of universal care know how to save a lot on Medicare, I am sure the rest of the country are eager to hear it.

But this idea that “we have to do something about health care, universal coverage is something, therefore we have to do it” smacks a good deal of either desperation or panic. Should we really take such an enormous, complex, and expensive step before we have reason to believe it will help?

Primum, non nocere is as good a slogan in health care reform as it is in health care. ISTM.

Regards,
Shodan

155

I don’t think that everybody will suddenly get on board with preventative care. Honestly, I’m not sure that preventative care other than vaccinations is particularly effective.

But universal coverage can help with early care. The care that you could get once symptoms start showing up–which now requires the uninsured either to have a ton of money or to go to emergency rooms unnecessarily.

156

It’s not untried. Nearly every Western nation has a national health care system that the vast majority of people are very happy with. It’s worked in country after country, time after time. We have solid proof that their systems work. We have solid proof that our system hardcore doesn’t.

157

No, I’m not talking about preventative care, in the sense of regular checkups. More that already alluded to earlier care. And care in appropriate more cost effective venues.

The fact is that the uninsured DO ultimately get healthcare and that it does ultimately get paid for. They are just such more likely to slow up in an ER -for care that could have been provided in a regular office visit if they could find one to take them, or for problems that were now major because they were ignored for too long.

Yes, they sometimes pay for it, but often the hospital is stiffed. These costs are shifted onto the injured populations. That’s how it ultimately is paid for.

We do not ration care in America; we irration care.

158

(I use a Tablet and that should have been “insured” not “injured” but it kinds of fits! )

159

What I am asking for is evidence that their system will work here.

One way of testing this would be to [ul][li]identify what about their system will reduce cost []implement this in one of our existing systems (Medicare and/or Medicaid) []See if it really does work[/ul]The Shah of Iran was once asked why his government treated its citizens so differently from the Swiss. His response was, “when my people act like the Swiss, they can be governed by the Swiss.” [/li]
My perception is that what is driving the increase in health care costs has more to do with different expectations, defensive medicine, and the general American attitude that any problem is solvable.

The other factor is one that is also (I suspect) underlying the drive to provide everyone with health care. That is the attitude that if something might help, there is a moral duty to provide it, regardless of cost. And therefore I suspect that the same people who recoil in horror at the suggestion that "no, I don’t want to provide health insurance for everyone because it costs too much will recoil in equal horror if we implement universal coverage, and someone complains they have to wait all day at the free clinic, and the taxpayers say, “no, I don’t want to spend the money to fix that either.”

At some point, in other words, the only thing that will arrest the upward trend in health care costs is for someone to say, “No”.

People perceive their health care as free. Their employer pays most of the cost, the government pays most of the cost - some one else pays the cost. And demand for health care is essentially infinite. Further shielding the consumer from the perceived cost by hiding it in payroll withholding is not going to address this, even a little. And therefore I don’t believe that universal coverage is going to cost less. Increasing the supply and hiding the cost is highly unlikely, in my view, to do anything but accelerate the trend.

But implementing rationing - in my view, the only thing that will address the proelm - can be implemented without universal coverage. And real rationing, to be effective, is going to have to pinch. But if we implement it on current programs like Medicare or Medicaid is going to go a long way to convince me at least that the political will exists to seriously address the underlying issues before we jump into another giant bureaucracy that is unwieldy, expensive, cumbersome - and immortal.

Regards,
Shodan

160

My best friend works in research for one the big drug companies (they make Embrel amongst other things), and from what she’s told me, JustAnotherGeek is right. The company that produces a miracle cure spends X on research and development. They go to countries and tell them that they’d sell them the drug for Y amount of money. The countries tell them to stick it because there’s no way they’ll pay that much money. So in the end the company sells it abroad for considerably less than what they’d like to sell it for. But not in the US. In the US the government doesn’t care what they charge people, so they add onto the price in the US in order to recoup research and development costs, so in effect the US is subsidizing worldwide prices because we bear most of the research and development costs. Apparently they do not lose money by doing this, since is SOP.