I doubt any state passes medicare for all, but a state could pass health reform that gave UHC if they wanted. A system like the Netherlands or Switzerland seem like the most realistic systems for a state to pass.
Does anyone think any state will pass true UHC anytime soon? Right now the trendline seems to be states pretending they want to pass medicare for all, then doing absolutely nothing about health care.
But sooner or later something will have to change, states can’t just keep pretending they want medicare for all and then doing nothing at all. Health care is such a mess that that stalling tactic won’t work forever and people are going to demand real change.
I personally think health reform will be like marijuana legalization. Politicians will ignore it until ballot initiatives start mandating it, then after a half dozen states pass ballot initiatives then maybe politicians will find the courage to pass it on the state level, then eventually it’ll go federal. I assume this entire process from the first state with a ballot initiative to federal legislation passing will take about 15-20 years total.
If they do, it would probably have to come with a rule that charges outsiders significantly higher rates than in-state residents, to prevent healthcare refugees from unfairly exploiting it.
(Coming from a country with UHC but quite complicated definitions of “outsiders”) the serious problem is likely to be the perception that it is a serious problem.
True, but this is America we’re talking about. If there’s a significant imbalance between states, there will be a lot of healthcare tourists. I mean, the lengths people go to now just to get around local restrictions on alcohol or fireworks is crazy; imagine if lives were actually on the line.
Public opinion is tied in so many knots on this issue that the ballot initiative route would be completely doomed to failure IMO. I believe the median voter hates the way the health insurance system works for everyone else but like the way it works for them. Any actual concrete plan with details and costs is going to get enemies, fast, as people realize that when things change, things change.
I think all we ever get is piecemeal under-the-radar reforms and expansions (like what might end up in the “infrastructure” bill).
I know that Vermont toyed with the idea and then abandoned it. It was going to be too costly was the only answer I got from a friend who lives there. It is true that it will be very costly as long as medicine is basically profit driven. There is an entire, utterly useless, profession of medical coders. Half work for insurance companies and half for hospitals and it is only a slight exaggeration to say that half dig ditches and half fill them up again, although I cannot say which is which.
But even so UHC is quite expensive. Even after tightly controlling costs and with federal subsidies, nearly half of Quebec’s budget goes for medical care. And Quebec taxes exceed federal taxes.
Oh, they’ll still be there in a UHC situation. What they do is for practices/hospitals/whatever where the provider doesn’t directly code their own via choosing diagnoses and treatments in an EHR or something, the coders read the visit records and translate that into ICD10 and CPT codes.
Put another way, your doctor may record that you presented with a 1.25" gash in your forehead, and that he stitched it up. That’s all well and good, but in terms of actual data, there’s just a sort of clinical narrative there that isn’t quantifiable or comparable to anything else. So the coders translate that into B35.4 - “Laceration without foreign body of other part of head, initial encounter”, and CPT 12013 “Simple/Superficial-Face, Ears, Eyelids, Nose, Lips, Mucous Membranes, 2.6 cm to 5.0 cm”.
That way, your injury and treatment are standardized and are now something that can be quantified- how many B35.4s were there last year? 12013? How much did they cost? How can that be brought down? And so on.
You better believe that diagnosis and treatment codes are going to be important in any sort of UHC situation; cost control is going to be a huge part of it, and that’s how the costs are determined- by the codes themselves.
Colorado had UHC on the ballot in 2017. It was resoundingly rejected; the “no” vote was about 80 percent. There are lots of reasons why it lost (I’ve posted about this before) but suffice it to say that I had made contingency plans to leave the state if ColoradoCare passed.
As long as there is free movement between states UHC won’t be possible as a state level. People already drive across state boarders to reduce their sales tax why wouldn’t they do it to save money on their health care. If the states don’t cover people for a residency period then they will need some kind of insurance market to fill the gap which means it won’t be UHC.
Maybe today, but as recently as six or seven years ago that wasn’t a reasonable solution. And I suspect it’s kind of like a lot of professions like that where the majority of the work could be automated, but there are still judgement calls that require someone to eyeball it and make a choice. A lot places still let their doctors write shit down on paper and have it transcribed… because doctors are above that or something.
The easiest solution is to basically make the doctor record his clinical stuff in a way that automatically records that sort of thing- that’s a lot of how it was done where I used to work- our doctors could record their clinical notes in a way that was aligned with the codes- menus, etc…
But doctors are a notoriously prickly bunch when it comes to technology. They either want as little to do with it as possible, and treat it as it it’s beneath them and their profession to dirty their hands filling stuff out in an EHR, or worse, they think that because they have immense God-given talents in doctoring, that it extends to knowing how technology should work, and proceed to tell us how to do our jobs in ways that aren’t feasible or even smart. Getting them to agree to do something that’s not exactly the way they want to do their jobs is damn near impossible. Even stuff like e-prescriptions got a surprising amount of non-compliance, “who gives a f**k, the prescription got filled, right?” and just flat out using prescription pads rather than bother with e-prescribing.
I agree with the facts you laid out, but as a physician, disagree with your interpretation. From my perspective, and many of my colleagues agree with this sentiment, it feels as if we now get paid to write a proper note (according to CMS standards as opposed to what is medically appropriate) rather than to see and treat patients. I work as a post-acute hospitalist, basically taking care of nursing home patients, most of whom receive long term care, with some that are there for skilled nursing and rehab. I started this job around 6 to 7 years ago, and at the time the notes were still of the handwritten variety. My estimate is that at the time I was able to see about 30 to 35 patients a day. About 2/3 of my time was in direct patient care and about 1/3 in documentation. Now I can see about 20 patients per day, maybe 25 at most if they’re all for routine follow up visits. About 1/4 of my time is spent on direct patient care and about 3/4 on documentation. This includes, as you mention, personally selecting the ICD 10 and CPT codes for all those encounters. The thing is, those weren’t things (writing notes to fit the billing codes as opposed to documenting the medical findings and plan, and then selecting those codes) that were emphasized in medical school and residency, even as recently as the 1999-2006 time period when I attended medical school and residency. It’s a daily frustration because I (and many of my colleagues) feel that our talents are best spent treating patients, not filling out paperwork. Yes, proper documentation has always been a part of practicing medicine, but there’s a difference between documenting a good H&P or progress note that let’s others know what the medical situation is vs. clicking on a bunch of bubbles just to meet a level of documentation demanded by CMS.
As far as e-prescribing goes, when it first rolled out a few years ago, it was a huge mess, and still is to a certain extent. The system I use supposedly uses two factor authentication, but in reality is four factor authentication. We have to first log into the system using our password for the EHR, then use a password when we first input the Rx, then a passphrase, then a code sent to an app on our phones. If you end up with a typo you get locked out of the system for 5 minutes.
The patients don’t have it any better either. Providng people with medical records now involves downloading a PDF with a unique password, having to send that password to whoever is receiving the record, then sending an encrypted PDF. Each note requires it’s own separate password.
To address the OP, I doubt that any individual state would ever be able to provide UHC. As mentioned by others, there would. be too much medical tourism, with people receiving benefits from a system that they haven’t payed into.
ETA: To paraphrase Dr. McCoy, damn it bump, I’m a doctor, not a coder.
Vermont tried single payer, which sadly they backed out on due to the tax hikes.
However in America, roughly 50-60% of all medical expenses are paid by the public sector as it is, the other 40-50% are paid by private sources.
However when you add in things like tax credits to buy insurance, it can rise to 70% of funding by the public sector.
Nationally, federal and state taxpayer dollars directly paid for 45 percent of health care expenditures in 2015 through insurance programs such as Medicaid, Medicare and programs for low-income children, according to a 2015 estimate from the Centers for Medicaid and Medicare Services.
But that figure may be vastly underestimated, say the authors of a new UCLA policy brief, who used a more comprehensive framework to analyze public spending California. Their analysis found that if additional sources of public spending are factored in — such as county public health expenditures and new Affordable Care Act subsides — the public spending rate would be much higher. Add foregone revenue from tax subsidies for employer-based health insurance, and the share of public funds used to pay for health expenditures is approximately 71 percent, the study reports.
Also the US spends far more on health care than other nations, so we already pay more in taxes than other nations. For example in the US we may spend 9% (at minimum) in our GDP as public sector funds for health care (plus another 9% in private funds). Meanwhile in Canada they spend about 8% in public funds and 3% in private funds. Basically we’re already paying for UHC and not getting it because of how expensive our system is here.
However there are a wide range of programs possible other than a single public funded health system. In the OP I mentioned the Netherlands and Switzerland. What they have is like a beefed up version of the Affordable Care Act.
Everyone buys insurance on the exchanges, and the insurance is subsidized. No out of network charges, no balance billing, and annual out of pocket expenses are enforced. If you don’t sign up for an insurance policy, you are auto enrolled.
A system like that in the US could work. Just beef up the ACA to auto enroll anyone not enrolled, increase subsidies, eliminate networks, eliminate balance billing, provide a medicare buy in option for anyone. Other than that people who want to keep their government health care (medicare, medicaid, VA) can keep it and people who want to keep their employer health care can keep it. Also the plan can be funded in part by negotiations and efficiency improvements in health care providers.
Its kind of similiar to the plan ‘medicare extra for all’
I think if any states pass UHC, it’ll probably be a plan similar to ‘medicare extra for all’, which doesn’t have the scary tax numbers that scare some people off of medicare for all.