At the local level, we were treated to stunning news that might have gone unnoticed by some. The Davis City Manager suggested that, in a few short years, the City of Davis will spend one-quarter of its payroll on health care for retirees.
At the same, national attention focused on seminal rulings from the Supreme Court, as it perhaps surprisingly bucked its conservative trends, siding with the Obama administration on both immigration and the health care reform.
Much of the news and expert analysis has focused on the impact on the presidential elections, with some arguing that the Obama Administration is propped up by some big wins this week. Others argue that the conservative opponents are energized by this ruling as they will rally around Mitt Romney who has vowed to roll back the health care reform.
From our perspective, however, the biggest development is that the Supreme Court itself, as an institution, was actually in some considerable threat. There was an increasing belief on the part of some that the court itself was becoming political and the current make-up lent itself to the belief that there was a solid conservative bloc of five, appointed by Republican presidents, positioned against a bloc of four more liberal members appointed by Presidents Clinton and Obama.
That perception seemed to have been undermining the legitimacy of Supreme Court rulings still reeling from the 5-4 Bush v. Gore decision that decided the 2000 presidential election more than a decade ago.
One line of thinking emerging is that Chief Justice John Roberts, who was the swing vote in both recent decisions, consciously moved in order to save the court from itself.
As David Savage of the Los Angeles Times writes, “Chief Justice John G. Roberts Jr. considers it an insult when he hears it said that he and the justices are playing politics. He has always insisted his sole duty was to decide the law, not to pick the political winners.”
But, “Until this week, however, not many were inclined to believe him. Those on the left – and the right – were convinced they could expect Roberts to be a reliable vote on the conservative side.”
“The chief justice took control of two of the biggest politically charged cases in a decade, involving the Affordable Care Act and Arizona’s immigration law, and he fashioned careful, lawyerly rulings that resulted in victories for the Obama administration,” he continues.
Mr. Savage, however, notes that one of Chief Justice Roberts’ heroes is Chief Justice Charles Evan Hughes, a progressive Republican who was chief justice in the 1930s when President Roosevelt, after a series of stinging defeats from the court over the New Deal, proposed a plan to increase the number of justices on the court.
Writes Mr. Savage, “When the high court and the Roosevelt administration seemed headed for a constitutional showdown, Hughes persuaded one wavering justice to switch sides and vote to uphold a minimum-wage law and a collective bargaining measure.”
That “switch in time that saves the nine” would go a long ways toward calming fears of a partisan court in the 1930s and therefore defused the President’s plan to add additional justices to the Supreme Court.
Mr. Savage argues, “This year’s court battle over the healthcare law did not rise to the level of the New Deal-era clash. But had the Roberts court struck down Obama’s healthcare law, Democrats and progressives would be making those historic comparisons this week.”
This is the take of many law experts and pundits this week.
Others believe that the political decision was not just about the Court but about Chief Justice John Roberts himself.
John Dean, the former counsel to President Nixon from 1970 to 1973, argued that those surprised by Chief Justice Roberts’ vote should not have been. “Not only was Roberts’ word at issue, but so too was the reputation of his Court. In addition, with this holding the Chief Justice truly made this the Roberts Court, rather than the Kennedy Court.”
As UC Davis Law Professor Vikram David Amar, along with Yale Law Professor Akhil Reed Amar, argue in the LA Times editorial today, up until this week, Justice Anthony Kennedy was the key swing vote, and has “most consistently been in the majority in hotly contested 5-4 rulings.”
“Roberts, on the other hand, has been in dissent in many significant criminal procedure decisions,” they write.
“It is common to refer to the Supreme Court by the name of its chief justice. But merely having the title isn’t enough to make a chief the court’s dominant legal presence” they argue. And this week, John Roberts emerged, as he “claimed the current Supreme Court as his own, and began to build for himself a legacy of greatness.”
John Dean writes, “Informed people understood that this case was a defining moment for the Roberts Court, as did the Chief Justice. Based on this ruling, if the Roberts Court had overturned this important new law, it would likely have been forever viewed as a Court controlled by conservative partisan political activists, rather than a Court where, in fact, justice could be done.”
Professors Amar write: “In the healthcare case that defined this term – and perhaps this decade – for the court, Roberts ruled and Kennedy lost (as did all the other justices, in a sense, because Roberts was the only justice who agreed with every single important thing the court decided in the case).”
They add, “It is not an exaggeration to say that the Affordable Care Act case was – in terms of the number of people affected, the amount of money involved and the symbolic, political and institutional stakes on the line – bigger than all the other 70-some cases the court decided this year put together.”
What does this mean? “It tells us he shares or at least appreciates the instincts of some of his most revered predecessors.”
The comparison to Chief Justice John Marshall in the Marbury v. Madison decision is particularly poignant, as “Marshall succeeded in moving constitutional law toward his own ideological sympathies while reaching an immediate result that avoided a direct political confrontation with a president (Thomas Jefferson) who opposed Marshall’s basic vision.”
They write, “Roberts’ healthcare ruling did exactly the same things. Even as it upheld a law in which the president had invested significant political capital, Roberts’ ruling placed new limits on Congress’ commerce and spending clause powers, thereby promoting the conservative constitutional values that Roberts has always espoused.”
They add, “Moreover, the chief justice accomplished this in the context of an overall outcome that makes it hard for Obama and others who differ from Roberts’ basic constitutional outlook to complain, and in a manner that enhances the credibility of the court as an independent, nonpartisan arbiter.”
Political Scientist Lara Brown makes a similar point.
“I think all of those pre-decision discussions about Marbury v. Madison (1803) influenced him because he politically pulled a maneuver not all that different from Chief Justice John Marshall. Like Marshall, Roberts gave the president the ruling he wanted and in doing so, he averted an inter-branch confrontation, which had the potential to turn into a constitutional crisis, given the mood of the country,” she wrote. “But also like Marshall, he upheld an important principle. In Marshall’s case, it was judicial review. In Roberts case, it was the commerce clause. Because his opinion clearly now establishes a limiting principle with respect to the commerce clause. The federal government cannot force Americans to purchase a private product unless not doing so is considered a tax. His opinion will surely be cited in future cases and will likely become precedent as far as limits on the use of the commerce clause.”
“Simply put, he told Congress: you can pass a tax, but you can’t hide behind the commerce clause any longer in your efforts to expand the federal government’s reach. In other words, conservatives should be happy because while liberals won the battle, conservatives won the war.”
The point is not lost on a New York Times editorial: “While they upheld the law’s mandate for individuals to buy insurance under Congress’s taxing power, the chief justice joined the four other conservatives to reject that provision under the Constitution’s commerce clause.”
The Times writes, “That rejection underscores the aggressiveness of the majority’s conservatism and marks a stunning departure from the long-established legal consensus that Congress has broad power to regulate the economy.”
“The current conservatives are not preserving a tradition or articulating a new social consensus. Instead, as the legal historian Robert W. Gordon put it, they have regularly been radical innovators, aggressively stepping into political issues to empower the court itself,” the Times add.
“The five in the majority have redefined judicial conservatism,” the Times argues. “The contrast in style and philosophy with the moderate minority is pronounced, including the conservatives’ willingness to flout court rules, constraints of precedent and well-established practices of legal reasoning to reach results they seek.”
They add, “It is no wonder that the court’s standing in public opinion polls is at its lowest level in a quarter of a century, with just one in eight Americans believing that the justices decide cases based only on legal analysis.”
Indeed, as another New York Times article notes, “In the wake of the blockbuster Citizens United decision, which by a 5-to-4 vote along ideological lines opened the door for corporations and unions to spend as much as they like to support or oppose political candidates, the court was accused of naked partisanship for seeming to favor Republican interests.”
It is perhaps these reasons that make the current decision so brilliant on the part of John Roberts, who was able to merge his own conservativism into a ruling that would appear to favor the President.
“It was masterful. Roberts believes in a modest role for the court, and he was doing just what he promised he would do,” said Stanford law professor Michael W. McConnell, a former appeals court judge appointed by President George W. Bush. “Had the court struck down the law, they would have been the focal point of the campaign. Now, the court comes out with its reputation enhanced.”
The issue of the Supreme Court figures to loom large, however, in the next presidential election. The 5-4 majority is as precarious as it is daunting. Should President Obama win re-election, there stands a reasonable chance he can appoint another moderate to center-left justice and swing the court the other direction.
Should Mitt Romney defeat the incumbent President, he may have the opportunity to solidify the conservative’s hold on the court, ensuring that these 5-4 decisions are 6-3 in the future.
—David M. Greenwald reporting
[quote]It was masterful. Roberts believes in a modest role for the court[/quote]
I completely agree with the first clause of this sentence and completely disagree with the second.
The decision as written by Roberts was indeed masterful in appearing to provide a victory with the ACA, while in the meantime restrict federal power through the commerce clause. It also conveys, on the surface, which is the only place most Americans will look, that the court and Roberts himself were acting in a non partisan manner.
However, to say that Roberts believes in a modest role for the court is to completely ignore what lies beneath.
The predominant trend for this court in socially and economically significant decisions of major magnitude has been the 5-4 split. These two decisions do not alter that history. I think the more telling comment is that the
5 in the majority, or at least the four more politically conservative hard liners, have indeed re written the concept of judicial conservatism to mean conservatism in the political sense, not in the sense of truly interpreting and conserving the intent of the founders and our constitution. I believe that his decision with regard to the ACA was a very clever political calculation that was anything but non partisan.
My prediction: the cost of health insurance is going to rise dramatically. Hope I’m dead wrong…
ERM: your prediction would be true regardless of the outcome of this case. For most people, it already has.
I have read more than one analysis that Justice Roberts was offended and disturbed by the visceral tone and over-reach of Justice Scalia. If so, he joins hundreds of millions of us in that regard.
How many liberals judges ever rule in favor of the conservative side?
How about a narrower question – subject matter, era, definition of conservative versus liberal sides, we gave had some strange verdicts even recently with liberals seeming to side with a conservative ruling and conservatives taking what one would think is a more liberal position.
At the same time Rusty, Roberts did not make a liberal ruling. That was part of the point of this article.
ERM: “My prediction: the cost of health insurance is going to rise dramatically. Hope I’m dead wrong…”
I had a conversation with someone who owns a small business mostly based in Davis. He has 70 employees and currently pays for a portion of their health benefits. He says under the new law he will have to insure not only his employees but also their families. He stated that he can’t afford that so he’s going to opt to just pay the $2000 tax per employee and drop the healthcare. So now each of his employees are going to have to find their own much more expensive insurance or pay the individual penalty tax. He also said that he’s going to have to raise his business fees to try and compensate for the higher taxes. One could also surmise that his employees will see less in the way of raises and compensation. I’m sure he’ll also think twice before doing anymore hiring. So it’s not just the business owner who’s going to take the hit. This will ripple all through the economy in higher prices and fees for everything as business owners try and recoup. Huge inflation is coming our way. I don’t think that those who back this law have really thought things out.
[quote]This will ripple all through the economy in higher prices and fees for everything as business owners try and recoup. Huge inflation is coming our way. I don’t think that those who back this law have really thought things out.[/quote]
Bingo! The adage that comes to mind is “be careful what you wish for…”…
My sense is that few actually wished for Obama’s plan. Those on the right think it’s socialism and those on the left preferred single payer.
ERM
“My prediction: the cost of health insurance is going to rise dramatically”
I think that this prediction as far as it goes may well be accurate initially. This has already been the pattern in this country for as long as I have been practicing medicine and that is within our current model of care. I doubt that pattern will be reversed in the short term. What I feel it ignores is that what is most critical is not “insurance cost” but the overall cost of the provision of health care.
Most people who write or talk about the PPACA law only focus on the insurance aspects. They forget that the bill deals with much more than just how the bills get paid. The insurance mandates are actually less than a third of the law.
My hope is that the remaining 2/3 of the bill which focuses on establishing an actual health care system rather than the fee for service hodge podge that we currently call a “system” will over time decrease the cost of the provision of health care, will promote best practice evidence based health care, and prevention rather than the much more expensive treatment after the fact emphasis that now prevails.
I see great potential and hope in the portions of the bill that address quality of care, monitoring and providing data to patients and insurers regarding actual health outcomes for various providers, and decreasing our current fee for service model and the practice of “defensive medicine” both of which unfortunately drives
providers to recommend and order unnecessary expensive tests and worse yet procedures to maximize their own profit and/or reduce their own risk regardless of what is best for the patient. I also see promise in those portions of the bill that encourage people to consider nursing, primary care medicine over sub specialization, and encourage the provision of health care to underserved communities.
Rusty: [i]”He stated that he can’t afford that so he’s going to opt to just pay the $2000 tax per employee and drop the healthcare.”[/i]
Your friend is a bit misinformed. For companies with 50 or more employees (starting in 2014), the penalty (or now “tax”) is $750 per ([url]http://www.billlosey.com/articles/how-will-obamacare-affect-your-small-business.php[/url]). Since that is much, much, much less than it would cost to provide health insurance, I am sure many employers who currently do not insure their workers will take that route. (Employers who currently pay for health coverage for their workers will not be affected.)
That $750 expense really is not such a horrible thing for our economy, if you keep this in mind: We already have a quasi-universal healthcare system. People who are not insured now, very often, wind up in emergency rooms, and many of them have very serious health issues which are expensive to treat. The hospitals are forced to treat these patients and they eat some of those costs, shift some to insurance companies and the rest is picked up by government.
By raising this $750/per employee tax, we will have fewer people using the emergency rooms as their health providers. We will lower the amount of this extremely expensive care and pick up more in primary coverage, which will reduce the number of emergency room visits. (One example of this kind of thing is people who have infections, but no primary care. They don’t go to a doctor to get a simple and cheap treatment. They wait and hope the thing goes away. Then, when they suffer very severe consequences from that infection, they wind up in an emergency room and burden all of us with huge costs which would have been avoided if they had primary care. The same scenario plays out with diseases like colon cancer, where early diagnosis and treatment is cheap, and waiting is costly and deadly.)
In thinking about the 50-employee provision in Obamacare, there are two other likely avenues which employers will use to avoid paying the $750 tax:
1) If the company has 60 or 55 or 52 employees, they will cut enough jobs in order to have 49 employees. That will save them a ton of money. Imagine, for example, a small manufacturing company which employs 59 people. They could fire 10 people–say everyone who works in bookkeeping, payroll, HR, marketing, and maintenance–and then just outsource those 10 jobs; and
2) A business with, say 90 employees, could split into two separate companies. Think of a real estate developer whose company builds apartment buildings and also manages and maintains them. She could avoid the $750 tax by turning the Sheila Johnson Corporation into Johnson Development (45 employees) and Sheila Real Estate Management (45 employees).
[i]”He also said that he’s going to have to raise his business fees to try and compensate for the higher taxes.”[/i]
This is probably untrue, no matter what your friend thinks. Rational business owners already set their prices as high as they can for the given demand. The notion that he will increase prices to cover this cost supposes that his company is not currently trying to maximize profits.
What is more likely is that if costs across the board go up for people in his industry, some companies in that industry will be driven out of business. And if that happens, a reduction in competition will likely allow higher prices for profit maximization.
Rifkin, it’s $2000 for every employee after the first 30 and $3000 for every employee receiving a subsidy.
“Penalties For Failure To Insure
For firms which do not offer insurance any insurance, have more than 50 employees, and have at least one employee receiving insurance subsidies, they must pay a tax of $2000 per subsidized employee. The individual mandate requires everyone to purchase health insurance. The tax is applied to all of a firm’s employees (after excluding the first 30), not just those that are subsidized. For example a firm with 51 employees would pay $42,000 in new annual taxes, and an additional $2,000 tax for every new hire.
For firms that do offer insurance, the penalty is the lesser of $2,000 for every employee (after exempting the first 30) or $3,000) for every employee receiving a subsidy.”
Another example:
“Even if you’re not part of what the President referred to recently as “the Affordable Care Act fan club,” back-of-the-envelope arithmetic shows that ObamaCare creates a cost-effective option for smaller companies that are inclined to drop employee health benefits. The prospective penalty for not offering employee health care benefits ($2,000-3,000/employee for employers of 50+ workers) is only a fraction of current, much less future, group health insurance premium.”
[i]A business with, say 90 employees, could split into two separate companies.[/i]
I believe there are provisions that will make that unlikely; specifically, if they are managed together in any way they will be treated as one company.
Rusty’s friend is misinformed at many levels.
One interesting side note for the wholesale end of my industry: seasonal employees aren’t counted toward the 50-employee threshold. For grower nurseries and most ag businesses, the majority of employees are seasonal.
Some employers will opt to drop coverage and instead pay the fine. So their employees will be heading to the health insurance exchanges to shop for insurance (as will I and my employees). He may find he loses some key employees because of his refusal to continue their coverage.
Rusty: [i]”He stated that he can’t afford that so [b]he’s going to opt to just pay the $2000 tax per employee and drop the healthcare[/b].”[/i]
One provision of the tax consequences of Obamacare: Small companies (25 or fewer employees) will benefit much more by offering health coverage than they do now, due to a 50% tax credit built into the law, for employers which purchase insurance through one of the Small Business Health Options Programs, or SHOP Exchanges. It is also presumed that SHOPs will help smaller companies buy insurance for the same prices that only very large employers can now get.
That said, it will still not likely make sense for employers (small or large) to buy insurance for their low-paid, low-skilled employees, even with this credit. A $10,000 plan will still cost them $5,000, and that does not make economic sense when an employee is now making $15,000 per year and is not worth a penny more to the employer.
[i]”Rifkin, it’s $2000 for every employee after the first 30 and $3000 for every employee receiving a subsidy.”[/i]
Not according to my source ([url]http://www.billlosey.com/articles/how-will-obamacare-affect-your-small-business.php[/url]).
You have a different source for that claim?
Rifkin, just do a Google search and you will find many sources that show it at $2000 to $3000.
Google: Obamacare penalties for employers.
Don, I think my friend is much more informed than you know.
Here’s what rusty’s friend’s penalty is about (see Wikipedia):
“[i]Firms employing 50 or more people but not offering health insurance will also pay a shared responsibility requirement[b] if the government has had to subsidize an employee’s health care.[[/i]/b]
This is rusty’s source: [url]http://www.obamacarewatch.org/primer/employer-mandate[/url]
Don and Rifkin, my friend and I are accepting apologies.
Rusty: [i]”Rifkin, it’s $2000 for every employee after the first 30 and $3000 for every employee receiving a subsidy.”[/i]
I Googled what you suggested and found this from Forbes ([url]http://www.forbes.com/sites/danielfisher/2012/03/23/obamacare-supreme-court-what-employers-are-watching/[/url]): [quote] Employers who [b]stop offering[/b] health insurance must pay a $2,000 penalty.[/quote] There is no mention at all in this story about the first 30, etc. But there is some mention of a $3,000 penalty, so I will take your word for it.
Your claim raises another question: Why would Obamacare incentivize an employer who now is covering his employees to stop doing so?
Take an employee who makes $60,000 per year and gets a health plan which costs his employer $9,000 per year (pre-tax). Together, this employee’s income is $69,000, but the employee only pays taxes on the $60,000 salary. The employee is better off getting his health coverage through his employer by roughly $2,700/year (or more if he could not buy that health coverage for that same annual price). Because the employer deducts the employee’s healthcare as an expense, the employer is equally well off paying $69,000 in salary or $60,000 salary + $9,000 health.
It makes no sense to suggest that this employer should stop buying health care now for his employee. I cannot imagine why you think it would?
This column from the Small Business Council ([url]http://www.smc.org/Will-ObamaCare-Cause-Small-Businesses-To-Drop-Coverage[/url]) says what I was thinking: Obamacare does not incentivize employers who now cover their employees to stop doing so: [quote]What if your company were to drop job-based coverage, pay the ObamaCare penalty, and increase employee wages by, say, $9,000/year? Let’s also say that your employees have been paying $3,000/year – before taxes — toward their group health insurance. This would mean an additional $12,000 in taxable income for federal and state purposes for each of your employees, plus the cost of buying their own health insurance. Low-wage employees would be eligible for federal subsidies to make their health insurance premiums more affordable. But most employees would see a net loss of several thousand dollars per year.[/quote]
[quote]Rational business owners already set their prices as high as they can for the given demand. [/quote]
I think it is important to remember that as things are now, this applies to the for profit branch of medicine in its current fee for service manifestation as it does to any other business. I have hopes that focusing on preventive care, early treatment for easy to manage conditions as Rich has pointed out, and an integrated care model with prepaid ( read salaried ) providers will eventually help, along with the other measures I cited above to curb the increasing cost health care.
rusty: “He stated that [b]he can’t afford that so he’s going to opt to just pay the $2000 tax per employee[/b] and drop the healthcare. So now each of his employees are going to have to find their own much more expensive insurance or pay the individual penalty tax. He also said that [b]he’s going to have to raise his business fees to try and compensate for the higher taxes[/b].”
You realize these sentences contain an internal contradiction.
Here is what actually applies:
[i]”…starting in 2014, a large employer may
have to pay an assessment if it does not offer affordable insurance
and one of its employees gets tax credits to purchase insurance in the
Exchange. These assessments do not apply to businesses with less than
50 employees.
Large employers that do not offer health benefits coverage at all may
be required to pay an assessment of $2,000 per year for each fulltime
employee, excluding the first 30 full-time employees. Larger
employers that do offer health benefits coverage that is unaffordable
or lacks minimum value may be assessed a payment of $3,000 per
year for each full-time employee receiving federal financial assistance.
However, this payment cannot exceed the assessment the business
would pay if it did not offer health care coverage.
Note: the U. S. Department of Health and Human Services estimates
that fewer than 2% of large American employers will have to pay these
assessments.”[/i]
[url]http://www.healthcare.gov/news/brochures/info-for-small-businesses.pdf[/url]
Don
Is the statement that businesses have to pay for families true?
Although thrilled with the SCOTUS decision, I am disappointed in the ACA in that I would prefer a form of single layer and divorcing health care from the employer/employee relationship.
I had thought the ACA got closer to the latter so am surprised at this thread of discussion so look forward to your response!
SODA: I don’t know the basis for rusty’s friend’s assertion that families have to be covered.
SODA
[quote]Although thrilled with the SCOTUS decision, I am disappointed in the ACA in that I would prefer a form of single layer and divorcing health care from the employer/employee relationship. [/quote]
I am with you on all points. It makes no sense at all to me to link insurance to one’s employment. Rich, Don, and anyone else with a good head for numbers, how do you think the city finances would look now if health insurance had not been linked to the compensation for public workers ? Just a thought ?
Medwoman
Yes, I am also in healthcare and am sure we both have seen many instances of sad situations linked to our current system.
So am very surprised to see rustys comment about linkage to employer and covering families and hope someone can clarify.
I agree that it is crazy that we have health care coverage tied to our jobs. That makes employing people (particularly lower-skilled people) more expensive; and in many cases it has made it very difficult for people who want to change jobs (or start a small business) to do so, because that might mean no insurance or worse insurance or problems with “pre-existing conditions,” etc.
The historical reason of why we developed employer-based health coverage is an interesting example of how interfering with market prices can cause an unfortunate and unintended consequence. I’m not sure exactly what year it was, but during WW2 the federal government had in place wage and price controls, which prohibited employers from raising wages in order to attract new employees. So employers–especially large companies with unionized workforces–started offering healthcare insurance to entice workers to come to work for them. In a few short years, most large employers paid for this insurance. In league with the large unions, the companies turned to Congress (I think after the War was over) and said “buying health insurance is a business expense; make it deductible.” Congress then did that; and they made the “income” from the insurance tax free for employees.
Once the tax laws changed and it became an institution, there was little chance of going back. Health insurance ever after has been tied to employment; and the tax laws work to hurt employees who don’t get healthcare from their employers, because they need to use aftertax income to buy it, and they cannot deduct the expense.
If we could go back, I would have adopted the Canadian system, despite its flaws*. Canada spends $2,900 per person on health care. We spend $7,900. They get better care, too.
No one’s coverage in Canada is employment based. Everyone pays income taxes (no more than we pay in the US ([url]http://slumbuddy.wordpress.com/2011/03/20/comparison-of-us-and-canadian-tax-rates-for-2010/[/url]), by the way) and that is used to fund the provincially based single-payer insurance system. Their medical care itself is largely private, though they also have public hospitals and clinics in some regions.
The key is that the single-payer insurer has the monetary power to determine what doctors and nurses make (much less than in the US), what drugs cost (much, much, much less than in the US) and what medical tests are provided and how much the clinics or hospitals can charge. …
An important result of the Canadian system is that [Canadians get better healthcare than we get on average. They live longer. And they tend to survive longer in major disease categories ([url]http://www.cbc.ca/news/health/story/2007/04/18/health-canada-us.html[/url]) (most cancers, diabetes, stroke, heart disease, etc.) and they have far fewer problems with infant mortality and health afflictions of young babies and young children.
*Canadians tend to have to wait longer for a lot of services that Americans with insurance get right away. Canada also is much slower to adopt new and improved medical technologies, and as a result, its best quality of service is lower than our best, but its worst is far, far better than our worst. Also, because Canada controls its drug prices, there is no incentive to develop new and better drugs there. But since we pay so much, new drugs are developed for the US, and the Canadians get a free ride on our backs. If we had the Canadian system for the last 65 years, I would guess that every single category of pharmaceuticals would be 35 to 40 years behind where they now are.
Rusty: [i]”He says under the new law he will have to insure not only his employees but also their families.”[/i]
Not true, according to this op-ed (which is against Obamacare) in today’s SF Examiner ([url]http://www.sfexaminer.com/opinion/op-eds/2011/10/lack-family-coverage-another-unpleasant-obamacare-surprise[/url]):[quote] It’s true that under Obamacare, firms with more than 49 workers have to offer affordable health insurance coverage to full-time employees or pay a penalty. But [b]the coverage only has to be for an individual policy, not a family policy.[/b] [/quote]
Rich,
Great comparison of US and Canadian health care systems.
As far as drug costs and drug development incentives; it seems to me that these can be re-negotiated/modifed within a single-payer type system.
Are you aware of any objective (3rd party) economic analyses of the % of health care costs that go to insurance company net revenues (I have heard estimates between 6% and 30%); and the reduction in such costs by having a system such as single payer?
What I appreciate about the Supreme Court’s decision is that it was clean. They didn’t divide up the law and hand it back to lawmakers to try and fix. The Affordable Care Act stands, and if you don’t like it — you know how you can vote. In the absence of a Romney victory and control of both houses of Congress, it takes effect in 2014 in full. I see Republicans plan to use reconciliation to overturn it if they win the Senate and presidency, so they feel they only need 51 votes. That may not be completely true, but it is their strategy.
So the opposition party needs to offer up its alternative, clearly and in full, before November.
Look no farther than the incubator state for Obamacare, Massachusetts, if you want to see how this plays out. The people there seem pleased with the outcome of Romneycare. Romney can’t run on his major success because of the caustic scorched earth anti-everything Obama tactics of the Republicans that have now become embedded in the minds of conservatives.
i haven’t seen any analysis about how Kennedy got pummeled by the right for upholding Roe v Wade in the 90’s. He might have been gun shy of rolling the right again. Roberts, it is thought blinked just before the ruling, perhaps waking up in a cold sweat at the thought of depriving millions of people healthcare for another generation. Remember, it took a century to get this done. This is why they got out of town on Thursday instead of the traditional last Monday in June. The Kennedy dissent also supports this conclusion taking about Ginsburg’s concurrence as if it was a losing argument.
As for the remark about the liberal jurists not ever giving ground. This shows a fundamental misunderstanding of how the Supreme Court Justices go about their work. Most decisions are not 5-4. This shows that most of what the Supreme Court does is non-partisan.
Accoding to the government healthcare site employers will have to offer insurance to their employees and dependants or pay a tax penalty.
[url]www.dol.gov/ESA/newsroom/tr12.01/html[/url]
Sorry, that link doesn’t work.
Here’s the actual wording:
“Employer Shared Responsibility
The employer shared responsibility provisions, contained in section 4980H of the Internal Revenue Code (Code), provide that an applicable large employer (for this purpose, an employer with 50 or more full-time equivalent employees) could be subject to an assessable payment if any full-time employee is certified to receive an applicable premium tax credit or cost-sharing reduction payment. Generally, this may occur where either:
1.The employer does not offer to its full-time employees (and their dependents) the opportunity to enroll in minimum essential coverage under an eligible employer-sponsored plan; or
2.The employer offers its full-time employees (and their dependents) the opportunity to enroll in minimum essential coverage under an eligible employer-sponsored plan that either is unaffordable relative to an employee’s household income or does not provide minimum value.”
Rich
I think that you have it just about right with regard to your comparison of the US and Canadian health care delivery.
[quote]Canadians tend to have to wait longer for a lot of services that Americans with insurance get right away. Canada also is much slower to adopt new and improved medical technologies, and as a result, its best quality of service is lower than our best, but its worst is far, far better than our worst. Also, because Canada controls its drug prices, there is no incentive to develop new and better drugs there. But since we pay so much, new drugs are developed for the US, and the Canadians get a free ride on our backs. If we had the Canadian system for the last 65 years, I would guess that every single category of pharmaceuticals would be 35 to 40 years behind where they now are.[/quote]
I am not as concerned about the downsides to the Canadian system that you have listed.
While the wait does tend to be longer for some services, they are all non critical, such as a longer wait for purely elective procedures. As for the new and improved medical technologies, many of these are much, much more expensive than the older ways of doing the same procedure and are often chosen not because of the large advantage to the patient, but because they can get the ” latest and greatest” from a competitor and thus everyone has to do the more expensive option to keep up. The same principle applies to new and supposedly, but not always better medications such as the “Celebrex” fiasco a few years back where the company was charging many times the price of Ibuprofen for a medication that was no more effective and no safer.
I would love for us to adopt the Canadian model, even though it would mean significantly less compensation for doctors except those who choose to maintain a private fee for service model which except for concierge type service would presumably become less and less in demand.
[i]”Are you aware of any objective (3rd party) economic analyses of the % of health care costs that go to insurance company net revenues (I have heard estimates between 6% and 30%); and the reduction in such costs by having a system such as single payer?”[/i]
I don’t know that. But I am sure the overhead aspects of the Canadian system are far, far lower than in ours.
I would imagine polls might show Canadians overall satisfaction with their system. Anecdotally we find that true with some Canadian friends we see yearly. And the person held in highest esteem by Canadians according to polls, is the founder of their system, Douglas (not sure of first name).
Rusty: [i]”Accoding to the government healthcare site employers will have to offer insurance to their employees and dependants or pay a tax penalty.”[/i]
Rusty, the link you gave does not work. Moreover, I searched the Department of Labor website and it has no information remotely confirming your claims.
I think what has you so bamboozled over this question of dependent coverage is that the ACA does say that insurance plans which already offer dependent coverage must offer that for dependent offspring up to age 26*. However, if a plan does not offer dependent coverge, then it need not offer any under the provisions of Obamacare.
Here is a source for my explanation from the National Conference of State Legislators: [quote] The Affordable Care Act requires plans and issuers that offer coverage to children on their parents’ plan to make the coverage available until the adult child reaches the age of 26. … [b]This law does not require that a plan or issuer offer dependent coverage [/b]but that if coverage is offered it must be extended to young adults up to age 26. [/quote] Since you cannot site a single source which backs up your claim, Rusty, and I have cited a number of them in this thread, I hereby declare myself the winner of this debate.
———-
*This will likely make the health plans offered by the City of Davis to its employees and to its retirees more expensive. Prior to the ACA, the Davis plans offered dependent coverage up to age 22. Nonetheless, one choice the City Council has (in the “negotiated” labor contracts) is to require employees to pay that added expense; and for retirees, I suspect it would be legal for Davis to require them to pay the added expense without any negotiation.
Sorry, I forgot to give the link to the NCSL explanation on dependent coverage ([url]http://www.ncsl.org/issues-research/health/dependent-health-coverage-state-implementation.aspx[/url]).
http://www.ncsl.org/issues-research/health/dependent-health-coverage-state-implementation.aspx
MEDS: [i]”… many of these (technologies) are much, much more expensive than the older ways of doing the same procedure and are often chosen not because of the large advantage to the patient, but because they can get the ‘latest and greatest’ from a competitor and thus everyone has to do the more expensive option to keep up.”[/i]
I think your explanation of why we tend to adopt so many advanced technologies is largely wrong. There are three much more significant reasons:
[b]1) Medical malpractice liability.[/b] Doctors in the US have a very strong incentive to order every possible test in order to avoid getting sued. So when an elderly patient is dying of cancer and will get no real benefit from an MRI series, her oncologist will normally order an MRI series, unless the patient (or her family) objects. Why would the doctor order the very expensive MRI? Because there is a chance that some ambulance chaser will contact the family of the patient, after she dies, and tell them, “Your doctor did not do everything to save your mother’s life. He should have ordered an MRI. It would have precisely located the tumor and maybe an operation then could have saved her. This is worth a lot of money in a lawsuit.” The family usually has no idea what is best for their relative who has cancer. They trust that the oncologist is doing what is best, so they agree to whatever tests he orders. And even though the doctor who does not order such an MRI series is medically and ethically right, if such a case makes it to a jury, there is a better than 50% chance that the knuckleheads who serve on juries will side with the dead woman’s family out of sympathy. This is how Sen. John Edwards became a multi-millionaire ambulance chaser. He specialized in b.s. lawsuits when children were born with birth defects that had no relation to bad medical practice. My example of the old lady with brain cancer is exactly what happened to my aunt. Fortunately, one of her sons is an MD and he told the oncologist, “No, we don’t want Rose to have an MRI now.” My cousin knew it was pointless.
As I mentioned to you recently, I had a hydrocelectomy two weeks ago. Part of the routine was to have me take an ultrasound. This is standard practice in the US for a hydrocele. But a hydrocele is easy to diagnose with a flashlight. That’s how they do it in Canada. They never give a man with a hydrocele an ultrasound. They don’t have to worry so much about ambulance chasers and moronic juries.
[b]2) Profits.[/b] Another driver of our high tech medicine is profits. Radiologists are very highly paid. And they only make money when they take a lot of expensive pictures with their expensive equipment.
[b]3) Patients don’t pay.[/b] If we had a cash-for-service medical system in the US, the cost of medical technologies would be a factor in which tests were run and which were not. I am not saying a cash system would be the best. But if a patient had to pay the full cost of his MRI, he might choose an X-ray.
And since patients (or at least most patients) don’t pay for the services they are getting, they will demand the best possible of everything, if they can. It’s like going to a car lot with a lot of marks and being able to select whatever car you prefer, but not paying any more, even if you choose the best. In such a situation, most folks are going to be driving a Mercedes Benze with all the bells and whistles. Very few are going to leave in a Yugo.
Rich
I agree with you about why doctors in many types of practice order unnecessary tests and procedures. I have been spoiled by the very large, non profit group with which I work. My malpractice is covered as part of my compensation so I have no incentive to order unneeded tests. My group does not promote ordering unnecessary tests so there is no incentive for me to do so. Also, since I am salaried, as are all of our physicians and surgeons, I have no incentive to do any unnecessary test or procedure. I get paid exactly the same amount taking care of a patient’s problem on line, by phone, or in the office as I would doing a surgery. This is part of the reason that I have advocated for a single party payer system with salaried health care providers for as long as I have been in medicine.
I think your third point is thornier. If patients had to pay for all of their services with medical care as expensive as it has become, people would be unable to pay for even badly needed care let alone the optional stuff. To carry your car analogy further, there are many who now can afford a
Yugo who would be riding a bike or walking.
Rifkin, I posted the relevant passage off of the Gov. healthcare site. It has nothing to do with the age 26 law. It definately states that employers will be assessed if they don’t offer insurance to employees and their DEPENDANTS. I think you’re the one that is bamboozled.
Here is the correct link, I tried to post the other one off of my Ipad and typed it in wrong:
http://www.dol.gov/ebsa/newsroom/tr12-01.html
Rifkin:
“Since you cannot site a single source which backs up your claim, Rusty, and I have cited a number of them in this thread, I hereby declare myself the winner of this debate.”
Sorry Rifkin old buddy but this is off of the ACA Gov. Healthcare website, not some blog that you had posted. I know you hate to be wrong but that’s twice today that you stated things I posted were untrue and as it turns out it is you that was in error. 🙂
By the way, you now owe me another apology.
Women no longer a pre-existing condition under Affordable Care Act ([url]http://www.examiner.com/article/women-no-longer-a-pre-existing-condition-under-affordable-care-act[/url])
Thanks wdf1
You made my day!
Rusty: [i]It definately states that employers will be assessed if they don’t offer insurance to employees and their DEPENDANTS.[/i]
4980h simplified:
[i]Starting in 2014, large businesses (those with 50 or more full-time workers) that do not provide adequate health insurance will be required to pay an assessment [b]if their employees receive premium tax credits to buy their own insurance[/b]. These assessments will offset part of the cost of these tax credits. The assessment for a large employer that does not offer coverage will be $2,000 per full-time employee beyond the company’s first 30 workers.[/i]
My source was the aca.gov website, searched for ‘business’. As is almost always the case, neither you nor Rifkin (nor pretty much anyone else here) got complete information. Neither did I: the damn bill as passed ran about 2700 pages, and it took awhile to drill down to find the provision. (The rulemaking process lasted over a year, and is available @ regulations.gov).
After all the comments here, the moderators might want to take this discussion to the Forum area.
[quote]Rich Rifkin: That $750 expense really is not such a horrible thing for our economy, if you keep this in mind: We already have a quasi-universal healthcare system. People who are not insured now, very often, wind up in emergency rooms, and many of them have very serious health issues which are expensive to treat. The hospitals are forced to treat these patients and they eat some of those costs, shift some to insurance companies and the rest is picked up by government.
medwoman: I think that this prediction as far as it goes may well be accurate initially. This has already been the pattern in this country for as long as I have been practicing medicine and that is within our current model of care. I doubt that pattern will be reversed in the short term. What I feel it ignores is that what is most critical is not “insurance cost” but the overall cost of the provision of health care.
Most people who write or talk about the PPACA law only focus on the insurance aspects. They forget that the bill deals with much more than just how the bills get paid. The insurance mandates are actually less than a third of the law.
My hope is that the remaining 2/3 of the bill which focuses on establishing an actual health care system rather than the fee for service hodge podge that we currently call a “system” will over time decrease the cost of the provision of health care, will promote best practice evidence based health care, and prevention rather than the much more expensive treatment after the fact emphasis that now prevails.[/quote]
I think there is a huge assumption here that whatever health care tax the gov’t collects will go towards the health care system. As we’ve seen w the Social Security System, the gov’t raids any type of system that collects money for the future to fund other things in the here and now. My guess is that all the good intentions of this new law will not be carried out, and we will see skyrocketing health insurance and medical bills.
[quote]Look no farther than the incubator state for Obamacare, Massachusetts, if you want to see how this plays out. The people there seem pleased with the outcome of Romneycare. [/quote]
Some don’t agree with your assessment:
[quote]RomneyCare is unpopular, and not viewed as “helping,” even in Taxachusetts.[/quote]
[url]http://minx.cc/?post=314646[/url]
Here is another one:
[quote]6. In Massachusetts, medical-related bankruptcies have continued to increase since Romneycare was imposed, and in general people are paying more for worse “policies”. In 2010 non-binding ballot measures directing state legislators to fight for single payer in Massachusetts won by large margins in every district where they were on the ballot. The people of Massachusetts hate Romneycare.[/quote]
[url]http://attempter.wordpress.com/[/url]
I’m so happy that the Vanguard posted on this. Excuse me while I get a bit partisan (surprise!). Note that this a highly partisan subject.
First, Chief Justice Roberts is the smartest guy in the room. Keep that in mind while you consider his decision.
One of the responsibilities of the SCOTUS Chief Justice is to protect the reputation of the court. What we have seen from the Obama administration, the Democrats in general and the left media… is a practice of full frontal attack against anyone and any organization standing in their way. Obama has been the most politically polarizing President ever. It is unprecedented how he continues to use his influence to attack the GOP and states. He seems to be in perpetual campaign mode. He leads, and Democrats in Congress follow… so does the main-scream media in what they chose to report on and how they report on it.
Obama – the likeable trained Chicago thug politician – and Congressional Dems went out of their way to demand that the money collected from the public for failure to purchase insurance was NOT A TAX. Then, realizing that the mandate requirement would be found unconstitutional as per the Commerce Clause, they argued to the SCOTUS that it indeed WAS A TAX. Not they are back to demanding that it is NOT A TAX.
Again, another indication that Obama and the Dems at this point don’t care about the truth… don’t care about harm… don’t care about the mess this legislation will make. All they care about is realizing their dreams of government-owned and operated health care (aka socialized medicine). These are liberal Democrats controlling the political agenda. They believe health care is a right. They think the European approach is what we should aim for. Given that, they really don’t care about pesky facts, truths, math, evidence, Constitutional rights, political protocol… all of these things just get the in the way of them doing what they want to do.
But, back to Judge Roberts’ decision…
I think he saw what happened when previous SCOTUS decisions went against these liberal Democrats controlling the political agenda and media narrative. He also sees what the liberal Democrats controlling the political agenda and media narrative have continued to do to tarnish the GOP brand. He knew that enough decisions preventing these guys from getting their way would cause them to start their attack on the court. He got a sense of this from previous decisions.
Just think of what would be occurring now if SCOTUS had voted Obamacare unconstitutional!? Claims of and activist court would be flying! The court would be labeled as not caring about all those poor people without healthcare. “SCOTUS = GOP” would be the Dems’ marketing campaign. They would use this as another wedge issue to enflame the public for reasons to vote for Obama in 2012 so he could appoint more left-leaning justices to create a more “caring” court.
So, Chief Justice Roberts decided to protect the reputation of the court, and he gave the liberal Dems what they wanted and he punished the GOP and moderates for failing to deal with this at the legislative level. Win, win, win for Chief Justice Roberts.
And he did so accepting that the mandate was a tax.
Now is can be overturned by a simple majority of the Senate. It sticks Obama with largest middleclass tax hike in history. It heats up the GOP base, and flips many moderates to Romney. It heats up the voters in swing states and gives GOP candidates greater support. Obamacare legislation is a mess. It will increase the level of uncertainty in the economy. It will cause high unemployment to continue. It will cause capital to seek investor returns that prevent next tax risks. It will cause many stories of care rationing and shortages of healthcare resources. It will have unintended consequences for people seeking tax avoidance and lower costs. All of this will be pinned on Obama and the Democrats.
I think Chief Justice Roberts played this exactly as he should have. Democrats got exactly what they wanted… and the GOP got exactly what they needed.
ERM, thanks for the links and the more fair and balanced observations than the cherry picked pro Obamacare ones being put on here as supposed facts.
RUSTY: [i]”By the way, you now owe me another apology.”[/i]
You still don’t get it. I don’t understand why you won’t admit you were wrong. The Dept. of Labor site that you cited states explicitly, right here ([url]http://www.dol.gov/ebsa/faqs/faq-dependentcoverage.html[/url]), that employers do not have to offer dependent coverage: [quote][b]Q15: Does the law apply to plans or issuers that do not provide dependent coverage?[/b]
No. [u]There is no federal requirement compelling a plan or issuer to offer dependent coverage at this time[/u]. However, the vast majority of group health plans offer dependent coverage and many family policies exist in the individual market. [/quote] Every item you have pointed out regards employers who currently offer health insurance with dependent coverage. The ACA says those employers cannot drop the dependent coverage once the ACA goes into effect, which it now has.
If you still don’t admit you were mistaken, Rusty, you need to take a remedial reading course. … I am willing to accept your apology anytime.
“ERM, thanks for the links and the more fair and balanced observations than the cherry picked pro Obamacare ones being put on here as supposed facts. “
I guess you meant to be ironic, since she seems to have cherry-picked the links off-anti-sites
ELAINE: [i]”RomneyCare is unpopular, and not viewed as “helping,” even in Taxachusetts.”[/i]
When you choose as your source a four-year-old column by an opinionated blogger who calls Massachusetts by the nickname that conservatives use to deride it, “Taxachusetts,” and that blogger does not refer to any objective data to support his claim that Romney’s program in Massachusetts is unpopular, I have to wonder how open minded you are on this topic.
Let me quote to you a Reuters news story dated March 10, 2011 ([url]http://www.reuters.com/article/2011/03/10/us-massachusetts-insurance-idUSTRE7296Z420110310[/url]): [quote]A large majority of Massachusetts residents are satisfied with the commonwealth’s subsidized health plan, which has components similar to the Obama administration’s federal plan, according to a poll released on Thursday.
The poll by Market Decisions, a research and consulting group, found that 84 percent of residents are satisfied with the Massachusetts plan, which requires most adults to have health insurance. [/quote]
In case you think that Market Decisions ([url]http://www.marketdecisions.com/index.php?sec=6&id=34[/url]) is an unreliable company, here is some background on them:
“Market Decisions was founded in 1977, initially focusing on business feasibility and site location studies using data gleaned from existing or secondary sources. In the early 1980’s the company added data collection to its services to provide primary data for decision-making. In these early years the company primarily served business and government in Maine and developed a reputation for high-quality research.
“Soon, the work of the company attracted the attention and then the business of large companies including Blue Cross Blue Shield, LL Bean, Bose, and Microsoft. By 2000 the company had grown from a small partnership to a full service research firm with a dozen researchers and interviewing and data entry staff of nearly 50.
“In 1999, a change in ownership brought new leadership. Curtis A. Mildner, an executive with over 20 years of experience in marketing and sales brought his passion for strategies based on market facts. Dr. Brian Robertson, a seasoned researcher with experience in both academic and business environments brought his obsession with sound research methods.
“From its beginning Market Decisions was known for both practical and advanced research. Market Decisions first used the advanced analytical technique called cluster analysis for market segmentation in the 1980’s. In the 1990’s the company was an early adopter of CATI or computer based interviewing. Today, the company uses an expansive toolbox of analytical software and tools to provide insights and explanations that simple methods may miss.
“Market Decisions conducts most of it research assignments outside of Maine including research for clients in more than 25 states. Each year we conduct more than 50-100 research studies on a wide variety of topics from public policy to branding to feasibility. Our assignments range in size from a few thousand dollars to multi-year contracts over a million dollars. Our clients include government agencies, non-profit organizations and private businesses.”
Jeff:
[i]All they care about is realizing their dreams of government-owned and operated health care (aka socialized medicine). [/i]
Which the ACA doesn’t even remotely resemble in any shape, form, or manner. The VA, Medicare, Medicaid? Sure. Those are gov’t-owned and operated. And reasonably popular, too.
[i]These are liberal Democrats controlling the political agenda. They believe health care is a right. [/i]
It is a right.
[i]They think the European approach is what we should aim for.[/i]
Which one? Europe is a bunch of countries with a bunch of different health care systems, ranging from straight single-payer to hybrid systems. Just as we have a hybrid system. So please specify which European model it is that you dislike so much, and what is so wrong with what is done in, say, Germany. You seem to have a notion that we could gain nothing by examining European models of health coverage. You probably also believe that America has the “best health care system in the world.”
[url]http://en.wikipedia.org/wiki/Universal_health_coverage_by_country#Europe[/url]
I agree that Chief Justice Roberts acted to protect the reputation of the court. Had he sided with the minority, it would indeed have been an extraordinary level of judicial activism: overturning a law passed by Congress and signed by the President, on constitutional grounds that didn’t even exist when the conservative Heritage Foundation first proposed the individual mandate, nor when it was implemented in Massachusetts.
If you don’t like the ACA, you should vote for Republicans. It’s that simple. Health insurance reform is one of the reasons I generally vote for Democrats.
Neutral: [i]“After all the comments here, the moderators might want to take this discussion to the Forum area.”[/i]
I can only move one post at a time, not whole portions of a thread. This topic is on the bulletin board:
[url]https://davisvanguard.org/index.php?option=com_kunena&func=view&catid=2&id=683&Itemid=192[/url]
Strangely enough Jeff Boone pretty much nailed it. However, Romney may be the wrong person to sell it.
The inside story: [url]http://www.cbsnews.com/8301-3460_162-57464549/roberts-switched-views-to-uphold-health-care-law/[/url]
“Strangely enough Jeff Boone pretty much nailed it. However, Romney may be the wrong person to sell it.”
You have two guys running for president. One is going to enact Obamacare and the other is going to throw it out. The voters have a clear choice.
Don: [i]”Jeff:
All they care about is realizing their dreams of government-owned and operated health care (aka socialized medicine).
Which the ACA doesn’t even remotely resemble in any shape, form, or manner. The VA, Medicare, Medicaid? Sure. Those are gov’t-owned and operated. And reasonably popular, too.”[/i]
Obamacare is not the end goal for the leading politicians supporting it. It is a large step toward the end goal of single-payer, government-run, government-controlled health care system like many countries in old Europe have relied on but are recently converting to more market-based changes to because of unsustainable cost escalation. You and every other progressive believing that access to health care is a right, and not a service you purchase, want a single-payer system. Strategic-thinking progressives support Obamacare even though it misses their mark, because they know once people get used to government entitlements, it is impossible to take them back.
America DOES have the best health care system in the world for those that can afford it. We also have the most innovative and best healthcare industry. Cost is a problem. Insurance rejection of pre-existing conditions is a problem. Both sides agree with these things. The difference is that one side wants to protect the best system and industry in the world while working to solve the two problems. The other side is driven by an egalitarian view that everyone should have the very same level of health care service access and quality. In other words, they are fine detroying the best health care system in the world as long as everyone has the same access and quality. Welcome to the collective!
David: [i]” Strangely enough Jeff Boone pretty much nailed it. However, Romney may be the wrong person to sell it.”[/i]
Now, I don’t think that is strange at all… 😉
“You have two guys running for president. One is going to enact Obamacare and the other is going to throw it out. The voters have a clear choice.”
And if there were no historical context you’d have a point.
“And if there were no historical context you’d have a point.”
Doesn’t matter, you either want Obamacare or not.
If Obama wins, and Congress goes to GOP, the GOP Congress will approve new legislation to undo Obamacare… then Obama vetoes.
If Romney wins, and Congress stays in Dem hands, then Reid will prevent a vote ever getting to the floor of the Senate.
If Romney wins and he has a GOP-controlled congress, then it will be a clear mandate from the voters to rid ourselves of this destructive legislation. Romney will use the budget reconciliation process to make his repeal of Obamacare filibuster-proof.
What I am missing here?
I think you’ve got it.
[i]I get paid exactly the same amount taking care of a patient’s problem on line, by phone, or in the office as I would doing a surgery. This is part of the reason that I have advocated for a single party payer system with salaried health care providers for as long as I have been in medicine. [/i]
So, medwoman, from this I assume your work for Kaiser. I have posted before that Kaiser seems to be one private health care insurance carrier/service provider model that is working better than others in terms of cost management. My company’s Blue Shield plan went up by 14% last year (partially because of future Obamacare impacts). I had to switch to a higher deductible plan. As an alternative I could have moved to a Kaiser plan and saved about 35% from my 2011 premiums.
However, my employees are fearful of Kaiser because of the old reputation for sketchy service. That has changed, but the fears don’t too easily. Kaiser now gets top marks for patient satisfaction. So does Sutter Health but that is a more traditional and common model of a network of smaller providers instead of the employee model used by Kaiser. Sutter is not doing nearly as well managing costs to patients… although my Sutter docs seem to help consult on diagnostics choices… mainly, I think, because I have a high-deductible HSA plan and I am on the hook for a maximum of $7000 of out-of-pocket every year. (Note, I like HSA plans and think a greater adoption of this type of plan model is what we should be doing to help drive down utilization… which will drive down insurance costs.)
More and more doctors coming out of medical school seem attracted to the Kaiser model where they get a paycheck, and paid vacation time. It seems that Kaiser is on to something big that should be more generally adopted.
My question for you… why, if Kaiser works so well, don’t you advocate an adoption of that business model in the private health provider market instead of advocating for a government-run single payer system? You do know that Kaiser’s model will have to change drastically if we get socialized medicine in this country, don’t you?
Personally, I like the idea of insurance and care provided by the same organization. This blends the two strategic objectives for profit (instead of one working against the other). It puts medical service equal to insurance service and causes a better-optimized decisions process (MDs and insurance professional working together). My thinking is that we should provide tax and regulatory incentives for this type of model. It is also more efficient and nimble… two attributes we can say goodbye to with a government-run system.
[i]The difficult part for Mitt Romney will be making a coherent argument against the ACA during the campaign and especially during debates.[/i]
I agree… especially since Romneycare.
However, if he plays this right, it actually gives him better credentials for speaking to the left and moderates. He cannot be a typical uncaring Republican having tried to implement healthcare reform in a state.
The problem with the right-leaning alternative is that it would include tort reform, regulatory reform, tax incentives and greater competition for carriers and providers. All of these things would be indirect contributors to lower priced healthcare options. In addition, Romney would need to make the case that “if you are earning a good wage, you should be able to afford your own healthcare”. It is a hard sell when Democrats are offering all this direct free stuff with indirect costs to them.
He just needs to pose a simple question to voters:
“If you would rather the government controls and provides more things for you, including your healthcare, and takes more things away from you to pay for them, then vote for Obama.”
“If you would rather the government focuses on strengthening the private economy while protecting your freedoms and allowing you to keep more of what you earn so that you can better take care of yourself and others, including the freedom and means to choose your own healthcare, then vote for Romney.”
“Doesn’t matter, you either want Obamacare or not.”
For most people, it’s going to come down to who sells the message the best and part of the confusing factor is the fact of Romney’s record as Governor. It’s difficult to imagine that if he makes an issue of the current proposal, that his past positions won’t come into play and by the time the election rolls around the record will be muddled and it won’t be nearly as clear as your sentence above implies.
rusty49: [i]You have two guys running for president. One is going to enact Obamacare and the other is going to throw it out. The voters have a clear choice.[/i]
Sort of. Romney just muddied his position:
[quote]Romney agrees with Obama on key part of healthcare law ([url]http://news.yahoo.com/romney-agrees-obama-key-part-healthcare-law-205103516–business.html[/url])
Campaign spokesman Eric Fehrnstrom acknowledged that Romney does not see the healthcare penalty as a tax, and instead considers it a penalty.[/quote]
JEFF: [i]”… like many countries in old Europe have relied on but are recently converting to more market-based changes to [b]because of unsustainable cost escalation.”[/b][/i]
In 2011, US medical inflation grew at 8.9%. It was 7.2% in Europe. (Source: http://www.towerswatson.com/assets/pdf/3585/Towers-Watson-Global-Medical-Trends-Svy-Rpt.pdf)
It is true that there are serious medical cost problems all over the world. The 7 major differences with our system compared with those in other rich countries are:
1) the others in wealthy countriess all expend less than half of what we spend per citizen;
2) they mostly have better outcomes per given disease, in terms of recovery. This is especially true with contagious diseases;
3) they have longer life expectancies* ([url]https://www.cia.gov/library/publications/the-world-factbook/rankorder/2102rank.html[/url]) and lower rates of infant mortality;
*The US is 50th in the world in life expectancy, just behind impoverished Portugal.
4) they cover everyone;
5) we uniquely have a rapidly growing share of our population with no medical insurance ([url]http://www.gallup.com/poll/152162/americans-uninsured-2011.aspx[/url]);
6) because of our large and growing uninsured population, we have a terrible allocation of medical spending on the emergency room end**; and
7) while other countries have all spent much more on integrating high tech information software into their healthcare ([url]http://americanmedical.com/2010/11/us-lags-behind-in-health-it/[/url]), the US system is still antiquated. And that lack of communication systems adds substantial costs to our overall structure.
**Source ([url]http://www.economist.com/node/13899647[/url]): [i]With the truly poor, the free-riders turn up at emergency rooms. This is hugely inefficient, because pricey late interventions and operations could very often have been avoided with a much smaller investment in preventive care. Insured people and taxpayers are forced to cross-subsidise such “uncompensated” and wasteful treatments to the tune of tens of billions of dollars per year. [/i]
And that’s the other problem I was alluding to, Romney not only isn’t very politically savvy, he tends to be somewhat of a blunt instrument where a precision scalpel is needed.
I must say I am a bit surprised by Rich’s position on this, I always thought he was a bit more conservative.
[quote]Poll: Most Want Obamacare Opponents to Move On ([url]http://news.yahoo.com/poll-most-want-obamacare-opponents-move-191724504–abc-news-politics.html;_ylt=A2KJjbw0KfJPeW0ALz3QtDMD[/url])
In the latest survey by the Kaiser Family Foundation, 56 percent of respondents said they prefer Obamacare opponents “stop their efforts to block the law and move on to other national problems,” while 38 percent said they prefer those opponents “continue trying to block the law from being implemented.”
….
Predictably, responses broke down on partisan lines, but independents who do not lean toward either party also preferred Obamacare critics drop their repeal push by a margin of 51 percent to 35 percent. Respondents favored the Supreme Court’s decision to uphold the law by a margin of 47 percent to 43 percent, Kaiser found.[/quote]
DAVE: [i]”I must say I am a bit surprised by Rich’s position on this, I always thought he was a bit more conservative.”[/i]
I am not an ideologue. I am not a conservative, a libertarian or a liberal or a socialist. I am a pragmatist. I let the evidence drive my conclusions as much as possible. If one system clearly works better than another system, I will opt for the one which the evidence shows works better. With medical systems, there is no evidence-based argument in favor of the US system vs. the Canadian system. So I favor what Canada has.
To the extent I have prejudices which influence my thinking, I am an anti-populist and an anti-ideologue. Politics driven by appeals to the moronic masses or to the hatred of the wealthy (like the 1%) are anathema to me. When anyone rejects established scientific concensuses because the conclusions run counter to their ideologies offends my sensibilities. I feel the same way about unscientific bans on GMOs (supported by the left) as the right’s rejection of climate science.
[i]”established scientific concensuses”[/i]
I also hate bad spelling. Make that “consensuses.”
[i]”…In 2011, US medical inflation grew at 8.9%. It was 7.2% in Europe.” [/i]
Rich, I have to stand by what I wrote based on the word “unsustainable.” Healthcare cost inflation in the US is also driven by demand for new state-of-the-art services not available in Canada and much of Europe. That is why the Premier of Nova Scotia, Danny Williams, skips using his wonderful Canadian system and gets his heart surgery in the US.
In 2007 85% of Americans had health insurance. Out of the remaining 15%, about 1/3 – mostly the children (about 7 of 10 children) – are already eligible for Medicaid and CHIP ([url]http://usgovinfo.about.com/gi/o.htm?zi=1/XJ&zTi=1&sdn=usgovinfo&cdn=newsissues&tm=158&gps=536_1430_1920_1061&f=20&su=p284.13.342.ip_&tt=2&bt=1&bts=1&zu=http://ccf.georgetown.edu/index/cms-filesystem-action?file=strategy+center/eligibleuninsured/eligibleuninsuredccf.pdf[/url]
Out of that remaining 2/3, it is estimated that half are not going to ever get health insurance for various reasons.
So, we are going to blow up this existing system to help that last 15 million people that currently want health insurance but cannot afford it or cannot access it for some reason? A related question… how many of that 45 million uninsured are illegal aliens or children of illegal immigrants? Estimates are about 20-33% of the 45 million.
[i]1) the others in wealthy countries all expend less than half of what we spend per citizen; [/i]
Like France where doctors make about half what US doctors make, but have their education paid for by the state and take about 75% of the US education time to get certified. Also, the wait times to see a specialist are much longer than the US. The same is true for Canadian wait times. There are many reasons that we spend more per citizen. One of them is that we are not Canadian or French.
[i]2) they mostly have better outcomes per given disease, in terms of recovery. This is especially true with contagious diseases; [/i]
Try cancer, and heart repair, and orthopedics…. The US blows away the service trends for other countries.
[i]3) they have longer life expectancies* and lower rates of infant mortality;[/i]
There are a lot of challenges to the cause for lower and higher infant mortality rates. For one, the birth rates in Europe are about half what they are in the US. Also, there is no absolute connection with these two measures and the quality of our health care system. The US has a much higher percentage of blacks in our population, and blacks on average have a lower life expectancy (higher rates for several chronic diseases like hypertension, heart problems, prostate cancer, guns, etc) . Then we have our fat culture. This has nothing to do with our healthcare system. It is our culture… and that does not change with a French style or Canadian-style healthcare system. On infant mortality, the data is not measured consistently. The US counts every child that exits the womb. In Switzerland for example, an infant must be at least 30 centimeters long at birth to be counted as living.
[i]4) they cover everyone; [/i]
Most French require private supplemental policies to get all the coverage they need. This practice has been growing and will continue to grow. They still don’t cover people that don’t want health care, or are too confused to go get it. But, you miss the point that the cost of these other socialized systems has become clearly unsustainable. It is like jumping on the Cost Concordia because the view is better for the moment.
[i]5) we uniquely have a rapidly growing share of our population with no medical insurance; [/i]
Let’s remove the Great Recession first, because if our government got their collective heads out of their posteriors and implemented some policies that actually helped restore some confidence in the economy and created more jobs, we would take care of a good chunk of this problem.
[i]6) because of our large and growing uninsured population, we have a terrible allocation of medical spending on the emergency room end**; and [/i]
I agree, but there are better ways to address this than throwing the baby out with the bathwater.
[i]7) while other countries have all spent much more on integrating high tech information software into their healthcare, the US system is still antiquated. And that lack of communication systems adds substantial costs to our overall structure.[/i]
Don’t tell me you expect the government to do a better job implementing medical information technology than you think the private sector will do. Have you every researched a large IT project run by government? I have worked on managing state projects as a contractor cleaning up their prior mess. Just Google “government IT project debacles” or “government Oracle contract debacles”. Again, there are MUCH better ways to do this than allowing the government to completely control it and run it.
I AM surprised that you see things this way, but I respect your opinions.
Jeff:
“However, my employees are fearful of Kaiser because of the old reputation for sketchy service. That has changed, but the fears don’t too easily. Kaiser now gets top marks for patient satisfaction.”
Jeff, my family has had Kaiser for the last 35 years and we have been very happy with it. The local clinic is very convenient and with hospitals in both Sacramento and the new location in Vacaville those trips have become much easier too.
RICH: [i]”…In 2011, US medical inflation grew at 8.9%. It was 7.2% in Europe.” [/i]
JEFF: [i]”Rich, I have to stand by what I wrote based on the word “unsustainable.” Healthcare cost inflation in the US is also driven by demand for new state-of-the-art services not available in Canada and much of Europe.[/i]
If you say healthcare is not sustainable in Europe due to rising costs and we have higher healthcare inflation and we are starting out with much higher costs, then you must think the US system is far less sustainable.
JEFF: [i]”In 2007 85% of Americans had health insurance. … So, we are going to blow up this existing system to help that last [b]15 million people[/b] that currently want health insurance but cannot afford it or cannot access it for some reason?”[/i]
Note: that is not 15 million people. It is 46 million out of 311 million (which is, as I think you meant to say, 15%). That percentage has not changed much since 2007.
Blowing up is hyperbole. Almost everyone who is now covered is either covered through Medicare or through their job, and for them, the changes will have no substantial effect. Where Obamacare will make a big difference is for the working poor who are not covered and those who qualify for Medicaid, but did not before.
RICH: [i]1) the others in wealthy countries all expend less than half of what we spend per citizen; [/i]
JEFF: [i] … the wait times to see a specialist are much longer than the US. The same is true for Canadian wait times.”[/i]
Earlier in this thread I noted that was one of the downsides of the Canadian system. But it is notable that it does not affect health outcomes negatively for Canadians. A Canadian diagnosed with cancer will live longer than an American; same with a heart attack or a stroke. The life expectancy for a person with diabetes in Canada is also longer than for an American who gets that disease at the same age.
RICH: [i]”2) they mostly have better outcomes per given disease, in terms of recovery. This is especially true with contagious diseases;”[/i]
JEFF: [i]”Try cancer, and heart repair, and orthopedics…. The US blows away the service trends for other countries.”[/i]
Not true across the board ([url]http://www.cbc.ca/news/health/story/2007/04/18/health-canada-us.html[/url]). (I concede I don’t have any sources regarding orthopaedic outcomes.) [quote] The death and disease rates for patients in Canada are the same or lower than those for people with similar diagnoses treated in the United States — even though per capita health-care spending is higher south of the border, a study suggests.
“In looking at patients in Canada with a specific diagnosis compared to Americans with the same diagnosis, in Canada patients had at least as good an outcome as their American counterparts — and in many situations, a better health outcome,” said one of the 17 authors, Dr. P.J. Devereaux, a cardiologist and clinical epidemiologist at McMaster University in Hamilton.
“And that is important because in the United States, they’re currently spending a little over $7,100 per individual on health care annually, whereas in Canada we’re spending a little over $2,900 per individual annually,” he said in a telephone interview from Brantford, Ont.
The study covered data on patient populations in the United States and Canada from 1955 to 2003. To conduct their meta-analysis, researchers identified almost 5,000 titles and abstracts. Of these, 498 appeared potentially eligible on initial review. Eventually, 38 studies were deemed to be eligible.
“Overall, Canada did better, and in fact we found a statistically significant five per cent mortality advantage [of survival] to people with diagnoses in Canada compared to their counterparts in the United States,” Devereaux said.
“What it [the study] shows is that despite an enormous investment in money, we do not see better health outcomes [in the U.S.],” Devereaux said.
“And importantly, where our two systems do diverge is that America has a mixture of private insurance in terms of the funding for health care whereas in Canada we have medicare system for hospital and physician services. The medicare system allows us enormous efficiencies in terms of cost-saving relative to private insurance.”
Some explanations for the results include the fact that U.S. health care has administrative inefficiencies that public funding — without multiple competing insurance companies — eliminates. Canadians also save on prescription drug costs because drug prices are controlled.
Few uninsured patients in the United States, who probably suffer the worst quality care, were included in the studies examined.[/quote]
RICH: [i]”3) they have longer life expectancies* and lower rates of infant mortality; “[/i]
JEFF: [i]”… the birth rates in Europe are about half what they are in the US.”[/i]
Not half ([url]https://www.cia.gov/library/publications/the-world-factbook/rankorder/2127rank.html[/url]), Jeff. Most range from about the same (Ireland) to about 90 percent of ours (Belgium). There are a handful which are even lower (Spain), but none is half of ours, not even in the former Communist countries, where they have very low fertility rates.
[i]”Most range from about the same (Ireland) to about 90 percent of ours (Belgium).”[/i]
Correction: I meant 80 percent, not 90 percent.
One topic I haven’t noticed on this thread is that of preventative care.
I wonder if the current system (and Obama care too, it would appear) has much incentive to do preventative care; as the odds are that most people will switch health insurance companies (along with job changes, or contract changes by employer, etc.) several times or more during their lifetime. Thus if preventative care is performed for a patient in youth or middle age; odds are the patient will have moved onto a different insurance company by the time the benefits of the preventative care are reaped, i.e. lower health care costs with aging as a result of those earlier years of pro-active preventative care.
Rusty49: [i]”Jeff, my family has had Kaiser for the last 35 years and we have been very happy with it.”[/i]
It is interesting, from people that use Kaiser, I rarely hear anything other than satisfaction. My wife and I had our first child delivered at Sutter in Davis and thought it was great. My wife’s best friend had her first baby a year before at the Kaiser hospital located on Alta Arden in Sacramento and when we visited her we it reminded us of a soviet facility. However, my wife’s friend loved it and still loves Kaiser. Now her grown kids love Kaiser too.
I think we are all a bit change-averse when it comes to our healthcare system we are used to. I try to remember that when I think about Obamacare and consider what changes may occur. I also consider that change is inevitable because of costs. For example, I told my employees this year that Kaiser may have to be an option next year depending on rates. My concern is not just that things will change with Obamacare (healthcare has to change), I think they will change for the worst for most Americans only to benefit a small minority of people. I think it is really, really bad legislation. It will cause more problems than it will solve.
Rich: [i]” If you say healthcare is not sustainable in Europe due to rising costs and we have higher healthcare inflation and we are starting out with much higher costs, then you must think the US system is far less sustainable.”[/i]
Absolutely, but with one key difference. With insurance and/or health care service as a private expense, many of us will have to make choices for what else we cut or work harder to earn in order to pay for it. We will also have choices to jump to other carriers and providers if we dislike the service provided. With government-controlled healthcare we eventually won’t have choice. It is the slippery slope to less choice that most concerns me.
However, I admit that I have been perplexed with our current system that there is not greater competition for insurers and providers to bring more affordability to the markets. This then gets me back to thinking this change-aversion theory. I remember my mother talking about how her mother would not change doctors even after he about killed her prescribing the wrong dosage of medication.
Regardless, I don’t see this debate between socialized and private healthcare as a binary choice. Frankly, I’m close to the “healthcare is a right” argument… for some base levels of access/service. I don’t want anyone to not be able to get necessary care. I also think some level of preventative care is needed for all people. Where the “rights” debaters lose me is their view that nobody should be able to purchase greater access and greater service… or even that they would be restricted to a degree of additional service because of limited healthcare resources that are forced to serve so many lower-paying customers. This is Orwellian… I see the US healthcare Gestapo policing a black market for providers trying to provide services to paying customers while refusing patients with only government redistributed dollars in their pocket. Don’t think this is an unfounded fear… lefty politicians are already trying to think of ways to force doctors to accept Medicare and Medicaid patients. It is the biggest problem with these egalitarian impulse that drive some public policy… no agreeable way to force free producers to bend to government will while government spends their money. These politicians keep moving the needle until it is only by history books (which they also try to rewite) that reminds us what freedom was really like.
In addition to my obvious problem with this Orwellian vision, I think our US government will just make a much bigger mess out of everything. I think we are better off keeping it a market-based consumer choice with as many options as possible. There are a great number of smart innovative people working in the private-side of the healthcare industry. With the right nudge from public policy, I think we would be much better off unleashing them, than to have this government takeover rammed down our throats by the Obama meritocracy pushing a Ted Kennedy memorial extreme social engineering.
Rich, I will have to go back and research your challenges to healthcare outcomes and birth rates. I was confident that my opinion of stronger US outcomes for cancer, cardiology and othopnea were correct. As for birth rates, yes I was considering Germany, Spain and Portugal as examples. However, you are correct that it is not half. Spain’s birthrate is 1.40… about 68% of the US birthrate of 2.05. Probably not statistically close enough for a trained economist smoking one of my favorite C.A.O Brazillia Gol robustos… but close enough for a banker! 😉
[i]”Frankly, I’m close to the “healthcare is a right” argument… for some base levels of access/service. I don’t want anyone to not be able to get necessary care. I also think some level of preventative care is needed for all people.”[/i]
[i]”…this government takeover rammed down our throats by the Obama meritocracy pushing a Ted Kennedy memorial extreme social engineering.” [/i]
The guy that said the first part needs to talk to the guy who said the second part. One of those two guys is reasonable.
[quote]My question for you… why, if Kaiser works so well, don’t you advocate an adoption of that business model in the private health provider market instead of advocating for a government-run single payer system? You do know that Kaiser’s model will have to change drastically if we get socialized medicine in this country, don’t you? [/quote]
I have many responses to much of what you have written but am exhausted and will have to come back to this topic later. However, I really feel I can address this point fairly quickly.
The answer is simple. I see private insurers as an unnecessary middle man who have had many, many years to operate ethically and have consistently chosen not to do so. This has provided us with the following types of very common scenarios ( all of which I have seen through the years):
1) Insurance company collects for years from healthy individual, then refuses to pay and/or reinsure when significant illness is diagnosed
2) Insurance company refuses to authorize obviously needed procedure until multiple unnecessary intermediary tests or procedures are done. In my field, for example, hysterectomy is obviously need for heavy bleeding resulting in anemia in a patient with clinically obvious tumors on the uterus. Patient needs hysterectomy. Insurer demands first that the doctor do an endometrial biopsy, then a D&C, then a pelvic US
each of which needs prior approval before doing the procedure necessitating that the patient leave and return for another appointment between each unnecessary visit. I have had patients literally cry in my office when I have told them that we can do all of the testing necessary within one visit with no need for anyone’s approval but hers and mine after she has spent literally months trying to get care in the some nonintegrated system.
3) Healthy person pays insurance fees for years. Bad diagnosis. Insurer refuses to pay based on the patient
making a minimal error in their application many years before such as forgetting to write down the diagnosis of adolescent acne.
4) Insurance company refuses to pay for indicated and scientifically demonstrated effective treatment which
insurance company has arbitrarily labelled “experimental”.
The bottom line is that yes, I do trust the government to create a better system of health care delivery than we have now. It could hardly fail since we have no system at all. The US has a free for all at present in terms of its fee for service medicine which provides incentives to do as much as possible as expensively as possible. Kaiser
does not fit this model and it is largely the reason that I built my career within Kaiser. I view medicine as a service, not as a business where the chief goal is to make as much money as possible.
And yes, I do believe that health care should be considered a right.
We have precedent for treating certain services as a right in this country. Every citizen now has the right to the expectation of protection by our military. We consider our military the best in the world. It is government run.
So since we already have this precedent, and it is government run, and we consider it the best in the world, why would we not want to provide a government system of health care emphasizing preventative care, establishment of evidence based best practices, patient and family focused care, and integration of services , with universal health records as the norm ? We strongly believe in the protection of our citizens from outside
threats, but staunchly refuse to see that we would be a much stronger society if we provided needed health care to all of our citizens thus protecting them as much as possible from the threats of illness and incapacitation.
Thanks, medwoman. Your perspective is very useful. This was just posted by a Facebook friend of mine.
“Husband works for 25 years for same employer, reputable local auto dealer, company closes suddenly. Out of job, but still has same second job he held for 25 years, delivering over 400 papers EVERY DAY on a rural route (awake at 4 in every weather, 3.5 hour route in a car). Second job has no benefits, and they cannot afford the coverage. Massive heart attack, codes several times, finally comes home, massive debt—needs surgery badly, but NO INSURANCE. Cannot get insured because of ‘pre-existing condition’–either of them. Don’t qualify for Medicaid—they still have a little equity in the house they lived in for almost 2o years. THAT IS WHAT the system is set up to do—does this seem sensible to any of you—they paid EVERY MONTH for 25 years, used virtually no benefits for him, and wham!! Done, and no hope until they become indigent. Does this seem fair? Of course not!!! Oh, BTW, after 3 days, still in coma, newspaper FIRES him because he can’t deliver the paper.”
Tell me what would happen to him in Europe? Canada? Australia?
Don Shor
Thanks so much for posting this example. This is an extreme example, but it is not unusual. Lest anyone think that this is rare, I can assure you that this kind of event happens on a daily basis for many people.
Changes in job, marital status, age all have brought many, many women to me asking to have some procedure or test done quickly before their insurance runs ou or before life takes them to a location where there is no Kaiser. They know that once they are not covered by Kaiser, they will not be able to have it done.
This is a far more eloquent answer to the question posed by Jeff Boone. If the insurance companies have not chosen to help protect these people after collecting insurance fees for years, why would I think the private sector would suddenly have an epiphany and start acting in an ethical manner now ?
As for what would happen to him in Europe, Canada, Australia…..he would get treated with no one asking how he was going to pay.
Jeff
[quote]There are a great number of smart innovative people working in the private-side of the healthcare industry. With the right nudge from public policy, I think we would be much better off unleashing them, [/quote]
Doubtless there are a great number of smart innovative people working in the private-side of the “health care
industry”. This is part of the problem. These smart innovators tend to see the world from the viewpoint of maximizing profit. Their goal is not to ensure as much health for as many as possible, but to make as much money as possible from the care that is provided. This is a major reason that many of these folks did not go into medicine. Their first priority is not the well being of the individual or the community or even the country as a whole, but with making money. While I do not have an inherent problem with this philosophy if your product is high end clothing, or if your service is cosmetology. I have a great deal of difficulty with it when it dictates who can or cannot obtain health care.
jimt
[quote]One topic I haven’t noticed on this thread is that of preventative care.
I wonder if the current system (and Obama care too, it would appear) has much incentive to do preventative care[/quote]
I have buried my comments about preventive care in some of my earlier diatribes ….er, I mean posts….
In the fee for service medicine model there is little incentive to provide preventive care. There are a number of reasons for this:
1) Preventive care can be provided in a number of inexpensive ways including classes provided by health
educators, group assessments and programs run by RNs and NPs all under physician supervision. Tracking
of progress can be done on line or through telephone appointments which is much less costly, but also
means much less profit in the short run. This is of course the perspective of the individual doctor who will
make more money in fee for service if the patient has to come in for an individual visit for each of these
visits.
2) In fee for service, there is no incentive to keep people healthy. Doctors are not evil. They don’t want their
patients to get sick so that they can charge them more to cure them. However, it is inevitable that if you are
going to make much more money doing a surgery than educating the patient on how to successfully
manage the problem with a behavioral approach or a more conservative medical approach, you are likely to
favor the more lucrative approach.
3) Because of the uneven way in which physicians are currently compensated in fee for service medicine, it is
much more lucrative to become a surgeon or subspecialist than to be a primary care doctor. This has led
to a real lack of primary care providers, especially for underserved populations. This is the antitheses of
focusing on prevention.
First, how this relates to the Kaiser model:
We have a huge emphasis on preventive care. We are scored individually and by group ( both location and specialty) on how well we perform in getting health care preventive services done for our patients. There is incentive ( no penalty if you don’t, but reward if you do) meet screening targets in areas such as high blood sugar, blood sugar and cholesterol management, mammography, cervical cancer screening, early pregnancy
care and other parameters that have been well demonstrated to have benefit in terms of being cost effective for the group as well as for the individual. So while I have no incentive to recommend an unneeded surgery,
I have a definite incentive to urge my patient to have her Pap and mammogram done at an interval based on her individual risk, not necessarily yearly because that would generate more money.
How I believe it will relate to the ACA:
I believe that there are several parts of the bill that will address this issue.
1) The bill does mandate that preventive services will be part of covered care
2) There is a provision encouraging movement to evidence based best practices which rely on large prospective randomized studies and meta analysis to determine the best treatment regimens rather than relying on the pharmaceutical companies and equipment manufacturers to tell us what works best.
Speaking of which….my best practice would be to head to work. More later.
[quote]When you choose as your source a four-year-old column by an opinionated blogger who calls Massachusetts by the nickname that conservatives use to deride it, “Taxachusetts,” and that blogger does not refer to any objective data to support his claim that Romney’s program in Massachusetts is unpopular, I have to wonder how open minded you are on this topic. [/quote]
The comment I was addressing was as follows: “Look no farther than the incubator state for Obamacare, Massachusetts, if you want to see how this plays out. The people there seem pleased with the outcome of Romneycare.”
I responded by showing that not all folks from Massachusetts agree “The people there seem pleased with the outcome of Romneycare.” The view of Romneycare is mixed at best. I also have relatives who live in Massachusetts, so I know of what I speak…
That’s kind of like citing the KKK as an example to show not everyone likes the civil rights act.
Re: Don’s Facebook story about the guy with the heart attack:
That’s a perfect illustration of how, when you allow insurance companies to pick and choose whom to insure and whom not to, it is not really insurance once a person gets sick. The ACA regulation which prohibits companies from discriminating based on pre-existing conditions should make this situation much better. Time will tell.
————–
I wrote a column once about the younger brother of a friend of mine who discovered he had an inoperable brain tumor. “Bill” had worked for a long time in media sales (mostly selling ads for a group of radio stations in Los Angeles), but lost his job a month after learning about the tumor, because the stations he worked for had been sold to a Spanish language media company. Bill had been married at that point for about 7 or 8 years and had been in a relationship with his wife since they were undergrads at USC. They had decided to put off having kids because they wanted to be established financially before starting a family. To make a long story short, Bill and his wife were completely wiped out with medical expenses. Eventually they lost their house, all their savings, etc. They got by on her income — she is a self-employed graphic artist whose clients are ad agencies — but all the chemo-therapy and radiation and so on overwhelmed them. The only good news is that Bill’s tumor has shrunk and it is not growing and he can walk without a cane and so on. He also is back working. I don’t know if he has insurance from his new job. He works for a television station in LA, and it is owned by one of the networks. So chances are that company is large enough to buy insurance for him, despite his pre-existing condition, which he will have the rest of his life. (The tumor is in his brain stem, and in that location it cannot be operated on.)
[url]http://www.wbur.org/2012/02/15/health-care-wbur-poll[/url]
62% support the Massachusetts law.
Darnit Don, you just proved her point, not everyone likes it.
ELAINE: [i]”I responded by showing that not all folks from Massachusetts agree.”[/i]
It seemed like you were actually saying that Romney’s health reform program was not popular in Massachusetts, and it seemed you used that blooger’s unsourced opinions as proof that it is unpopular.
Yet when 84% of people in Mass. say they like it, that is a very strong vote of confidence for Romney’s program. Even if that poll had a margin of error of 5%, it would still be an overwhelming majority in favor.
What confuses me is what you, Elaine, think so many people would dislike about a program like that or like the ACA. I understand that ideologues who have a philosophical opposition don’t like Obamacare or Romneycare because any government role in healthcare offends their ideology. They have the same objections to Medicare and Medicaid and having government involved in public health campaigns. But for people who are not driven by ideology, why would they dislike a program like the ACA or Romneycare? If they are well insured already, the program will have no effect on them. If they run a small business, like a Redwood Barn, and they cannot afford to buy health insurance for their employees now, this program is designed to make that much less difficult. If they have pre-existing conditions or a family member or other loved one with a major illness and thus cannot get health insurance, why would they object to the ACA or Romneycare?
Again, I get it when people are driven by an ideology. But most people are self-interested, and it is hard to see how this kind of a reform harms the self-interest of most people. It seems to me that most of us will not be all that impacted by the changes, at least not as long as we are relatively healthy. Maybe we will benefit when we are sick.
[i]”62% support the Massachusetts law.”[/i]
The WBUR poll may have asked a slightly different question, but the Market Decisions poll showed that 84% of Mass. residents were “satisfied” ([url]http://www.reuters.com/article/2011/03/10/us-massachusetts-insurance-idUSTRE7296Z420110310[/url]) with Romneycare.
Medwoman, with all due respect, I don’t think you are thinking my question through and you are automatically responding. I asked you why not advocate for a Kaiser model. You tell me what is wrong with the insurance industry, and then continue to laud what Kaiser is and does. That is a little frustrating to me that you would focus on the glass half empty while ignoring your own positive experience as a solution.
I also don’t get your ongoing demonization of profit. Last I checked we need profit to tax so we can help all those people in need. If you were a dairy farmer I think you might be predisposed to beating your cows for producing milk because you don’t like milk… (Note that I expect your nuanced response that you “don’t have a problem with profit”… yet you apparently do based on quote like this: [i]”I view medicine as a service, not as a business where the chief goal is to make as much money as possible.”[/i])
Health insurance is a different beast than other insurance because it is transactional. However, there are great companies out there keeping costs low and keeping patients satisfied. Kaiser is an example. VSP and Delta Dental are another two examples. I think one key difference in how healthcare insurance or managed care companies work, is the level of connection to the practice of medicine in their strategy and operations. Doctors sit on the boards of VSP and Delta Dental. Kaiser is both a care provider and health care insurance company.
I reject your opinion that these and other insurance companies seek profit at the expense of patient well-being. You and others in the medical profession do not have exclusive ownership of the “we care” banner. I have worked for large healthcare insurance providers and last I checked the employees of these companies are flesh and blood humans no different than is a doc or a nurse. They have no more or less caring impulses. They certainly are motivated to manage the costs of care. Yes, to make a profit. But also to keep their premiums as low as possible so they are more competitive and more people can afford their products. Frankly, I have had plenty of experience with uncaring medical professionals. How about those US nurses being paid more than nurses in any other country and working fewer hours? Let’s demonize them for being so uncaring contributing to the skyrocketing cost of healthcare. Why is their greed less critical than is the same for somebody working for an insurance company?
Don, that is a troubling and touching story. Remember though, there is bipartisan support for controlling for pre-existing conditions. There is also agreement that we need to drive down costs. I also think there should be a new chapter of bankruptcy for healthcare-related debt. If the Democrats wanted to solve those problems, they would be able to working with the GOP. However, what the Democrats are doing is using these stories as emotive wedges to help them ram their Ted Kennedy memorial dreams of socialized medicine down our throats (sorry, but I guess I have to continue to be that multi-personality unreasonable guy). You know this to be the case and you, and most other folks with left-leaning political views, are complicit in it.
I also bristle at the inference here that there is another side that does not care about these stories (Don’s and Rich’s stories). Again, the GOP supports fixing these things. But as Joe Biden pointed out a good liberal Democrat does not let any crisis go to waste. Better to create posters of the victims to enflame the public to win the ideological war.
There are going to be so many ugly consequences of Obamacare. For example, talk to anyone working to handle Medical claims… their caseloads will go through the roof, and there is no money to hire new employees. That is just one of thousands of messy impacts this lousy legislation will cause.
[i]” Again, I get it when people are driven by an ideology. But most people are self-interested, and it is hard to see how this kind of a reform harms the self-interest of most people. It seems to me that most of us will not be all that impacted by the changes, at least not as long as we are relatively healthy. Maybe we will benefit when we are sick.”[/i]
Negative Impacts from Obamacare:
[url]http://www.heritage.org/research/projects/impact-of-obamacare[/url]
Read it and weep. I did. Still am. More debt we are handing to our kids.
It is not ideology driving my objection, it is the fact that it is crappy legislation that will create more problems than it will solve. IT is primarily ideologically-driven from the left. And when you make the case that the opposition is ideologically-driven, why don’t you consider the historical evidence that everything government does costs more than it should? I think facts, math and evidence supersede ideology in this case.
Um, Kaiser is non-profit.
[i]For example, talk to anyone working to handle Medical claims… their caseloads will go through the roof[/i]
Yes, because that is how many people who presently don’t have insurance will be getting health coverage. That’s kind of the point.
[i]and there is no money to hire new employees. [/i]
So, they’ll have to work harder? Is that the problem?
Your focus is on the people who provide health insurance. My focus is on the people who don’t have it.
[i]Remember though, there is bipartisan support for controlling for pre-existing conditions. There is also agreement that we need to drive down costs. I also think there should be a new chapter of bankruptcy for healthcare-related debt. If the Democrats wanted to solve those problems, they would be able to working with the GOP.[/i]
Republican are not focusing on the uninsured and never have.
The Republicans are just dusting off their old proposals from 2009 as their “alternative” to the ACA. At the time, the CBO analysis showed that:
— The Republican plan would extend health coverage to almost nobody who didn’t presently have it;
— their plan would have reduced the deficits less than the ACA.
[i]”Um, Kaiser is non-profit.”[/i]
I would guess that the reason Kaiser incorporated as a non-profit is not entirely or even mostly about an altruistic motive. I would guess that they did so because when you own your land, your hospitals, your clinics, your extremely expensive medical equipment and so on, there are real financial advantages to not having to pay property tax or an equipment tax ([url]http://www.brighthub.com/money/personal-finance/articles/32870.aspx[/url]) which a “for-profit” enterprise is required to pay.
Moreover, because KP does not have to pay income tax, they can take all the money they save from not paying property tax and all their excess revenues (what others would call profits) and use that capital to grow their company, to invest in more land, more buildings, more equipment, etc.
I don’t know what percentage of the largest private companies which own hospitals are incorporated as non-profits. But it seems like most of the industry is “non-profit” because of the tax benefits of being so.
Locally, for example, KP is non-profit. The very large Catholic healthcare system, CHW, which changed its name recently to Dignity Health, is a non-profit. Sutter is also a non-profit ([url]http://www.sutterhealth.org/about/[/url]). There probably are some hospital chains which are for-profit. But they are (at least locally) the exception.
This non-profit private industry raises an obvious question: Are the directors of these companies not motivated by money? I would guess (without knowing their salaries) that they are still money-seekers. I bet the directors of Sutter and KP make much higher salaries than the directors of for-profit companies. The difference is that the directors of the for-profits get bonuses based on profitability and get stock options which are not available to the heads of the non-profits.
I also would bet that if Sutter or KP had expenses which exceeded revenues, the directors would be ousted. As such, their incentives are pretty much the exact same over time as those who run for-profit companies. They have to keep down costs and increase income and try to please their customers. That is the name of the game in all private businesses.
JEFF: [i]”Negative Impacts from Obamacare: Heritage Foundation argument”[/i]
Heritage: The ACA is bad for seniors because it will hurt Medicare.
Rifkin: I guess time will tell on this one. However, it is odd that the right-wing ideologues who want the government out of the medical industry base their argument that this new government program will harm an existing government program.
Heritage: “Under the new law, seniors are going to pay higher taxes.”
Rifkin: If the ACA moves people who now use “emergency room” medical care into more of a primary care situation, it will have a systemic cost savings. Time will tell, again, on that one.
Heritage: Doctors will not be reimbursed properly.
Rifkin: If so, this will create a new problem, and that will have to be addressed. However, keep in mind that US doctors make double what most doctors around the world make. So there likely is some room for a reduction in income for MDs. I think a bigger problem is that the US produces too few doctors. We need to expand our med schools. By increasing the supply of MDs, we would reduce their market power and hence their incomes.
Bottom line: I don’t yet know if the ACA will create a great number of problems and those problems will be worse than the problems we now have. What I object to is 1) the notion that our system now is funcitoning well. It is way, way too expensive; it is bad for US business and competitiveness; and it is terribly inefficient for those on the margins of the system; and 2) the notion that what we now have is a private system, and the ACA is a socialist system. Both arguments are false. More than half of all medical payments in the US are made by the government now*. The problem is that the incentives in our system make our healthcare overly expensive and that has created seriously bad medical services for roughly 20% of Americans.
——————
*Source ([url]http://truecostblog.com/2009/11/16/what-percentage-of-us-healthcare-is-publicly-financed/[/url]): [i]”Public, taxpayer-funded health care spending will pay for for 53% of US health care in 2009. If health care tax breaks are included, this figure rises to 62%. [/i]
Heritage: [i]”The hodgepodge of new taxes that have already or will soon take effect as a result of the Patient Protection and Affordable Care Act may not all show up in the income tax tables, but their huge cost is still very real. This cost will become most apparent in lost wages and international competitiveness, and it reduces middle- and low-income families’ wages just as surely as an income tax hike would. These taxes break President Barack Obama’s promise not to raise taxes on families making less than $250,000 per year.”[/i]
Rifkin: One of the craziest parts of the right-wing ideology (which began during the years of the huge Reagan deficits) is that we can accrue endless governmental debts and take on all kinds of governmental expenses, but these debts and expenses don’t ever need to be paid for with tax increases.
The fact is that our medical system now is creating all sorts of liabilities, most of them covered by government. At some point these bills have to be paid for. So the right-wingers don’t object when the costs are being generated–for example, are the right-wingers saying that when someone with a heart attack goes to the ER and has no insurance, he should be put out on the street?–they simply object when taxes need to be raised to pay the costs we have accrued.
I am sure–based on history–that the costs for the ACA will be larger than Obama says they will be. But I don’t object to funding our expenses by raising taxes, if we are going to be accruing these expenses all along. I think the right-wingers would make a much better case if they said, “OK, it costs a lot of money to treat all these uninsured people we are treating. Let’s raise income taxes on everyone by 5% and we will keep our system the same, but pay our bills.” But the right just pretends that we are not accruing these expenses. And they pretend that our system has the right incentives in it to make medical care more and more affordable. Etc.
[i]… there is bipartisan support for controlling for pre-existing conditions.[/i]
How does the Republican/conservative opposition propose that pre-existing conditions be dealt with if they oppose the individual mandate? If you just tell insurance companies that they have to insure anyone who applies, and can’t cancel due to pre-existing conditions, costs will skyrocket. If you don’t then regulate the costs of premiums, or regulate the minimum care that can be insured, you will exacerbate two trends that were already underway: rising premium costs making insurance unaffordable, and reduced benefits leading to millions of Americans being underinsured.
Only by bringing in the healthy uninsured can you make the whole system pencil out. That’s why the Heritage Foundation (irony noted) proposed the individual mandate in the first place. Though in fairness, theirs was to be enforced by a loss of tax credits, not a fine. Nevertheless, it was their recognition of the impact of adverse selection that led to the proposal.
[i]”How does the Republican/conservative opposition propose that pre-existing conditions be dealt with if they oppose the individual mandate?”[/i]
I believe they want those folks deported.
[i]”Rifkin: One of the craziest parts of the right-wing ideology (which began during the years of the huge Reagan deficits) is that we can accrue endless governmental debts and take on all kinds of governmental expenses, but these debts and expenses don’t ever need to be paid for with tax increases.”[/i]
Rich: That wasn’t right-wing ideology… that was general stupidity on both sides based on some unbridled optimism that we would continue to expand and grow the economy to someday catch-up and pay off our debt. We nearly did under the Clinton/Tip O’Neal years… but that was at least partially due to our unbridled optimism over tech ideas and stocks. That crashed.
The right-wingers found fiscal Jesus during the last few years of the Bush administration. The Tea Party was forming and general unhappiness with the deficit was a big conservative media talking point. Then the crash and bailouts and all hell broke loose with conservatives.
I think the right gets it now. I also think libertarian types get it.
The problem now is the left and left moderates that do not apparently appreciate the urgency for fiscal discipline to push back the debt by trimming spending and growing the economy. They don’t get it at the Federal level, they don’t get it at the state level, and they don’t get it at the local level. Frankly, we could not have picked a worse time to implement Obamacare. Many people, including myself, see it as the probable beginning to the end of the US as a fiscally-viable country.
I support the Obamacare outcome objectives… I really do. I would like nothing better than to have healthcare nirvana where nobody has to worry. A system where everyone knows when they get sick they just go to the doctor and get treated and they won’t get any bills they could not afford to pay. First point to make… that will NEVER happen in our lifetime in this country. We have so many structural differences in our healthcare system that it will take decades of painful change until we look anything close to a Canadian or French system. And we will probably never get there because Americans demand greater control of their own lives than do people with multiple generations of family trained to expect their government to care for them. We are much better off approaching this using the free market and competition.
You mention that we need more doctors. I agree. How is that addressed with Obamacare as it floods offices with more people having access to free care?
Rich: Your analysis of non-profits in the healthcare industry appears spot-on to me. I worked for VSP for six years. They were a non-profit but highly competitive and determined to retain and grow market share. About 6-7 years ago, the IRS won a case to make them a taxable corporation. They are still a private company though. The execs were paid well, but not excessively.
My own employer is a 501(4)(C). We are in a hyper-competitive industry and would disappear if we didn’t compete at a top level.
The tax benefits for non-profits come with quite a few strings. One is that our annual financial audits are a big deal. Another is scrutiny on employee compensation. However, a big one is how much net-excess cash is produced by the operation and what it is used for. In general it should be used for the benefit of the communities served. VSP donated a lot of money to programs like Healthy Families, and free eye care clinics… and grew their economies of scale to keep eye care insurance premiums affordable. Where they appeared to get in trouble was their strategy to grow market share in the eyeglass frame industry. That move could not be defended as serving the community… it was serving the egos of VSP execs that wanted to grow a bigger company. I understand VSP is going international now. How about that… an American healthcare company selling its products to Europeans used to getting their entire healthcare from their nanny government?
[i]I believe they want those folks deported.[/i]
LOL! Only the ones here illegally.
Key points of the GOP plan…
[quote]Enact Medical Liability Reform
Skyrocketing medical liability insurance rates have distorted the practice of medicine, routinely forcing doctors to order costly and often unnecessary tests to protect themselves from lawsuits, often referred to as “defensive medicine.” We will enact common-sense medical liability reforms to lower costs, rein in junk lawsuits and curb defensive medicine.
Purchase Health Insurance across State Lines
Americans residing in a state with expensive health insurance plans are locked into those plans and do not currently have an opportunity to choose a lower cost option that best meets their needs. We will allow individuals to buy health care coverage outside of the state in which they live.
Expand Health Savings Accounts
Health Savings Accounts (HSAs) are popular savings accounts that provide cost-effective health insurance to those who might otherwise go uninsured. We will improve HSAs by making it easier for patients with high-deductible health plans to use them to obtain access to quality care. We will repeal the new health care law, which prevents the use of these savings accounts to purchase over-the-counter medicine.
Ensure Access for Patients with Pre-Existing Conditions
Health care should be accessible for all, regardless of pre-existing conditions or past illnesses. We will expand state high-risk pools, reinsurance programs and reduce the cost of coverage. We will make it illegal for an insurance company to deny coverage to someone with prior coverage on the basis of a pre-existing condition, eliminate annual and lifetime spending caps, and prevent insurers from dropping your coverage just because you get sick. We will incentivize states to develop innovative programs that lower premiums and reduce the number of uninsured Americans. [/quote]
And last but not least…
REPEAL OBAMACARE AND EXTEND THE BUSH TAX CUTS TO INJECT FISCAL CERTAINTY IN THE ECONOMY
LOWER TAXES AND REDUCE REGULATIONS TO SPUR ECONOMIC DEVELOPMENT
GET MORE AMERICANS WORKING SO THEY CAN PAY FOR THEIR OWN HEALTHCARE.
REFORM THE EDUCATION SYSTEM SO MORE AMERICANS BECOME EMPLOYABLE.
SECURE THE BORDER AND THEN DEPORT ILLEGALS IN THIS COUNTRY THAT DO NOT HAVE THE MEANS TO SUPPORT THEMSELVES FINANCIALLY.
CUT GOVERNMENT SPENDING TO DIRECT MORE MONEY TO NEEDED PROGRAMS LIKE EDUCATION
In addition, I think we need a new bankruptcy chapter for debt related to catastrophic illness.
Lastly, we need to focus on the healthcare models that are more affordable (like Kaiser) and use tax and regulatory incentives to encourage clones to form.
[i]” We nearly did under the Clinton/Tip O’Neal years…”[/i]
Tip O’Neill retired in 1987, 6 years before Bill Clinton became president. … Maybe that was a typo-brain fart or maybe you call all fat white haired Speakers of the House Tip O’Neill?
[img]http://blogs.discovermagazine.com/gnxp/files/2011/12/220px-Newt_Gingrich_by_Gage_Skidmore_3.jpg[/img]
I do give Gingrich and Clinton together much of the credit for the nearly balanced budgets. But some of it was more luck than design. And if one did not have the other, it never would have happened.
The big keys to the balanced budgets of the late 1990s:
1. The extraordinary growth of the economy, due to the tech boom which began in the mid-1980s and turned highly profitable 10 years later. This caused naitonal income, and hence taxable income to go up dramatically starting around 1995.
2. The Clinton tax hikes of 1993 and the Bush tax hikes of 1992. In very strong contradiction to what some ideologues would predict–that higher tax rates stunt growth and the result is lower tax revenues–the tax hikes by Bush and Clinton resulted in huge government revenue gains, once the 1991-92 recession ended. I should point out: high tax rates can make investment much less enticing and thereby stifle it. But modest tax hikes will hardly have any effect on investing if we have a potentially hugely profitable new industry to invest in, which we did with computer hardware and software and later the internet. (Also, if you want low tax rates, then first cut the bleeping spending programs and cut the long-term liabilities where they are building up.)
3. Gingrich/Army/etc. If the Dems had retained power after 1994, they would likely have spent all the new money on new programs and more. The Republicans never really cut out any old spending. But once “the era of big government” was over, no new programs came on line. (Big government really returned in a big way with GW Bush: Iraq, Iraq, Farm subsidies, Iraq, Afghanistan, Iraq, Farmer welfare, Iraq, Medicare Part D, Iraq, etc. … and then very late in the Bush years, banks, banks, banks, banks … and Iraq.)
[i]”You mention that we need more doctors. I agree. How is that addressed with Obamacare as it floods offices with more people having access to free care?”[/i]
I heard on Fox News that Mr. Obama has a plan to import witch doctors from Africa?
[img]http://3.bp.blogspot.com/_HyyDHyAwI6k/SmiZb9cN1AI/AAAAAAAAF6k/VTpO_8OT9EY/s400/obama+witch+doctor+image.jpg[/img]
1. Enact Medical Liability Reform
2. Purchase Health Insurance across State Lines
3. Expand Health Savings Accounts
4, Ensure Access for Patients with Pre-Existing Conditions
You realize these four planks of the Jeff Boone/Republican/conservative health insurance plan would do practically nothing at all? Would hardly expand insurance coverage to the uninsured by even a tiny percentage? Would barely even affect the cost of health care (#1) and that #4, if enacted without actually expanding the pool of the covered, would vastly increase the cost of health insurance?
In other words, these warmed-over proposals are laughably short of achieving anything whatsoever?
The rest of the stuff you posted IN ALL CAPS has nothing to do with health care. So it is just conservative boilerplate.
How about some actual proposals that would cover any significant percentage of the uninsured?
This is one of my favorites: “[i]We will incentivize states to develop innovative programs that lower premiums…”[/i]
Do tell.
[i]That wasn’t right-wing ideology… that was general stupidity[/i]
So the fiscal policies that prevailed during [i]20 years of Republican presidencies[/i] were ‘stupidity’? And we should trust Republicans now, when the leading candidate has a completely unsustainable series of fiscal policy positions, to somehow — as you put it — ‘come to Jesus’?
[i]”1. Enact Medical Liability Reform … Would barely even affect the cost of health care …”[/i]
I think you are wrong, Don. I think eliminating medical liability would go a long, long way to reducing costs built into our system. Liberals (who are often overly influenced by the lawyer lobby who help fund the Democratic Party) tend to incorrectly look at the costs of medical liability. They add up the awards given out by lawsuits and the cost of insurance and note that these costs are only a fraction of overall medical costs. But the actual amounts awarded and of insurance are themselves only a fraction of the full medical liability costs that hamper our entire system.
If you want a real accounting for how much medical liability adds to the cost of the American system, add up the number of all expensive tests and procedures per patient here and subtract the number for a similar patient in Canada and multiply that by the total number of patients treated in the US system. That will be a very, very large number.
A quick note on procedures: In the US 32.8% of children are born by caesarian section. I don’t know the number in Canada, but I recall a cousin of mine who is an OB/GYN some years ago that it was one-fifth of the rate in the US.
My cousin said that before medical malpractice liabiliity became such a huge concern with regard to birth defects, doctors would very often counsel women to have natural births. Or rate of caesarians was then 5%.
But since the 1980s when John Edwards and his fellow shysters made a fortune suing doctors whose patients had babies with birth defects, doctors stopped that sort of counseling. She told me it is not the case that doctors advise women who don’t need a caesarian to have one. She said that when a woman requests one, they always give in to her wishes, even if it is not medically the best choice. Giving in takes aways the doctor’s liability.
Let me repeat a post I made in this thread earlier which explains how I think the threat of lawsuits adds to our costs:
Doctors in the US have a very strong incentive to order every possible test in order to avoid getting sued. So when an elderly patient is dying of cancer and will get no real benefit from an MRI series, her oncologist will normally order an MRI series, unless the patient (or her family) objects. Why would the doctor order the very expensive MRI? Because there is a chance that some ambulance chaser will contact the family of the patient, after she dies, and tell them, “Your doctor did not do everything to save your mother’s life. He should have ordered an MRI. It would have precisely located the tumor and maybe an operation then could have saved her. This is worth a lot of money in a lawsuit.” The family usually has no idea what is best for their relative who has cancer. They trust that the oncologist is doing what is best, so they agree to whatever tests he orders. And even though the doctor who does not order such an MRI series is medically and ethically right, if such a case makes it to a jury, there is a better than 50% chance that the knuckleheads who serve on juries will side with the dead woman’s family out of sympathy. This is how Sen. John Edwards became a multi-millionaire ambulance chaser. He specialized in b.s. lawsuits when children were born with birth defects that had no relation to bad medical practice. My example of the old lady with brain cancer is exactly what happened to my aunt. Fortunately, one of her sons is an MD and he told the oncologist, “No, we don’t want Rose to have an MRI now.” My cousin knew it was pointless.
As I mentioned to you recently, I had a hydrocelectomy two weeks ago. Part of the routine was to have me take an ultrasound. This is standard practice in the US for a hydrocele. But a hydrocele is easy to diagnose with a flashlight. That’s how they do it in Canada. They never give a man with a hydrocele an ultrasound. They don’t have to worry so much about ambulance chasers and moronic juries.
Just heard this on NPR this afternoon:
[quote]Does Medicaid Make People Healthier? ([url]http://www.npr.org/blogs/money/2012/07/03/155920847/does-medicaid-make-people-healthier[/url])
On the face of it, it seems like Medicaid would make people healthier, by giving them access to health care they wouldn’t otherwise be able to afford.
But there is a counterargument. It says that being on Medicaid is really worse for you than being uninsured, because it provides you with such low-quality health care.
The debate has raged for decades because every study has lacked a control group. There was no way for researchers to randomly assign people to either receive Medicaid or go without. The Oregon lottery allowed them to do just that.
Katherine Baicker, a professor of health economics at Harvard University, compared those who won the lottery, and those who entered but did not get covered.
Fifty thousand mail surveys and 750 in-person interviews later, they concluded that Medicaid did, in fact, make people healthier.[/quote]
Rich: I understand the principle of the impact malpractice cases can have on health costs. But quantifying that is daunting ([url]http://econ.duke.edu/uploads/assets/dje/2009/Johnson.pdf[/url]) and certainly not conclusive, and enacting ‘reform’ has consequences as well. The point is, malpractice reform is probably not a significant method for getting more uninsured people to have coverage or health care. Yet it is nearly always the first thing conservatives mention.
Conservatives and Republicans either don’t think lack of insurance is a problem, or they propose legislation that simply doesn’t address it. Denial and diversion, you might say.
[i]”The point is, malpractice reform is probably not a significant method for getting more uninsured people to have coverage or health care.”[/i]
It certainly won’t make insurance more affordable for people who have no money. But if a serious reform took away the incentives for all American doctors/hospitals to order unnecessary tests and to do medically unwise procedures, it would reduce the cost of healthcare in the US by around 10%, and that would reduce the price of health insurance and that would make health insurance affordable to some on the margins.
If it were up to me, we would get rid of our entire medical malpractice system. The idea of capping rewards is insufficient, though I am for it. The idea of getting rid of rewards for pain and suffering are insufficient, though I am for that, too. Even the smart idea (as they do almost everywhere but in the US) of making the loser pay the court costs and lawyer fees of the winning side is insufficient.
What would work best is if we adopted the French system. It’s not perfect but it is better than all other systems. The French have removed medical malpractice from their civil courts and out of the hands of idiots who we call jurors. In France, they use special commissions with experts to judge medical malpractice, based on medical science, not emotional b.s. They also have something in France where in cases that there is a bad medical outcome–such as a child born with a birth defect but it was not the fault of the doctor–they will compensate the family from a special fund set up for that sort of thing.
Not surprisingly, medical care in France is on the whole much better than it is in the United States.
Rich: [i]Tip O’Neill retired in 1987, 6 years before Bill Clinton became president. … Maybe that was a typo-brain fart or maybe you call all fat white haired Speakers of the House Tip O’Neill?[/i]
Ha! Now that was funny! I was running out the door typing fast and thinking slow. Yes, Gingrich. Major brain malfunction on my part.
[i]”But there is a counterargument. It says that being on Medicaid is really worse for you than being uninsured, because it provides you with such low-quality health care.”[/i]
And here we have the fingerprints of the liberal progressive machine marching toward a final goal of perfectly equal outcomes. How about this… if we screw up the health care system for all the non-Medicaid folk, maybe we can make it equal to the Medicaid folk and then we will all be satisfied… NOT.
Or, how about this… Medicaid is base care… it is not that great. So be motivated to earn enough to buy private insurance.
Medscape Ob/Gyn Compensation Report: 2012 Results
Jeff
“I asked you why not advocate for a Kaiser model”
With all due respect, I do not know where you got the idea that I have not advocated for the Kaiser model.
I have spent the past 25 years advocating for the Kaiser model at seminars, conferences, society meetings,
educational sessions, before student groups and at career seminars. This has led, until very recently, to a great deal of frustration, when the presentation of what I consider to be a far superior model of care was met with skepticism, derision and some cases frank contempt largely coming from those in the fee for service model who felt their incomes threatened by a model in which physicians were willing to work for less.
” I also do not get your ongoing demonization of profit.”
Perhaps you do not “get it” because that is not and has never been my position. I have no problem seeking as much profit as possible when we are discussing luxuries. If a designer wants to charge $ 3000.00 for this season’s woman’s jacket and can find buyers, I say have at it ! However, I do have a strong moral objection to people seeking to maximize their profits through exploiting another’s illness.
I believe that their are some products and services that should come to the individual automatically based on their membership in a group, be it a tribe, a state, or a nation. Amongst these are protection against attack,
food, water, clothing, housing, education and medical care. If the society will not see to the basic needs of its members it will inevitably be weakened.
” I reject your opinion that these and other insurance companies seek profit at the expense of patient well-being.”
Well, you can reject it all you like. But again, I have seen many, many cases while although less dramatic than the example provided by Don, are functionally the same. These are cases in which the insurer has collected from a well individual for years, and then declines to pay when the individual becomes ill. I would challenge you to provide another motive than profit for this action on the part of a company.
“You and others in the medical profession do not have exclusive ownership of the “we care banner”.
Brilliant use of the straw man argument. If you have read my posts, you would be aware that I have indicted doctors as much as any other group in the excesses of the fee for service model of care which promotes
unnecessary testing and procedures as a means of increasing physician compensation. This is one of the main reasons that throughout my career I have advocated against fee for service medicine and promoted a model in which physicians are salaried and there are only two ways to increase your total compensation:
1) Work more hours
2) Earn incentives for providing superior care by meeting pre established targets for preventive health care,
blood pressure, cholesterol and diabetic control and other measures proven to provide individual and
population benefit.
I have advocated consistently for the application of this model nationally. I have advocated for adoption of the Kaiser model of care, for universal coverage not dependent upon employment, for an integrated model of care in which one can choose ones own physician regardless of insurance or group membership, for a national patient records data base that would allow any provider in the country access to electronic records freely with patient permission in order to make care seamless whether your lasts tests were performed in the same office, or across the country.
The closest I have seen to the Kaiser model of care was actually provided by the Public Health Service which during my two years of service was actually years ahead of any private model including that of Kaiser in utilization of an electronic medical record. So much for the government messing things up.
I do not expect you to know about these aspects of medical care since you are not in the business of caring for patients. But I do think it would make for a richer discussion, if instead of trying to fit me snugly into your
characterization of what a liberal must think, you would actually consider the merits of what I am saying based on my background and experience, rather that prejudging based on what you have decided a “liberal” must believe.
medwoman,
Good to see your postings on preventative care and Kaiser.
I’m embaressed to say I hadn’t realized that Kaiser was non-profit; good to hear. My father and sister are both physicians, and each of them are also uncomfortable with the current healthcare system; particularly the insurance company and corporate for-profit aspects of healthcare.
My concern regarding preventative treatment (in a previous post of mine) is not so much with unethical doctors (it has always seemed to me most doctors have very high ethical/professional standards); but that the pointy-haired MBA boss might step between the doctor and patient; pressuring doctors on what treatments or procedures they should or should not provide. Good to hear this is not the case at Kaiser!
But if it is true that most patients will switch healthcare providers several times or more during their lifetime; it is still not clear to me what financial incentive the healthcare company has to provide long-term preventative care; since when the fruits of that preventative care are reaped by better health of the patient several years or more later; odds are by that time the patient will be with another health-care provider (even if the patient wanted to stay with Kaiser, for example, the patients employer might have a contract with a different provider).
By the way I was insured with Kaiser in Davis for a couple of years about 5 years ago and had a good experience with them; hope my next employer will have an option for employees to go with Kaiser!
Or how about adopting the ancient Chinese system of preventative healthcare?
The way I heard it; at the beginning of the year the community doctor was paid a certain fee by each family in the community. If someone in the family got sick that year; then not only was the doctor responsible for treating the patient, but he had to pay back to the patient’s family part (or all, if very ill) of the fee! That is, the doctor had failed in his responsibility to keep that patient healthy; and thus had to pay a penalty for it!
If the community stays healthy, the doctor gets to keep all his fees (and is also presumably less busy treating patients, though presumably he spends some time and effort with preventative care!)
Speaking of Chinese medical care; how about a pic joke (let’s call it Confucian):
Question: When is Chinese dental time?
Answer: 2:30 (hint: say it out loud)
jimt
[quote]it is still not clear to me what financial incentive the healthcare company has to provide long-term preventative care;[/quote]
Many of my patients have been with me since I arrived 21 years ago.
Being only partially facetious, one answer is because they keep coming back. It is not unusual for my patients to have Kaiser for a few years, go off when their employer doesn’t offer Kaiser for a couple of years or they change jobs, and then come back. Just thinking about the uncertainty and inconvenience that causes some patients is enough to make me advocate for uncoupling health care from employment, but I digress.
A couple of relatively short term and one very long term examples from my own field to illustrate:
1) Obstetric care situation #1 – the couple who are not yet financially situated to have a child. Her contraception is a covered benefit. She does not get pregnant until financially stable and the pregnancy is desired. The couple have acted responsibly and the medical group does not have to provide the very expensive care involved in the pregnancy package we offer ( all inclusive ) at a time when the couple did not desire pregnancy.
2) Obstetric care situation #2 – when she does conceive, all care is included usually from 8 weeks on. Routine early onset obstetric care has been shown to decrease one of the most expensive outcomes in all of medicine,
namely preterm birth with it’s lifetime. sometimes severely disabling consequences for not only the baby and family, but the medical group as well to say nothing of the entire society.
3) Gyn care situation #1 – Cervical cancer screening – patient gets regular Pap smears, is diagnosed with
precancerous condition that can be treated with a simple office procedure rather than a hysterectomy if caught
possibly a few years later. Procedure is discussed between patient and doctor only, no pre approval needed thus cutting down on administrative costs.
4) Gyn care situation #2 – Patient presents for routine gyn care. Gyn doc notes she has not been to see her
Family Practitioner for years and that the patient has risk factors for diabetes. Orders all the appropriate labs rather than sending the patient to the other doc. Finds pre diabetes, sends note with labs electronically to FP
who takes out of electronic in box same day and arranges preventive program directly with patient on line.
Patient takes it seriously, enrolls in program, follows dietary and exercise recommendations and does not progress to the much more expensive condition of diabetes with its multiple complications.
Of course, these are best case scenarios. But I see it every day.
jimt
[quote]at the beginning of the year the community doctor was paid a certain fee by each family in the community.[/quote]
In a way, with the exception of copays, this is the basic prepaid Kaiser coverage model. In recent years, Kaiser has added additional insurance plans, but the one that I promote is essentially what you wrote. The patient or insurer pays Kaiser a given amount of money and Kaiser provides services as needed for that patient or patients for that year. That is how our system worked for the first 15 or so years that I was with the group.
I strongly recommend it. It definitely encourages us to “live within our means” and for those who think it would mean that they would not get the care they need, I can honestly say that I was never pressured to not provide the best care available for any patient. I can also say that with the exception of two experimental procedures
which ended up being approved after a brief telephone conversation, I have never had to get pre approval or justify my plan of care.
[i]”With all due respect, I do not know where you got the idea that I have not advocated for the Kaiser model.”[/i]
medwoman, It was a previous post where you advocated for Obamacare. That is not the Kaiser model. Thanks for explaining some of the resistance you have received. That is not surprising. I think Kaiser’s model will catch on. It would catch on more with incentives from the government.
Don asked a question about how the government can provide incentives to get private providers and carriers to reduce their costs. There is that principle “what gets measured gets done”. I am a fan of public-private partnerships. This is what India is moving to because their government system is failing. In my industry our federal regulator sets performance benchmarks and requires reporting. My company has had our semi-annual exam waived for the last three years because of our high scores. Note that we have to pay for these exams. There are other incentives based on certain performance measures for programs and enhancements to programs that allow us to make more money. Using a sports analogy, I would rather have the government setting rules and officiating, than coming onto the field to play the game. Government is generally lousy at playing the game.
[i]”But I do think it would make for a richer discussion, if instead of trying to fit me snugly into your characterization of what a liberal must think, you would actually consider the merits of what I am saying based on my background and experience, rather that prejudging based on what you have decided a “liberal” must believe.”[/i]
Sorry to get partisan on this, but with little exception the opinion in this country seems to be divided down our ideological lines. It is a political fight at the highest level. I do respect your opinion… even more so because you are a doctor.
“with little exception the opinion in this country seems to be divided down our ideological lines. “
I agree, and perceive this as a major impediment to any kind of improvement in our society. When we essentially stop listening to the ideas of someone we have pegged as a member of the opposition, we lose the ability to consider any alternative outside our own comfort zone.
Perhaps it is at least partially because of my medical training that I tend to look at the idea itself rather than its source before coming to a conclusion. However, I freely admit to my bias, but I keep working on it and want to be more like our local pragmatist, Rich. When I grow up.
[i]Don asked a question about how the government can provide incentives to get private providers and carriers to reduce their costs.[/i]
No, this was what I was responding to:
[i] “We will incentivize [b]states[/b] to develop innovative programs that lower premiums…”[/i]
How do you propose that the federal government incentivize states? And how do you think such top-down ‘incentivization’ will yield better health outcomes and broader health care coverage?
This sounds like a health-care version of NCLB to me.
With the amount of mobility of the population from one state to another, I simply do not see the advantage of state incentivized programs over a national system. What I would like to see is a system that meets the following criteria:
1) universal coverage
2) independent of employment
3) patient choice of provider limited only by licensing and credentialing
4) electronic medical record with provider access limited only by patient permission
5) incentives for evidence based best practices and for meeting natioally recognized quality standards
6) salaried physicians with incentives to provide the least invasive, least expensive care compatible with the patients condition
Kaiser, imperfect as it is,is probably as close to this standard as we have right now.
I support the ACA not because I believe it is ideal, but because I believe that getting some legislation on the books has been critical to changing the conversation about the fact that our current lack of a “system” for the provision of health care is costing us enormously by weakening both individuals who cannot access care and our society as a whole. I believe in the ACA as a starting point because I believe we can do better.
A few brief thoughts before I return to celebrating our Independence from those scandalous Brits …
Jeff Boone has said he likes the Kaiser model, where there is (what economists call) vertical integration. I very much like this model, too.
In a vertically integrated provider, the insurance company is also the hospital company and the medical clinic and the radiological clinic and the pharmacist and it includes every possible medical specialist and it includes device sellers and technicians (such as optometrists and audiologists, etc.) and every doctor, nurse and other type of health professional works under that one label, that one umbrella.
Kaiser, almost uniquely among such companies, is also a court, where it compels its customers/patients into mandatory arbitration ([url]http://en.wikipedia.org/wiki/Kaiser_Permanente#Mandatory_arbitration[/url]) before going to the civil courts for questions of malpractice. …
Other than the fact that Kaiser has to operate in the rubric of the American system (our tax laws, our malpractice laws, our exorbitant drug pricing, our excessive testing, etc.), KP operates quite a lot like the integrated British medical system or similar set-ups in many other European countries.
You might think that the major difference is that Kaiser is private and has to compete for business. But keep in mind that even in England, the government system operates with limited resources and its doctors and nurses are free to leave and everyone middle class and above has the choice to go outside the system for private health care. In all large metropolitan areas of England, there is far more “competition” for patients than there is in small metropolitan areas of the United States where they have at most one hospital within 50 miles and not too many specialists or other providers to choose from.
Ideally, I would like to see the US government incentivize a vertical integration of all medical service in the US. (This could easily be done by our tax laws, which created our employment-based medical insurance system in the first place.) However, it is worth pointing out that when we have vertical integration, we inevitably will have less competition. A metro area like Sacramento might have three systems to choose from (say KP, Sutter and Dignity). It is already the case that cities like Davis and Woodland have hospitals which are monopolists. That would not change if we had 3 Kaiser-like operations.
With vertical integration, there is a much larger financial barrier to entry. In order to make it work, you need a huge volume of patients. To get a huge volume of patients, you need to own a lot of clinics, hospitals, etc. It’s just not the case that you can become a Kaiser-like company overnight.
So what we would get (in metro areas of Sacramento’s size) would be a very limited amount of price competition in an oligopolistic model. In the much larger Bay Area or LA/Orange County, there would be more vigorous competition. But in small metro areas–say the size of Reno or Fresno or Des Moines–vertical integration would likely mean (due to the necessities of economies of scale) a monopolist: either Kaiser or Sutter or whatever, but not two or three of them.
…. And thus, if the government did nothing to force down prices within those less than competitive markets, medical care would likely be more expensive and less satisfactory than it is, now.
Although I agree with most of Rich’s points, I disagree in that competition in the area of health care does not help hold down prices. Instead what it tends to do is to force them upwards as everyone tries to have the most modern, fanciest equipment and facilities to attract the patients who can pay more. Jeff illustrated this very well in his recent comment about visiting the Sacramento Kaiser facility and perceiving it as “Soviet style”.
Many people, correctly perceiving that it is old and not visually appealing, inaccurately interpret that to mean that their care will be inferior.
What this has led to in the greater Sacramento area is the construction of newer facilities by each of the major groups who then compete against each other instead of doing what would obviously be the most effective by sharing facilities and developing shared centers of excellence, thus using everone’s equipment and facilities in the most cost effective manner possible.
[i]”I disagree in that competition in the area of health care does not help hold down prices.”[/i]
I need to parse that sentence. If you disagree that competition does not hold down prices, then you would agree that competition does hold down prices. Or did you mean the reverse of what you said?
[i]”Instead what it tends to do is to force them upwards as everyone tries to have the most modern, fanciest equipment and facilities to attract the patients who can pay more.”[/i]
If there were perfect competition–and as I tried to explain above that there will not be perfect competition if we had a model where everyone was in a KP–like system–then there would be some market stratification: Some companies would try to serve the premium market. Call them the Mercedes or Lexus hospitals. Most would try to meet the needs of the vast middle: the Toyotas and Fords. And there would be some which targetted the most price sensitive: the Yugos.
However, there can never be perfect competition (or anything very close to it) in such a market. Among the many reasons, beyond barriers to entry and economies of scale, is the fact that consumers of medicine will always lack perfect information, and very often they have to make quick calls based on almost no information when they are suddenly ill. Without a lot of personal experience with them, they won’t be able to really properly distinguish between the capabilities of one doctor or another, or know if one fancy testing machine is worth the price or not. Consumers of medicine almost always know too little to make really rational decisions. (It is for that reason that credentialling of doctors, nurses, etc. is a great benefit to patients.)
And given all that, the medical market won’t ever look like the stratified car market. It’s more likely to have very few competitors, all of whom look about the same as the others.
You’re still wrong if you think that private hospital companies won’t take whatever measures they can to try to control costs. They won’t buy fancy machinery if it does not return more to them in the long run than the machines cost. But you are right that selling the line “we have the best machines” might be an irrational attraction to uninformed consumers.
[i]”What this has led to in the greater Sacramento area is the construction of newer facilities by each of the major groups who then compete against each other instead of doing what would obviously be the most effective by sharing facilities and developing shared centers of excellence, thus using everone’s equipment and facilities in the most cost effective manner possible.”[/i]
The “ideal” you describe would be achieved with a government-owned monopoly, as they have in Britain.
[quote]Chris Collins: ‘People Now Don’t Die From Prostate Cancer, Breast Cancer’ ([url]http://www.huffingtonpost.com/2012/07/03/chris-collins-cancer_n_1647196.html[/url])
GOP congressional candidate Chris Collins knows health care is expensive these days, but he argues it’s for good reason: People are no longer dying from deadly forms of cancer.
“People now don’t die from prostate cancer, breast cancer and some of the other things,” he told The Batavian in an interview that was flagged Tuesday by City & State NY. Collins was discussing his desire to repeal Obamacare.
“The fact of the matter is, our healthcare today is so much better, we’re living so much longer, because of innovations in drug development, surgical procedures, stents, implantable cardiac defibrillators, neural stimulators — they didn’t exist 10 years ago,” he continued. “The increase in cost is not because doctors are making a lot more money. It’s what you can get for healthcare, extending your life and curing diseases.”
In fact, a lot of people do die from breast cancer and prostate cancer, despite advances in treatment. An estimated 577,190 people in the United States will die from cancer this year, including about 39,920 deaths from breast cancer and 28,170 from prostate cancer, according to the American Cancer Society.
The organization also points out that uninsured people are less likely to detect cancer in its early stages, making it far more expensive to treat.[/quote]
Rifs
I knew you would catch that. Parse away ! I also knew that you would get to the essence:
[quote]The “ideal” you describe would be achieved with a government-owned monopoly, as they have in Britain.[/quote] Correct! We have had approximately 225 years to provide quality care to all of our citizens through the “free market” and haven’t done so. I would say it’s time to try a different approach. Especially since others are doing statistically much better as you and others have pointed out.
[i]”Correct! We have had approximately 225 years to provide quality care to all of our citizens through the “free market” and haven’t done so.”[/i]
I will neither attack or defend the free market in medicine here. However, it’s not the case that we have a free market*.
For one thing, our system was created out of the government’s tax code. Employer paid for health insurance is based on the IRS notion that income in the form of a medical premium is not taxable income to a worker; and that a business, but not an individual can deduct from income the expense of buying health insurance.
That the government decided we would have a third-party payer insurance system removes the most important mechanism that makes any free market work: price information from the consumer’s perspective. Most of us don’t pay even 20% of the cost of our insurance, and most of us have no idea how much the medical procedures we require cost. Most of us have no incentive whatsoever in any of our care to choose a lower-cost alternative. Medicine may be a market for the sellers. But it is not one for most consumers. (The real exception to this is with things like cosmetic surgery or “alternative” sh!t which is not covered by insurance.)
Moreover, about half of the money that is spent on healthcare in the US–prior to Obamacare–is government spending. It is closer to two-thirds if you consider the subsidies that grow out of the tax code.
Additionally, the US government and state agencies play a huge role when it comes to regulating medicine, medical devices, pharmaceuticals and even various procedures.
On top of that, our intellectual property rights’ laws (patents, trademarks, etc.) have a large role in deciding how much profit there is in drugs and how long those profits will last. These are not “free market” profits. They are government policy determined profits.
And if all that were not enough, we don’t have a free market judicial system. The civil courts play a big role in how medicine is practiced here (as we discussed earlier) when it comes to malpractice suits, standards, awards, lawyer compensation, etc. Some US states are particularly lucrative to file and win lawsuits; others less so. Whenever there is some sort of class-action lawsuit, it will be filed in a state where the laws are especially friendly to the plaintiffs bar and allow the biggest rewards. These court decisions greatly affect the cost and profits of medical care, drugs, devices, etc.
Finally, to repeat what I said above: a free market is based on free consumers who have full access to information** making free decisions with their own money. That simply can never happen in a medical marketplace, though it could be much closer to a free market than what we have.
*I am perplexed by conservatives & libertarians who go to such lengths to justify what we do have. They seem to think the US system is a free market when it is very far from that.
**Free access to information is not the same as having a medical degree. An intelligent consumer could in theory rely on outside objective experts, who, based on the experience of many other consumers are deemed reliable. The problem is really that even if this sort of information market existed–notice that it does not–what good would it do the rural or small metro consumer who does not have a choice of hospitals or a choice of brain surgeons? And what happens when you are in a car accident and in serious trauma? Are you going to stop the ambulance to call up your expert service to find out which ER you want to be taken to … as your heart stops beating?
As a health consumer, I barely make the important decisions about health care.
Each child had a serious pediatric emergency. In neither case did we decide which hospital the child was taken to. The pediatrician did. I couldn’t exactly shop around to see where I could get the best deal on infant ICU. The decisions about my son’s multiple ankle break were made entirely by the doctors on site; all we did was say ‘yes’. The bills could have been $1000 or $100,000, and would have made just as much sense to us in either case (the bill for the ankle break came to $17,000).
We didn’t even really have much choice as to where they were born. And our decision to use a midwife for the first one, conducted at Sutter Davis, cost an extra $1000 because they required an extra nurse be standing by. She was a nice lady, but she did nothing of consequence. Their decision, enforced at the hospital while my wife was in labor. So we couldn’t exactly say ‘no, sorry, we’ll go to another hospital’.
Even if you’re an informed consumer, you’re not the decision-maker in most cases. And when you buy insurance, you simply can’t make an informed decision about the likely events that will occur. Lots of kids break bones. But you wouldn’t expect a $17,000 bill for it, so that 80/20 plan suddenly doesn’t seem so desirable.
Rich
You are right of course. My use of the words “free market” was erroneous because it of course only applies to the “fee for service” portion of health care provision and does not reflect where the money actually comes from.
I also feel that Don’s point combined with your comments about the lack of time and knowledge to make important health care decisions does make health care unique. What I am actually providing when I sit down with my patients is knowledge acquired over many, many years and hopefully the ability to translate that into language that makes sense to them so they can make an informed decision. A small portion of my time is spent doing procedures opand surgeries that require technical skill.
7/2/12:
[quote]Romney agrees with Obama on key part of healthcare law ([url]http://news.yahoo.com/romney-agrees-obama-key-part-healthcare-law-205103516–business.html[/url])
Campaign spokesman Eric Fehrnstrom acknowledged that Romney does not see the healthcare penalty as a tax, and instead considers it a penalty.[/quote]
7/4/12:
[quote]Mitt Romney calls individual mandate a tax ([url]http://news.yahoo.com/romney-calls-individual-mandate-tax-contradicts-top-aide-174634430–abc-news-politics.html[/url])
“The majority of the court said it is a tax, and therefore it is a tax,” Romney said in an interview with CBS Wednesday, citing the Supreme Court’s health law ruling last week that the individual mandate fell under the federal government’s authority to levy taxes and was therefore constitutional.
….
As governor of Massachusetts, Romney championed a health care law that imposed a mandate similar to that in Obama’s health care law. Romney has insisted that the mandate he supported in Massachusetts was good for the state, but would not be good for the country.[/quote]
Thanks for all the great dialog on this important subject. I don’t disagree with Rich’s post above that health care is not a free market industry. However, a few points…
1. No industry is 100% free market. The government has its tenacles in just about ever bit of commerce.
2. Many conservatives and libertarians think there is too much government in everything we do – including commerce, and especially including health care.
3. Much of the high costs of health care are related to governent regulations and our government protected tort system. Conservatives and libertarians believe we have reached a point that we need significant reform (reduction) of these things and not more of the same which Obamacare provides. We believe that the exploitation of all the opportunities of free-market competition will result in a lower-cost and higher quality product than we can achieve by any other means.
Don’s points and examples about a lack of ability to use choice and discretion when requiring healthcare service, is, in my opinion, wrong and part of the problem. Certainly health care is different than auto repair; but there are enough similarities to make a constrast. First, you purchase auto insurance and there are many companies competing for your business. Next, you can chose the body shop and mechanic to fix your car. You might not know a thing about cars and end up paying more and getting crappy service; however, most of us see this as at least partially a responsibility of the consumer to be educated enough to make good choices.
After my mother was diagnosed with a grade-4 brain tumor her family began a journey into what it takes for extreme patient advocacy. We were researching everything we could get our hands on, and working all of our connections to get her into see the service providers with the best reputation. We fired several doctors during her two years of care before we lost her. The entire experience was eye-opening to me in terms of how screwed up the entire system was/is. My business brain was spinning noting the lack of advocacy and customer service.
I find Don’s comments very interesting because our opinions on health care and education seem to cross. He has previouly commnented that parents need to be involved working with the education system to extract a quality education outcome… but he doesn’t seem to expect that same level of decision capability for his kid’s health care. My point was/is that the education system should do more because there are many parents that lack the capacity to be capable advocates. I think there is a lack of advocacy, customer service and choice in both of these systems. They are overly beaurcratic and lack the customer-focus that exists in well-run private business models.
Check this to see an example of how private free enterprise can help improve choice and drive down costs… [url]www.bidonhealth.com[/url]. I bet there are government officials and trail laywers itching to put this out of business.
wdf1: Maybe Romney’s confusion over the question over the madate being a tax or not has to do with the fact that his President also seems to be confused about it. First Obama demanded that it was not a tax. Then his administration argued to SCOTUS that is was a tax. Now he is back to saying it is not a tax.
[i]” First, [b]you purchase[/b] auto insurance and there are many companies competing for your business.”[/i]
One big difference between auto insurance and medical insurance is that with the former “you” purchase it and with the latter, due to the tax laws, you normally don’t purchase it, even if you have a choice between two or three plans.
So if what conservatives really want is a free market–or much closer to a free market–the very first step has to be to change the tax code, so that employers would no longer be able to deduct from their income the amount they spend on the health insurance for their employees, so that if an employee received a healthcare insurance benefit from his job, that income would be taxable income, and that even if an individual bought health insurance, he would have to pay the full amount.
Yet I have never heard any conservatives call for this primary change to a market mechanism. Maybe I am just not listening to enough Rush Limbaugh or his clones or Fox News or whatever. So if it is the case that the first step the right-wingers are calling for is to reverse the tax laws which created employer-paid health insurance, let me know that I am wrong (and please show me your source for that).
The second most obvious change that would make our system much more of a free market would be to get rid of the FDA and all drug and medical device regulations and to no longer have government credentialling of doctors or nurses or procedures. I frankly have heard libertarians call for this sort of thing. But I don’t remember any Republican thinkers or elected officials who spout a “free market” line really calling for a free market in medicine where patients could choose what drugs they want to take and anyone could call himself a doctor.
But let’s just say conservatives really did want a free market in medicine and they did accomplish the changes in how medicine is paid for (by reversing the tax laws) and then they deregulated the activities and options of the buyers and sellers. You think that would result in better health outcomes? You think in a country where 50 percent of the population is fat and cannot figure out for themselves how to eat a proper diet, the typical American idiot is going to be able to make wise decisions in a deregulated healthcare market? You think your average American is that much smarter than Americans were prior to the Pure Food & Drug Act when every snake-oil salesman made a living hyping up crud which did more harm than good?
Jeff, I had ZERO say in which emergency room or infant ICU my kids went to. And if the auto is in bad enough shape, you just declare it totaled and buy a new one. And as Rich has pointed out, there is nowhere near the choice in health care that you have in any other industry (especially auto repair!).
“.[i]..many parents that lack the capacity to be capable advocates….?”[/i]
Have you ever dealt with a pediatric emergency, Jeff?
“Hold on, honey, I know your ankle is broken in three places, but I have to call around to see where I can get the best deal on fixing it.”
“Hi, my daughter isn’t breathing. What are your rates for infant ICU?”
When your kids were born, did you have a choice of hospitals? We didn’t.
Bottom line again, Jeff: what do you and Republicans propose to do to get 45 million people insured? What do you propose to do to get 20 million underinsured people better health care. Nothing. You don’t think it’s a problem and you propose measures that accomplish nothing. We don’t even agree on the problem, so I don’t see how we can agree on any of the solutions.
[i]Then his administration argued to SCOTUS that is was a tax.[/i]
The Supreme Court ruled that a tomato is a vegetable. That was based on the tax issue involved in importing tomatoes in the early 20th century. For tax purposes, it was a vegetable because that is how tomatoes are used; they aren’t used like fruit (which were taxed higher at import).
Every botanist knows that a tomato is a fruit (technically, it is a berry). But the Supreme Court ruled that it is a vegetable for tax purposes.
The Supreme Court ruled that the mandate is a tax for constitutional purposes. Actually, Justice Roberts argued that; I don’t know if the majority agreed with him on that specific point.
The Supremes are neither botanists nor semanticists. They decide points of constitutional law.
If Romney says it is a tax, then so is what he did in Massachusetts.
Rich: [i]”So if what conservatives really want is a free market–or much closer to a free market–the very first step has to be to change the tax code”[/i]
Like I wrote, we don’t have pure free markets in anything. I am not advocating for 100% free markets in healthcare. What I want is for the government to change its game to see its role as partnering with private industry that provides the direct services, and government provides service to the providers.
[i]”The Supreme Court ruled that the mandate is a tax for constitutional purposes.”[/i]
Don, you are conveniently ignoring the fact that this is what the Obama administration argued. [url]http://washingtonexaminer.com/obama-lawyer-mandate-functions-as-a-tax-law/article/2501375[/url]
Don: [i]”Have you ever dealt with a pediatric emergency, Jeff?”[/i]
Absolutely, and I wish someone had taken care of my family as good as Vanderhamm Goodyear takes care of them when we have care trouble. I understand that there is little choice… that is a problem that Obamacare will exacerbate. I also get that health care emergencies are different than auto emergencies in that we generally do not have the luxury of time for making a choice. This is why we should demand excellence from all providers so that our emergencies have a better chance of being handled well.
Rich: [i]”So if what conservatives really want is a free market–or much closer to a free market–the very first step has to be to change the tax code.” [/i]
Jeff: [i]”Like I wrote, we don’t have pure free markets in anything. I am not advocating for 100% free markets in healthcare.”[/i]
Why don’t you want a market in healthcare which is more like the auto insurance market, the industry you compared it to above?
Jeff: [i]”What I want is for the government to change its game to see its role as partnering with private industry that provides the direct services, and government provides service to the providers.”[/i]
Forgive me, but that sentence is indecipherable.
Moreover, since you compare auto insurance to health insurance, would you also like to see government partner with Mercury, GEICO and All-State and various repair shops in such a way that GEICO and Meidas provide the direct services, and government provides services to the auto mechanics and the insurers?
And since you skipped over the hard question, let me ask it again: Why are you not calling for a change in our tax laws that would get rid of employer-based (hence third party) insurance purchases, and thus a return to our pre-WW2 system of having consumers of healthcare buying their own health insurance plans?
Rich: “GEICO and [u]Meidas[/u] provide the direct services”
Make that Midas, not Meidas.
JB: [i]Maybe Romney’s confusion over the question…has to do with the fact that his President also seems to be confused about it.[/i]
It’s okay for Romney to be confused over it because the President is confused over it, according to your narrative? That seems to be pissing off conservatives:
Wall Street Journal, 7/5/12: Romney’s Tax Confusion: The candidate’s response on the ObamaCare mandate reveals larger campaign problems. ([url]http://online.wsj.com/article/SB10001424052702304141204577506652734793044.html[/url])
Jeff: [i]”(The Supreme Court decision) sticks Obama with largest middleclass tax hike in history.”[/i]
I had no idea where this bombast came from until I found out reading PolitiFact that it was a tall tale being spun by Rush Limbaugh. Mr. Limbaugh literally said “it is the biggest tax increase in the history of the world.”
I’d bet everything I own and every dollar I will make in the next 10 years that Rush Limbaugh knows far less about history than I know, and I have no history degree. (I think Limbaugh majored in gourmand science ([url]http://dictionary.reference.com/browse/gourmand[/url]) at the University of Missouri, IHOP.)
Sadly, Limbaugh combines ignorance with hubris, so he just does not give a f&*# when he tells lies or gets facts wrong and his dittoheads lap it up as if Limbaugh is credible.
Yet I also must concede that I was unaware of all the various taxes inside the ACA. I had thought the only tax increase was the one in the individual mandate. That amounts to $27 billion over 10 years, and thus it is nowhere near “the biggest tax increase in the history of the world.”
Here are all the taxes being raised by the ACA ([url]http://www.tampabay.com/news/politics/stateroundup/article1237768.ece[/url]), accordint to “the Joint Committee on Taxation, a nonpartisan committee of Congress with a professional staff of economists, attorneys and accountants:” [quote] • Starting in 2013, Medicare payroll taxes increase 0.9 percentage points for people with incomes over $200,000 ($250,000 for couples filing jointly). Also, people at this income level would pay a new 3.8 percent tax on investment income. The 10-year cost: $210.2 billion. [/quote] Those are very high income earners compared with “the middle class” that Jeff said were paying for Obamacare. [quote] • Starting in 2018, a new 40 percent excise tax on high-cost health plans, so-called Cadillac plans (over $10,200 for individuals, $27,500 for families), kicks in. That’s expected to bring the government a total of $32 billion in 2018 and 2019. [/quote] I would bet very, very few people in the private sector, other than a few executives get “Cadillac plans.” However, it would not surprise me if this tax mostly hits public sector employees.
[quote] • Starting in 2011, a new fee for pharmaceutical manufacturers and importers began. It is expected to raise $27 billion over 10 years. [/quote] This tax probably does hit the middle class, and it will be hidden, but paid for through higher systemic costs. [quote] • Starting in 2013, a 2.3 percent excise tax on manufacturers and importers of certain medical devices starts. The 10-year total: $20 billion. [/quote] Again, this kind of hidden tax will hit everyone to some extent. [quote] • Starting in 2014, a new annual fee on health insurance providers begins. Total estimated 10-year revenue: $60.1 billion. [/quote] Hidden tax, all will pay. [quote] • Starting in 2013, the floor on medical expense deductions on itemized income tax returns will be raised from 7.5 percent to 10 percent of income. That’s expected to bring in $15.2 billion over the next 10 years. [/quote] About 95% of the benefit of itemizing deductions goes to people who are in the top 5% of income earners. So this will hardly touch the middle class and will affect mostly the wealthy. [quote] • Starting in 2011, a 10 percent excise tax on indoor tanning services kicked in. It is expected to bring in $2.7 billion over the next 10 years. [/quote] This is an idiot tax. Most of the money will be paid for by the morons on The Jersey Shore. [quote] There also is money in the law going the other way. The plan includes government money, in the form of tax credits, to subsidize the cost of health insurance for lower-income people who don’t get insurance through their employer. And there is a tax cut for some very small businesses that allows them to write off a portion of the cost of providing insurance to their employees. [/quote] Hard to figure that what Limbaugh called the world’s biggest tax increase effectively cuts taxes for some lower-income people. Or maybe in Limbaugh’s mind these folks don’t count? [quote] Combined with various other revenue-generating provisions, the Joint Committee on Taxation estimates the health law will bring in more than $437.8 billion by 2019. (The nonpartisan Congressional Budget Office estimated $525 billion.) [/quote] Various analysts peg this as the 6th largest US tax increase since 1940. In real dollars, it is much smaller than Reagan’s tax increase in 1982. But don’t bother to tell those who pray at the House of Limbaugh that fact.
Jeff: [i]”(The Supreme Court decision) sticks Obama with largest middleclass tax hike in history.”[/i]
That got a “pants on fire” rating Politifact.com.
[img]http://static.politifact.com.s3.amazonaws.com/rulings/tom-pantsonfire.gif[/img]
Rich
[quote]Hard to figure that what Limbaugh called the world’s biggest tax increase effectively cuts taxes for some lower-income people. Or maybe in Limbaugh’s mind these folks don’t count?[/quote]
I think this may be closer to the truth than some would like to admit. I gained some new insight into this way of framing reality during an interview with Ayn Rand that I watched about a week ago. She stated outright that
she did not believe that “the weak” were worthy of love. I can only suppose that she also did not believe that they were worthy of respect or consideration. It would seem to me that the cavalier disregard for those who have not achieved the same degree of wealth or power in our society by those at the top would be a manifestation of this particular disdain for anyone who has managed to acquire less. In other words the establishment and maintenance of an American caste system based on ruthless acquisition where any attempt to provide equal opportunity is seen as a handout to the “weak”.
Rich: [i]”Why don’t you want a market in healthcare which is more like the auto insurance market, the industry you compared it to above?”[/i]
I do want it more like. Certainly though, as Don points out, people are not cars and we won’t tolerate too many mistakes for doctors making the equivalent of mechanical errors. It might work well enough if the market was highly tuned with quick response to high customer expectations. A good example of this is the restaurant market in New York city. It is hard to get a bad meal in Manhattan because New Yorkers demand top quality and bad restaurants don’t survive. However, as you point out the barriers to entry for healthcare business are significant. Much more so that for auto insurance, auto repair and food service.
As you know, pure free market capitalism is one that requires creative destruction. Consumers benefit from the competition, but must tolerate the lag for bad operators to suffer the consequences of their losing ways. We won’t tolerate this lag very well, hence we are going to need a level of government oversight to minimize it.
[i]”Jeff: “What I want is for the government to change its game to see its role as partnering with private industry that provides the direct services, and government provides service to the providers.”
Forgive me, but that sentence is indecipherable.[/i]
Yes, it was poorly written. The point I was trying to make was that we are often better off having government outsource direct consumer services to private industry and and then focus on partnering with private industry to help provide the best service possible. This really starts with a change in mindset which appears to be connected to ideological views. Folks with left-leaning political views tend to think of social problem solving as government providing direct service to end users. Righties tend to think we are better off having private business provide more direct services to end users. I agree with the latter, but augmented with a refocus of government as a partner with these private service providers… of which oversight and regulation are a subset.
In my industry, 25 years ago SBA certified private companies to provide small business loans to end users because the agency was not doing a good enough job with a centralized approach. SBA is our partner (they are our overseer and regulator too). We share the same mission. I think this model should be replicated in healthcare, education… just about anything were we as a society require services.
Rich, you do know that Rush Limbaugh is an entertainer. His comments should be taken as seriously as Bill Maher’s. However, I will stop using the point that Obama care is the largest tax increase to the middle class… I will just say that it is a very large tax increase to the middle class.
Customer satisfaction scores, private vs. public:
[img]http://davismerchants.org/vanguard/healthsatisfaction.png[/img]
Don, The satisfaction level of VHA customers is noteable. However, before 1990 it was a mess. Remember the Tom Cruise movie “Born on the Forth of July”?
[quote]So, it may have been politics as usual that kept the floundering veterans health-care system going. Yet behind the scenes, a few key players within the VHA had begun to look at ways in which the system might heal itself. Chief among them was Kenneth W. Kizer, who in 1994 had become VHA’s undersecretary for health, or, in effect, the system’s CEO.
A physician trained in emergency medicine and public health, Kizer was an outsider who immediately started upending the VHA’s entrenched bureaucracy. He oversaw a radical downsizing and decentralization of management power, implemented pay-for-performance contracts with top executives, and won the right to fire incompetent doctors. He and his team also began to transform the VHA from an acute care, hospital-based system into one that put far more resources into primary care and outpatient services for the growing number of aging veterans beset by chronic conditions.
By 1998, Kizer’s shake-up of the VHA’s operating system was already earning him management guru status in an era in which management gurus were practically demigods. His story appeared that year in a book titled Straight from the CEO: The World’s Top Business Leaders Reveal Ideas That Every Manager Can Use published by Price Waterhouse and Simon & Schuster. Yet the most dramatic transformation of the VHA didn’t just involve such trendy, 1990s ideas as downsizing and reengineering. It also involved an obsession with systematically improving quality and safety that to this day is still largely lacking throughout the rest of the private health-care system.[/quote]
Part of the reason this worked is that the VA is a closed loop system with leaders able to make difficult management decisions without a public cry-fest ensuing. This is the benefit a private-sector business has. However, if we were to adopt the VHA model for the general public it would look like the system before 1990 but WITHOUT the ability to have a CEO champion lead it to re-engineered success.
I think it is a losing cause to make a case that government service to direct consumers results in higher customer satisfaction. Private-sector business competing in the same industry ALWAYS wins. Just ask the USPS.
[i]I think it is a losing cause to make a case that government service to direct consumers results in higher customer satisfaction.[/i]
Um, it is a losing cause to [i]show you[/i], as I just did, that a government service to direct consumers [i]has[/i] higher consumer satisfaction? Because [i]I just did[/i] show that, and that has been the case for several years. So how is it ‘a losing cause’, Jeff? I’m definitely not understanding your logic.
The public health care system — the VA — [i]did what the private health care industry has been unable to do[/i] — with effective leadership it reinvented itself, and their customers are happier with it. So, I”m supposed to accept that[i] the facts[/i] I’ve presented to you are not true or are not an argument in favor of public health care because….what? Basically, the facts contradict your ideology, therefore you don’t think they’re real?
Ideology apparently trumps reality.
Here’s the reality you don’t seem to want to accept, Jeff. Two of the most effective, efficient, and customer-satisfying systems delivering health care in this country right now are a non-profit organization (Kaiser) and a public entity (the VA). Millions of Americans are very happy with their single-payer Medicare. Meanwhile, the private health-insurance industry delivering what you call the best [i]medical care[/i] in the world is one of the worst [i]delivery systems[/i] in the western world. Republicans have no plans to replace the ACA with anything that protects the millions of Americans who were left out, thrown out, or underinsured by that private health insurance industry. But they want to overturn the ACA as their top policy priority.
Why should we wait for the health insurance industry to reinvent itself? There’s no profit in reinvention, so they won’t do it. As with so many things, they have to be forced to change by federal law, or just be left in the dust by federal programs. I, for one, wouldn’t mourn the loss of the health insurance industry at all.
Jeff
[quote]However, if we were to adopt the VHA model for the general public it would look like the system before 1990 but WITHOUT the ability to have a CEO champion lead it to re-engineered success. [/quote]
Why would you make this assumption ? I have been involved with the two most efficient health care systems as cited by Don, the VA ( and the public health service), and a 26 year career with Kaiser. On the personal level, I can tell you that these systems with their prepaid care, salaried physicians, and emphasis on integrated care and prevention are vastly superior to what is provided in a transient ( depending on what your employer chooses to offer, if anything) non integrated fee for service model. Don’s numbers tell part of the story.
Another part of the story is offered by the comparison of cancer and cardiac survivor numbers in which Kaiser
is now far ahead of the fee for service world, not in my opinion because we have better doctors, but because we have an integrated system of delivery. I fail to see how the private insurance industry has added any value to health care in this country. Rather than have the fragmented public-private partnership that you are advocating, I would prefer to cut out the middlemen ( private insurers) entirely and provide universal coverage with single party payer. Don’s numbers clearly demonstrate that patient’s are also highly satisfied with health care delivered in this manner.
Don, yes you did show me one example of a government business resulting in higher customer satisfaction than its private alternatives. But I explained why the VHA is unique and not replicatable to the general public. The general public is chock full of competing special interests and polarized politics. The military, like a typical private company, does not have to answer to and respond to all this. Both can identify targets for service delivery and make decisions moving the organization to achieve the targets.
Supporters of Obamacare fail to consider that the US is different than the examples they use. We are not Canada. We are not like any of the European countries exemplified. We are the third most populated country in the world. We are the most diverse large county in the world. We are the most free and we have higher expectations for controlling our own lives. We also have higher and growing expectations for participatory democracy. We are fiesty and argumentative. We are a country of individualism not collectivism. We expect choice. We expect to be the best at everything.
Just look at how this plays out in California politics. It has to do with this large mass of people unwilling to give up and accept decisions for the greater good. California is ungovernable because leaders cannot and do not make effective decisions that provide for long-term health of the state. Turn over healthcare to the federal government and it will be a similar big mess. It will cost more while delivering lower service access and quality.
I am advocating for a uniquely American approach to improving our healthcare system; one that has the government accepting a different role partnering with private service providers. I don’t want the US to implement a Canadian or French system… I want the US to have the best system. In fact, we are already the best system in many measures. Did we look to replicate other countries for our space industry, or our tech industry? We need to break out of this mindset that we can only strive to do as good as a few other countries. I believe in American exceptionalism so why would I want to run backwards to be like some other country?
[i]”…yes you did show me one example of a government business resulting in higher customer satisfaction than its private alternatives. But I explained why the VHA is unique and not replicatable to the general public.”[/i]
No you didn’t. Not at all. There’s nothing unique about what the VA did. And as for delivery, medwoman spells it out: [i]”prepaid care, salaried physicians, and emphasis on integrated care and prevention…”[/i] How is the private health insurance industry going to implement that when their profit motive discourages it?
[i]”I believe in American exceptionalism so why would I want to run backwards to be like some other country?”[/i]
How is it backwards if they have better outcomes? Why would you call it American exceptionalism if it isn’t better by objective measures? Why are you so opposed to looking to other countries for ideas? As I said earlier, there are lots of different systems in Europe and elsewhere, blends of public and private health care delivery. Why assume we know best when statistics and objective data show otherwise? Just plain and simple jingoism?
[i]In fact, we are already the best system in many measures.[/i]
Really? You keep saying this, but I think it isn’t true. We’re absolutely, provably [i]not[/i] the best system for getting the most people health care in an efficient and effective manner.
Why do you keep defending a crappy system and refuse to look outside of our crappy model?
Don: With all due respect, your are all output and no input. I might as well be posting to a wall.
You have your mind made up. Frankly, I don’t remember many times you have conceded a single point. It is all glass half empty for you.
From my perspective you and others pushing for steps torward a single-payer healthcare system are going to be responsible for the biggest mess we can fear. I hope I am wrong, or I hope you fail, for my children’s sake.
I do have my mind made up that Republicans and conservatives have nothing to offer on health insurance reform. Because you and they have offered nothing that will achieve the goal of expanded health coverage to those who don’t have it.
For the record: the ACA isn’t single-payer, doesn’t even resemble single-payer. That went off the table before negotiations even began.
The current system isn’t even a glass half empty for those who don’t have insurance. It is a total, ongoing, present-day disaster. Until Republicans and conservatives recognize that, there is no point in trying to work together.
[i]”For the record: the ACA isn’t single-payer, doesn’t even resemble single-payer.”[/i]
True, but is another step in that direction.
[i]”It is a total, ongoing, [b]present-day disaster.[/b]”[/i]
That is a fatalistic glass half empty statement.
Out of the 45 million that don’t have health insurance, 15 million have access to Medicaid and other services that they do not use. 15 million just don’t get insurance for some reason. Out of the remaining 15 million that want it and cannot get it, 5 million are pre-existing condition cases… you know that problem that those know-nothing Republicans and conservatives agree needs to be addressed. So, we have 10 million people out of 310 million that you are using to make a case of “disaster”. How is Obamacare going to help force those first 15 million to go get services? What percentage of the next 15 million are going to purchase health insurance when they reject it today? How are we going to reduce unemployment with all these new taxes and so much uncertainty of the unknown consequences of this crappy legislation?
[i]”Until Republicans and conservatives recognize that, there is no point in trying to work together.”[/i]
Ideas have been presented. But you reject anything that does not fit your ideological views for solutions. This is the the problem with folks on the left these days. They are in control of the white house and the Senate and California state government… and today our politics are the most polarized in the history of this country. The reason is that they are closed-minded to all but their ideas. If I thought Obamacare was going to fix enough of these problems without causing a mess of other problems, I would support it. However, it is junk. Sorry.
From the Kaiser Foundation, here are the facts about the uninsured: [url]http://www.kff.org/uninsured/upload/myths-about-the-uninsured-fact-sheet.pdf[/url]
15 million people don’t “reject it today.” They can’t afford it. You are blaming the uninsured for their lack of insurance?
[i]Ideas have been presented.[/i]
Not any that substantively decrease the number of uninsured. The ideas you described, from the Republicans three years ago, have been scored by the CBO and other analysts. They barely accomplished anything.
Jeff
[quote]We expect to be the best at everything.
[/quote]
And yet we are definitely not the best at health care delivery. We have no delivery system. We treat health care, which is arguably one of the most complex of human endeavors as though it were the equivalent of restaurants. Have very little money ? Don’t eat out or buy food at a McDonald’s where some of the choices have been demonstrated to destroy health rather than provide nutrition. Have a lot of money? Chez Panisse every night if desired. This is the model our insurance companies have provided to date.
[quote]I hope I am wrong, or I hope you fail, for my children’s sake.[/quote]
That would depend on whom you are including in “my children”. Do you mean only your own biological children whose father doubtless is able to provide adequate insurance, or are you also including the lives of other American’s children, such as those whose employer’s do not provide health insurance and fall into the increasing number of those who make too much to be covered by the government, but not enough to feed and house their family and still buy insurance ?
I would like to share a story about Obamacare and an individual patient. The patient is a highly intelligent, motivated student, recent graduate of Cal, 92% on the MCAT, many public service activities both locally and abroad, planning to apply to medical school this year, when diagnosed with a life threatening illness ( 1/5 lifetime mortality), a chronic relapsing disease which typically requires a number of hospitalizations each costing over $ 150,000. The patient is fortunate enough to have a parent who could probably cover a few of these hospitalizations before going bankrupt, however, is even more fortunate to have had the illness diagnosed at age 22 while still covered under parent’s health care plan, which yes, is Kaiser, but is still able to be covered by what you describe as “junk”. I doubt that this family considers the life saving treatment received by this young adult as “junk”. I doubt that this family will consider the provision of the ACA that will allow this individual , after age 26, to purchase health care insurance without being denied due to the pre existing condition “junk”.
Is the ACA everything I would like to see? Of course not. There are provisions that I think are very valuable. There are provisions with which I do not agree. However, to call the entire > 1000 pages of the bill
which contains much of value “junk” is to me a clear case of ” rejecting anything that does not fit your ideological views for solutions. ”
Jeff
[quote]That is a fatalistic glass half empty statement.
[/quote]
I just realized what I find disconcerting about your frequent use of this analogy.
If it fine to view the glass as half full if you are one of the fortunate individuals who has access to the liquid held in the glass. If you are one of the many individuals who do not have access to the liquid, it doesn’t matter if the glass is half full, you still don’t have access. My message is not one of pessimism as you seem to be portraying. I just believe that either the emphasis should be placed on completely filling the glass, or if not possible, making sure that everyone has access to the contents of the glass.
medwoman, I see your point. But there will always be some people with less. To only focus on them is seeing the glass half empty. There are a lot of things about the US healthcare system that are great. Yet, the arguments in support of Obamacare paint our US healthcare system as a total failure.
For comparison, I find it interesting that most people cannot afford to live in Davis, yet we don’t disparage the entire city because of it. We try to add some affordable housing and put a few programs in place to help bridge that gap, but we don’t ignore all the great things about our town.
Here is a great idea for improving healthcare access to the poor… if only the damn government would get out of the way…
From the Sacramento Biz Journal
[quote] The health care delivery system looks very different to ethnic minorities than it does to others. That’s because, for example, Hispanic Americans are 20 percent more likely to be obese than whites. African Americans are far more likely to develop and die from cancer. And together, African Americans, Hispanics and Native Americans develop diabetes at twice the rate as white counterparts.
What’s more, minorities are far less likely to be insured or have access to quality, affordable health care services. More than one in three Hispanics throughout the country lack health insurance, compared to one in eight Caucasions.
All this adds up to mean that, for certain racial and ethnic groups, the community pharmacy is also a very different place. It is not simply a place to fill prescriptions; it is also a vital resource for health care. The truth is, for many families in ethnically-diverse and lower-income neighborhoods, a visit to the local pharmacist is the most frequent interaction they have with a medical professional.
It goes without saying, then, that pharmacists ought to use every tool available to improve the health of their patients. This is what pharmacists are educated and trained to do. They help patients manage their medications in order to get the best effect and monitor how prescription drugs may be interacting with each other. Not only does this result in improved health outcomes, but it also saves Americans money. The New England Healthcare Institute says poor medication management costs Americans $290 billion annually.
However, in California, government regulation prevents pharmacists from using all of the tools available to them. Safe tests such as those that measure a patient’s cholesterol level, blood glucose and body composition are effectively prohibited because of state rules that require pharmacies to hire lab directors in order to oversee simple procedures. Hiring a physician to serve as a laboratory director is expensive and complicated.
More than three dozen other states allow pharmacists to perform these types of tests, and so should California. In fact, federal law already authorizes pharmacists to perform these tests, but over-regulation precludes it. California Senator Gloria Negrete-McLeod has introduced Senate Bill 1481, a law that would put California in line with the other states and with federal law. The Legislature should act swiftly to pass it.
This proposal breaks down an unnecessary barrier to healthcare access and removes one hurdle among minorities, low-income and displaced workers. For the 7 million Californians who lack health insurance, this change would mean greater access to the kinds of affordable, simple tests that can prevent illness and disease. And for ethnic groups who experience higher levels of chronic illness such as diabetes and cancer, these tests could quite literally save lives.
All Californians deserve access to routine, preventive health care. Pharmacists are trusted, trained, capable medical professionals who stand ready to provide that kind of care.
The state ought to allow pharmacists to use every tool available to improve patients’ health and save consumers money. [/quote]
[i]”Since most people who don’t have insurance lack it because they can’t afford it, you have just made the problem worse. Hence the individual mandate”[/i]
Don, first thing… you don’t get something for nothing. This scheme counts on all the people that won’t buy insurance to pay a penalty (tax) and then that money will be used to expand coverage for the poor.
Obamacare will cost 2.23 trillion over 10 years according to the CBO.
Also, the CBO report that repeal of Obamacare will increase deficits is false. First, the CBO is required to assume that current law will be enacted as written. There are a number of healthcare-related actions that could be taken in replacement of Obamacare that would serve to reduce the deficit. Examples include the “doc fix” not passing. Also, the Medicare cuts in Obamacare are unlikely to be sustained for the entire period. The CBO cannot add those numbers even though most experts agree that the aging of the population will cause the need to expand Medicare again.
Obamacare also contains a couple of budget gimmicks that double count the revenue from the new CLASS system and the savings from Medicare cuts.
Lastly, the CBO does not count the number of Americans currently with insurance today that will have their insurance dropped by employers so they can save money having their employees get the taxpayer-subsidized coverage. There are estimates of that being as many as 35 million additional people that the government would need to subsidize.
You do know that a family of four making $90,000 will qualify for subsidy, don’t you?
The Democrats worked this plan to force the CBO to estimate it to their advantage. It will end up costing much more. We will have much higher deficits.
Jeff
I certainly agree that the kind of changes that you cited in terms of allowing pharmacists a bigger role free of
excessive regulation would be a good idea, and indeed clinical pharmacists do exactly this in Kaiser. But these kinds of changes are very small and piecemeal. My plan is much broader but very simple.
1) Universal coverage ( we believe in universal military protection for all citizens, why not universal
health care ?)
2) Single party payer – no dependence on employer provided care which merely serves to fragment patient
care. No refusal for pre existing conditions.
3) Salaried physicians with incentives to those willing to work with underserved populations and provide
primary care
4) Creation of centers of excellence. Instead of having wasteful competition between groups providing
comparable services within blocks of each other competing for the wealthier patients and attempting to
minimize care for those who cannot pay, have physicians and hospitals maximize their physical and
health care provider resources by creating highly effective teams specializing in a given service.
5) Patient choice of physician with a national electronic record system with access limited only by patient
permission.
6) Nationwide targets for maintenance of health, and prevention of disease. These kinds of targets have
proven successful in the past in terms of elimination of some infectious diseases through immunization
and more recently in terms of AIDS prevention and treatment. I think this can be extended to many
preventable diseases with great cost savings if we would stop squabbling and implement.
7) Now lest you think I am arguing for no possibility for higher earnings , I think it would be perfectly fine for
those who have more money to choose to hire an individual physician to provide a ” concierge type service”.
I also think it would be fine for those who desire elective services, such as plastic surgery, to pay for these
services out of pocket. And if an individual wants to spend additional money of their own to see a strictly
private service doc…I also have no problem with this. AFter all, I have no problem with the very wealthy
buying the services of body guards even though they pay taxes to support the military and police.
I do have difficulty with the concept of the rich not paying taxes to support the military and the police just
because they can afford private body guards, and I feel exactly the same about health care.
Jeff
[quote]But there will always be some people with less. To only focus on them is seeing the glass half empty.[/quote]
Spoken like someone who clearly has more.
Your analogy to the town of Davis is not really applicable. If someone cannot afford Davis, they can probably afford a place in Winters, or Woodland or West Sac. If all else fails they can probably move in with a family member. With health care, if you cannot afford insurance, you are just plain our of luck unless you are extremely healthy, only have conditions that can be dealt with optimally in the ER, or happen to have a condition amenable to a folk remedy. Otherwise in our country, you are simply out of luck.
Now if there were no examples of systems in which this were not the case, I would say your are right, aren’t we fortunate? But that is not the case. There are many countries that do far better than we do in caring for their entire population as Don has so appropriately pointed out. We do not lack the money, or the know how.
What we lack is the will to improve. We know how to fill that glass. We choose not to do so.