hR Think Tank: Universal Health Care

[BurgundyNGold]

We have some pretty smart folks up here who have some pretty good ideas. It got me to thinking that, for fun, we could try to solve some of these policy problems, rather than to just praise or piss on the plans that politicians do. We could make an hR "Think Tank" for such issues and, in the process, learn a lot more about the issues.

As in reality, we will have to "reach across the aisle" in a "spirit of bipartisanship" and come up with solutions to some of our nation's most pressing problems.

So let's try an exercise.

Whether we like it or not, President Obama has allocated nearly $700B as a down payment to reform health care in America. Clearly, the cost of health care has gotten to the point where it is an unsurmountable burden on businesses large and small and on individuals alike. It is affecting our ability to compete in the global marketplace and is a rather embarrassing state of affairs for the richest nation ever to exist.

Something has to be done. But what? The task is for this think tank to figure out a health care proposal that could theoretically be implemented.

I would propose that the health care plan have the following cornerstone values:

1) Every American must be fully covered
2) Prescription drugs must be more affordable
3) Preventive health care is included
4) The plan must be cost sustainable

Any other cornerstone values are welcome to be recommended. They might not be in the final version of our plan, but that is to be decided by the think tank.

Submit and explain your plan and the rationale behind the model. We'll debate it, take the best parts from the various plans and then submit them to the forum at large for a "vote".

Sound like fun to anyone else?

[Biggie]

I love the idea, although I'm not nearly smart enough to know what to do about it.

One thing I do know (through years of experience going through the medical system) is that its incredibly inefficient. Obama's idea of modernization and electronic information storage is a good one, as I think anyone who's had to go through multiple hospitals and doctors can tell you. If the same idea has been implemented for many other kinds of records, why not medical ones?

So, basically, that's my contribution to the plan: Digitize medical records to allow for easier access by physicians, less hassle for both healthcare facilities and patients, and fewer costs associated with the tons of tons of paper that go into it now.

[akhhorus]

Its pretty clear that just on sheer costs, the system has to be totally changed. Medicare and Medicaid alone will cost 20% of GDP within a couple decades, and thats only one part of the system.

The Canadian system is too structured frankly, I think you could meld the british style system of total coverage with rewarding quality health care providers with some sort of public takeover of the HMO structure in place. Maybe a sliding scale co-pay, where you can pay more for quicker(and maybe better) service?

[shally]

I love the idea, although I'm not nearly smart enough to know what to do about it.

One thing I do know (through years of experience going through the medical system) is that its incredibly inefficient. Obama's idea of modernization and electronic information storage is a good one, as I think anyone who's had to go through multiple hospitals and doctors can tell you. If the same idea has been implemented for many other kinds of records, why not medical ones?

So, basically, that's my contribution to the plan: Digitize medical records to allow for easier access by physicians, less hassle for both healthcare facilities and patients, and fewer costs associated with the tons of tons of paper that go into it now.

that is a straw man.. like gasoline additives
given super gas mileage .. once fully implemented it wont result in ANY substantial savings. that ispure poppycock.

what it will do is 2 things: make health history readily available, hopefully preventing mistakes AND open pandoras box as far as making medical records available to anyone who wants to snoop

any proposal that uses electronic medical records to balance the cost of the system is a sham and should be ignored..is is bogus. any savings will be eaten up by rising costs associated with the softwear, administration of the system, etc etc...

[shally]

Its pretty clear that just on sheer costs, the system has to be totally changed. Medicare and Medicaid alone will cost 20% of GDP within a couple decades, and thats only one part of the system.

The Canadian system is too structured frankly, I think you could meld the british style system of total coverage with rewarding quality health care providers with some sort of public takeover of the HMO structure in place. Maybe a sliding scale co-pay, where you can pay more for quicker(and maybe better) service?

there is a quiet private system in britain that has flourished because people who can afford to avoid the brit system, DO avoid it.

there will be problems if the feds make any kind of alternative system illegal
to squash competition.

the approach they will use is to "slowly boil the lobster" by incremental changes.. older people will still have freedom. younger people will be indoctrinated into the new "european style" system and wont know any better..

no matter what you do, there willbe some rationing of care to contain costs. good things will happen because you wont have 95 years olds getting cardiac bypass procedures.. on theother hand, people will have to wait for colonoscopies, or MRI's, or PSA's, or a thousand different things..
people will die because of that.. then again, people now die because of TOO much care..

the big thing is that children and maternal perinatal care HAS to be fully covered. that is where you get the most bang for the buck from a nation wide system

what might suffer greatly is cutting edge technology.. hard to tell but it is an issue to watch

[Fathead]

Waiting for MRIs really sucks, btw.

[akhhorus]

there is a quiet private system in britain that has flourished because people who can afford to avoid the brit system, DO avoid it.

there will be problems if the feds make any kind of alternative system illegal
to squash competition.

the approach they will use is to "slowly boil the lobster" by incremental changes.. older people will still have freedom. younger people will be indoctrinated into the new "european style" system and wont know any better..

no matter what you do, there willbe some rationing of care to contain costs. good things will happen because you wont have 95 years olds getting cardiac bypass procedures.. on theother hand, people will have to wait for colonoscopies, or MRI's, or PSA's, or a thousand different things..
people will die because of that.. then again, people now die because of TOO much care..

the big thing is that children and maternal perinatal care HAS to be fully covered. that is where you get the most bang for the buck from a nation wide system

what might suffer greatly is cutting edge technology.. hard to tell but it is an issue to watch

Im no fan of some giant gov bureaucracy, but the choice is coming whether to dump all governmental health help or have a system that really doesn't help people choke the entire budget. I think at the very least, they should do a system where regular checkups(medical, dental, etc) and preventative medication+prescription drugs should be covered by the government. Thats in the interests of the public health and would actually cut costs of healthcare across the board.

[shally]

Im no fan of some giant gov bureaucracy, but the choice is coming whether to dump all governmental health help or have a system that really doesn't help people choke the entire budget. I think at the very least, they should do a system where regular checkups(medical, dental, etc) and preventative medication+prescription drugs should be covered by the government. Thats in the interests of the public health and would actually cut costs of healthcare across the board.

preventitive health care is meaningless, unless it leads to definitive care.

what good does it do anyone if a blockage is found in an artery if treatment is not provided? or if someone has a bad hip and joint replacement surgery is postponed 3 years ? or if the definitive tests like MRI are not approved for 6-12 months ?

cut to the chase, the desire of the government overall is to reduce the amount and cost of medical by any means necessary.. some of it HAS to be done (there are WAY too many spinal fusions being done, for example)..
on the other hand, reducing prostate surgery may or may not be a good idea.. it takes 20 years to know the outcome of some things

but, given that we definitely have an aging population that loves to eat and hates to exercise, it is expected there will be a rising need for health care for all those aging baby boomers.. you can deny health care, but it is going to result in increase deaths.. then again, those people wont need health care any more, will they ?

as daschle has written, some people should just accept their fate and move off the earth quietly to benefit the overall population

[akhhorus]

preventitive health care is meaningless, unless it leads to definitive care.

what good does it do anyone if a blockage is found in an artery if treatment is not provided? or if someone has a bad hip and joint replacement surgery is postponed 3 years ? or if the definitive tests like MRI are not approved for 6-12 months ?

cut to the chase, the desire of the government overall is to reduce the amount and cost of medical by any means necessary.. some of it HAS to be done (there are WAY too many spinal fusions being done, for example)..
on the other hand, reducing prostate surgery may or may not be a good idea.. it takes 20 years to know the outcome of some things

but, given that we definitely have an aging population that loves to eat and hates to exercise, it is expected there will be a rising need for health care for all those aging baby boomers.. you can deny health care, but it is going to result in increase deaths.. then again, those people wont need health care any more, will they ?

as daschle has written, some people should just accept their fate and move off the earth quietly to benefit the overall population

Preventative care does help reduce costs since health care providers can do less complicated solutions(and less costly ones) like giving someone a supplement or medication to end a problem long before it requires surgery or a massive program of specialized drugs to combat it. If a doc can give someone a drug to help a patient's arteries when they aren't blocked much, that will save a major surgery down the line.

[shally]

Preventative care does help reduce costs since health care providers can do less complicated solutions(and less costly ones) like giving someone a supplement or medication to end a problem long before it requires surgery or a massive program of specialized drugs to combat it. If a doc can give someone a drug to help a patient's arteries when they aren't blocked much, that will save a major surgery down the line.

maybe.. thatis the rationale.. but in a lot of european countries where health care is a right, procedures are STILL rationed..

no matter how you parse, or define it, there is going to have to be one hell of a reduction in procedures to even begin to make a dent in health costs for 20-30 years.

i see people here who have type 2 diabetes regularly in their 20-30's..
lots of them. it is frightening how much care these people are going to need over the remainder of their lifetimes..

the thrust has to be in early childhood. but how to do combat moms who feed their kids so much fat because fresh fruits and vege's cost more than processed crap ? or it is easy to prepare ? and dont even get me started onthe lack of exercise in our kids. we are going to see an absolute epidemic of hypertension, type 2 diabetes and cardiovascular diease inthe next 30-40 years.. very scary

[Biggie]

that is a straw man.. like gasoline additives
given super gas mileage .. once fully implemented it wont result in ANY substantial savings. that ispure poppycock.

what it will do is 2 things: make health history readily available, hopefully preventing mistakes AND open pandoras box as far as making medical records available to anyone who wants to snoop

any proposal that uses electronic medical records to balance the cost of the system is a sham and should be ignored..is is bogus. any savings will be eaten up by rising costs associated with the softwear, administration of the system, etc etc...
Sorry. :(

[shally]

Sorry. :(

sorry to bust your bubble but that one really gets me going.. that is pure alchemy.. no real savings in the long run.. there are really only 2 ways to do it realistically

1. deny care

2. reduce payments to providers

both will cause real pain. both will happen at some point. it is the only way

[BurgundyNGold]

sorry to bust your bubble but that one really gets me going.. that is pure alchemy.. no real savings in the long run.. there are really only 2 ways to do it realistically

1. deny care

2. reduce payments to providers

both will cause real pain. both will happen at some point. it is the only way
What would your ideal system that met the initial objectives comprise? As a doctor, I'm sure you have some great ideas and I'd love to hear them. I'm still noodling the initial draft of my plan through.

[hogskins]

sorry to bust your bubble but that one really gets me going.. that is pure alchemy.. no real savings in the long run.. there are really only 2 ways to do it realistically

1. deny care

2. reduce payments to providers

both will cause real pain. both will happen at some point. it is the only way

Private insurers already deny coverage and shaft providers, in my experience. All at an administrative cost that is much larger than Medicare, for example. (I've seen figures in the neighborhood of 20-25% for private insurance versus 2-5% for Medicare).

It's ironic that we have developed medical advances that far outstrip our ability to pay for them, and the technological and pharmaceutical advances are a bell that we can't unring. Rationing is inevitable, it seems.

There's no way that the US moves to a single-payer government system in the near future--too much fear-mongering about it opening the door to "rampant Socialism". And I'm not anxious for that kind of system to become our universal direction anyway. It seems to me that the "universal" part will be mandated baseline coverage, including some of the things discussed previously in this thread, with a government plan (or plans) competing with other private plans. Pool sizes would be big enough to absorb some of the higher-risk, currently "uninsurable" folks out there. "My" plan would require that we keep the door open for supplemental insurance available to those willing and able to pay. I'm not sure what to say about an opt-out option, though...

[akhhorus]

Private insurers already deny coverage and shaft providers, in my experience. All at an administrative cost that is much larger than Medicare, for example. (I've seen figures in the neighborhood of 20-25% for private insurance versus 2-5% for Medicare).

It's ironic that we have developed medical advances that far outstrip our ability to pay for them, and the technological and pharmaceutical advances are a bell that we can't unring. Rationing is inevitable, it seems.

There's no way that the US moves to a single-payer government system in the near future--too much fear-mongering about it opening the door to "rampant Socialism". And I'm not anxious for that kind of system to become our universal direction anyway. It seems to me that the "universal" part will be mandated baseline coverage, including some of the things discussed previously in this thread, with a government plan (or plans) competing with other private plans. Pool sizes would be big enough to absorb some of the higher-risk, currently "uninsurable" folks out there. "My" plan would require that we keep the door open for supplemental insurance available to those willing and able to pay. I'm not sure what to say about an opt-out option, though...

I think the only way it could happen is if the business world is begging for it. If a massive group of CEOs of both big and small businesses came out and said that they would be willing to pay a tax to get rid of their healthcare costs, and then it would be hard to play the socialism card against it. And if you gave the biggest companies in the country a choice between paying healthcare legacy costs or paying a 7-11% new tax to pay for a Canadian style system, they'd probably pay the tax.

[shally]

Private insurers already deny coverage and shaft providers, in my experience. All at an administrative cost that is much larger than Medicare, for example. (I've seen figures in the neighborhood of 20-25% for private insurance versus 2-5% for Medicare).

It's ironic that we have developed medical advances that far outstrip our ability to pay for them, and the technological and pharmaceutical advances are a bell that we can't unring. Rationing is inevitable, it seems.

There's no way that the US moves to a single-payer government system in the near future--too much fear-mongering about it opening the door to "rampant Socialism". And I'm not anxious for that kind of system to become our universal direction anyway. It seems to me that the "universal" part will be mandated baseline coverage, including some of the things discussed previously in this thread, with a government plan (or plans) competing with other private plans. Pool sizes would be big enough to absorb some of the higher-risk, currently "uninsurable" folks out there. "My" plan would require that we keep the door open for supplemental insurance available to those willing and able to pay. I'm not sure what to say about an opt-out option, though...


absolutely true.. docs feared the government, and got shafted worse by insurers.. they will back some kind of system outside of insurers now as long as they have realistic input into the decision making.. that is what killed hillary-care. docs were left out totally
What would your ideal system that met the initial objectives comprise? As a doctor, I'm sure you have some great ideas and I'd love to hear them. I'm still noodling the initial draft of my plan through.

let me think on it.. but realitically it is going to have to involve some rationing of care. there is no other way and in some ways it would be a good thing

I think the only way it could happen is if the business world is begging for it. If a massive group of CEOs of both big and small businesses came out and said that they would be willing to pay a tax to get rid of their healthcare costs, and then it would be hard to play the socialism card against it. And if you gave the biggest companies in the country a choice between paying healthcare legacy costs or paying a 7-11% new tax to pay for a Canadian style system, they'd probably pay the tax.

big business will beg for the yoke of medical care expenses to be lifted off of them

[Keino]

I am for any plan that runs doctors like Shally out of business. LOL

(Just kidding of course)

[shally]

I am for any plan that runs doctors like Shally out of business. LOL

(Just kidding of course)

actually, i am pretty much immune since i left private practice... as long as there are lawyers, courts, arguments over injuries and work comp cases there will be a need for guys like me...

even the scandanavian systems, those most socialistic, have disputes. so i will probably have work for as long as i can drag myself to the office..

[hogskins]

I think the only way it could happen is if the business world is begging for it. If a massive group of CEOs of both big and small businesses came out and said that they would be willing to pay a tax to get rid of their healthcare costs, and then it would be hard to play the socialism card against it. And if you gave the biggest companies in the country a choice between paying healthcare legacy costs or paying a 7-11% new tax to pay for a Canadian style system, they'd probably pay the tax.

Employers had been rapidly shedding legacy medical costs, much in the way that they have managed to dump defined-benefit pension programs over the past 10 years, in favor of defined-contribution, 401k-style retirement accounts. (I don't know where you are on your way to a retirement of some sort, but I believe that this is the week that I break even versus stuffing all of my retirement contributions into a mattress beginning a dozen years ago.) My employer now kicks a small percentage of my salary into a "retirement" medical account which may almost be large enough to allow me to afford my first double-bypass surgery, which, at this rate, will occur WAY before I can afford to retire...

The only employment sectors I can think of that will be anxious to get out from under legacy costs that would be worse than an SS-style payroll deduction are union-dominated industries, and possibly government. And union-dominated industries will crap the bed and have to be bailed out by government anyway. Employers will have the workforce over a barrel when it comes to negotiating health insurance benefits in the short-term, I think. Right now, employees are heavily sunsidized by employers, but why wouldn't that change in a hurry if unemployment hits 10 or 15%?

[akhhorus]

Employers had been rapidly shedding legacy medical costs, much in the way that they have managed to dump defined-benefit pension programs over the past 10 years, in favor of defined-contribution, 401k-style retirement accounts. (I don't know where you are on your way to a retirement of some sort, but I believe that this is the week that I break even versus stuffing all of my retirement contributions into a mattress beginning a dozen years ago.) My employer now kicks a small percentage of my salary into a "retirement" medical account which may almost be large enough to allow me to afford my first double-bypass surgery, which, at this rate, will occur WAY before I can afford to retire...

The only employment sectors I can think of that will be anxious to get out from under legacy costs that would be worse than an SS-style payroll deduction are union-dominated industries, and possibly government. And union-dominated industries will crap the bed and have to be bailed out by government anyway. Employers will have the workforce over a barrel when it comes to negotiating health insurance benefits in the short-term, I think. Right now, employees are heavily sunsidized by employers, but why wouldn't that change in a hurry if unemployment hits 10 or 15%?

Its not just the union driven companies, and despite the companies shedding costs where ever they can, they're still stuck with long term costs from vested pensions and contracts they've signed. Any company with 1000 employees will love the idea. Any small business doesn't have to make their employees contractors.

[hogskins]

Its not just the union driven companies, and despite the companies shedding costs where ever they can, they're still stuck with long term costs from vested pensions and contracts they've signed. Any company with 1000 employees will love the idea. Any small business doesn't have to make their employees contractors.

I wasn't trying to be argumentative. Your idea has some appeal as a predictable, long-term cost of doing business. I wonder what the overall national average (as a % of salary) is for employer contributions to employer-sponsored plans? Would this represent a matched amount, like the other payroll taxes?

Employers might still prefer the flexibility of releasing contract employees at will (at least that is how contracts are written in my industry--that may not be representative of general trends).

In any event, I suspect that transitional insurance would have to operate very differently than the current COBRA arrangement.

[BurgundyNGold]

OK, so before I can put the broad strokes of my plan out there, here are the facts, as I understand them. I will put my plan up later...

Background

More than 250M Americans have at least some form of health insurance. The current HMO model works for these people to one degree or another. And, contrary to what Michael Moore would have you believe in "Sicko", nobody can legally be turned away from an emergency room because they are uninsured. The resulting bills may be very expensive, but that's why you buy insurance.

That said, it seems to me that the larger provider network works, although obviously not for everybody because some 45M Americans are uninsured. That's about 1/7. Interestingly, the number of uninsured motorists? About 1/7. I'm starting to see a pattern there.

Most people get health insurance through their employers, although you can buy pretty good personal plans for as little as $80/month and slightly more per person for family plans. Many of these plans have prescription drug co-pays that cap what you will pay for most drugs. There are co-pays for doctor, hospital, lab and specialist visits. The visit co-pays generally range from $0 to $40 and are usually in the $10 - $20 range.

In the United States, direct Federal funding of health care is limited to Medicare, Medicaid and the State Children's Health Insurance program. Also, through the DOD, the military funds active military health care. The Federal government also funds veteran health care through the Veterans administration.

Prescription drugs cost more in the US than in any other country in the world. This is primarily because of three reasons. First, there are very few large purchasers of prescription drugs that could reduce the costs by volume purchases. Second, there are actually laws in place that prevent Medicare and Medicaid from negotiating volume discount prices. Third, the drug testing and safety procedures in the US are longer and more exhaustive than nearly any other country, leading to a higher cost of production.

Due to malpractice litigation, courts and settlement costs, the United State also has the highest legal cost per person ($16 in 2006) attached than any other country in the world.

What Do Other Countries Do?

The UK has a completely socialized health care system, under which anyone in the country who requires treatment -- preventive or acute -- gets treated at no cost to them. All doctors are licensed and the vast majority of doctors are, in fact, government employees. They accept paychecks from the government at a rate that is more than what generally government employees earn but far less than what private practice doctors can command. Similarly, hospitals and health clinics are government buildings.

They have a nominal fee for prescription drugs for most patients, regardless of drug or the number of pills. The very young, old and poor are exempt from this fee. They can do this because the government has negotiated volume rates with drug manufacturers and subsidizes the cost of prescription drugs that are either outside of the negotiated plan or that are more costly than the median drug cost.

France has a similar system, however they have taken the term "health care" to mean some pretty peripheral things, including rehabilitation, child care and a host of other fringe social costs.

Canada has what is called the "single payer" system. The Canadian system has sometimes been demonized as "socialized medicine" but that is more political rhetoric than fact. Unlike the UK and France in which the health care system and its providers are part of the public sector, in Canada the health care providers and hospitals are actually private sector professionals. What Canada has chose to do is to make it a federal law that each person must have health insurance, and that they must be fully insured without co-pays or fees for medically mecessary treatment. On the other side of that equation, the government then guarantees the providers that they will be paid for any legitimate services that they provide for insured patients.

Like the US, Canada has a private sector prescription drug policy based on insurance. About 65% of Canadians have prescription drug coverage through insurance. Drugn prices are usually much lower in Canada than in the US. This is because provicial governments negotiate volume contracts with drug manufacturers. These drugs are then available for purchase to private suppliers, with the majority of drugs available to hospitals as part of the reimbursible Medicare system.

[shally]

there are also a small number providers in the UK outside the system.. more every day

the scandanavian system is the most inclusive because of their uniform population, little poverty and their social ethos. they just believe in it completely. but they pay for it in higher taxes

the basic problem is that we dont want to pay for the care we receive.. we want it passed on to someone- whether you are talking about the government, or employers, or health care providers eating it, because they are all rich and greedy

it is this disconnect between cost and responsibility for care that has yielded the bizarre system we have now

sooner or later, you either ration care, or you pay more for it.. there is no other way to make the equations add up

what has to happen first, is to provide basic care for every child and pregnant mother. the dollars put into that system are by far, the best spent and yield the most long term benefit

on the other hand, an astonishing amount of all medicare dollars are spent on the last few weeks of covered people's lives. what that means, more likely than not, is that every possible procedure and device is used to stave off the final, inevitable demise of the patient.. from an insiders point of view, it is often cruel and inhumane. palliative, merciful, end of life care is not that expensive. spending 6 weeks in an ICU with tubes running in and out of every possible opening, and being maintained by artificial means isnt.. but, leave off one possible, out of the blue treatment, and sure enough, some long lost, distant relative is going to file a lawsuit against everyone.. or, in the name of sanctity of life, the exact opposite occurs..

there has to be some flow chart, or paradigm that allows appropriate care, but lifts the burdens from hospitals to provide endless care in a hopeless situation.
real dollars are saved that way. real lives are helped that way.

beyond that. there are procedures that are being done, that shouldnt be being done. someone has to be able to say NO, based, not upon bean counting, but upon evidence-based studies..

[Fathead]

Can I say that whatever the French have doesn't work. Stupid MRI waits almost killed me.

[shally]

Can I say that whatever the French have doesn't work. Stupid MRI waits almost killed me.

there is always going to be a relationship between costs and availability. if you reign in costs by limiting the number of spots available for certain tests like MRI's, CT's, etc then people are going to have to wait.. and people are going to die.. on the other hand, if you dont put some limits, there will be an MRI center at almost every corner driving up the overall cost of health care.

in some states they try CON's (certificates of need) but then that opens the system to corruption because politicians control the system and eventually most either expect kickbacks, or funnel them to favored individuals..

i dont have any answer for that one, except to say i would far prefer that diagnostic tests be available at the highest level, even if procedures arent.. better to know, than to not know what is going on.. afterwards you can wrangle over the best treatment for the condition, but if you dont know what is going on, you cannot make any reasonable decisions..

[Fathead]

Those pesky subdural hematomas are not fun, especially when you can't get an MRI.

[shally]

Those pesky subdural hematomas are not fun, especially when you can't get an MRI.

CT scan is about as good, and virtually every hospital has one of those

[Fathead]

CT scans are usually good, but every once in a while you have to get the MRI. Or you die.

[shally]

CT scans are usually good, but every once in a while you have to get the MRI. Or you die.

agree.. but if you go into an ER with head trauma, a CT scan is the standard test they will do to look for bleeding

[hogskins]

Good summary, overall, although this part is a little "reductionist", and misses some of the newer dynamics that I've noticed:


Most people get health insurance through their employers, although you can buy pretty good personal plans for as little as $80/month and slightly more per person for family plans. Many of these plans have prescription drug co-pays that cap what you will pay for most drugs. There are co-pays for doctor, hospital, lab and specialist visits. The visit co-pays generally range from $0 to $40 and are usually in the $10 - $20 range.


You can probably find a few examples of "pretty good" individual plans in the $80/month range, but I bet they are exceedingly rare, depending on how you define "pretty good". There are a number of supplemental plans in that range for folks who already have Medicare, but they vary a lot in cost by geography and level of coverage. I've known some small business owners who get killed when they seek health coverage in the open market--so much so that they return to wage slavery with a larger company for that reason alone. (Anecdotal, I know, but I bet it's not uncommon).

An increasingly relevant factor is the deductible limits for anything out of the ordinary. Preventive care and office visits for primary care are typically covered with co-pays in the range you've described. Bigger ticket maladies require hitting deductible limits that have grown exponentially in typical plans, in recent years. If I compare deductibles in the plan I've been enrolled in over the past 5 years, the per person deductible has grown 10x. Granted, the original deductible of under $300/person was very low, but the almost $3000 that it's grown to represents a fundamental impact to folks who have seen real wages shrink (or disappear, due to layoffs) over time. I'm not talking about so-called "high-deductible" plans, either. Those, often coupled with inducements for HRAs, strike me as purely a gambler's strategy. So, people (and employers) are paying more for base coverage, deductibles, and % of care after the deductible is met, at a time when ability to pay is falling. For a family that is just scraping by, a kid's broken leg or appendectomy has the potential to sink their financial ship. For this reason, I contend that arguments based on 6/7 of us being "insured" and therefore "in good shape" are likely to be overstated.

[shally]

Good summary, overall, although this part is a little "reductionist", and misses some of the newer dynamics that I've noticed:



You can probably find a few examples of "pretty good" individual plans in the $80/month range, but I bet they are exceedingly rare, depending on how you define "pretty good". There are a number of supplemental plans in that range for folks who already have Medicare, but they vary a lot in cost by geography and level of coverage. I've known some small business owners who get killed when they seek health coverage in the open market--so much so that they return to wage slavery with a larger company for that reason alone. (Anecdotal, I know, but I bet it's not uncommon).

An increasingly relevant factor is the deductible limits for anything out of the ordinary. Preventive care and office visits for primary care are typically covered with co-pays in the range you've described. Bigger ticket maladies require hitting deductible limits that have grown exponentially in typical plans, in recent years. If I compare deductibles in the plan I've been enrolled in over the past 5 years, the per person deductible has grown 10x. Granted, the original deductible of under $300/person was very low, but the almost $3000 that it's grown to represents a fundamental impact to folks who have seen real wages shrink (or disappear, due to layoffs) over time. I'm not talking about so-called "high-deductible" plans, either. Those, often coupled with inducements for HRAs, strike me as purely a gambler's strategy. So, people (and employers) are paying more for base coverage, deductibles, and % of care after the deductible is met, at a time when ability to pay is falling. For a family that is just scraping by, a kid's broken leg or appendectomy has the potential to sink their financial ship. For this reason, I contend that arguments based on 6/7 of us being "insured" and therefore "in good shape" are likely to be overstated.


it depends upon how you choose to define coverage

what we have now, in most cases, is catastrophic care.. insurance to cover something terrible, not routine care or preventative care.. that is not a bad concept philosophically because it protects most insured people from catastrophe, and yet makes them aware of some of the inherent costs of medical care. but it leave a lot of people in financial trouble as it is..

where we seem to be headed, is to include at least a lot of the preventative care. probably a first step towards universal coverage. and even that may be very very expensive

there is simple no way around it-- to cover every one is going to require a re ordering of national priorities and tax structure

[hogskins]

it depends upon how you choose to define coverage

what we have now, in most cases, is catastrophic care.. insurance to cover something terrible, not routine care or preventative care.. that is not a bad concept philosophically because it protects most insured people from catastrophe, and yet makes them aware of some of the inherent costs of medical care. but it leave a lot of people in financial trouble as it is..

where we seem to be headed, is to include at least a lot of the preventative care. probably a first step towards universal coverage. and even that may be very very expensive

there is simple no way around it-- to cover every one is going to require a re ordering of national priorities and tax structure

Yes--I ignored the macro view for a minute to address some insurance coverage details.

I agree with your characterization--anything "universal" is a new gestalt, and expensive...

[shally]

Yes--I ignored the macro view for a minute to address some insurance coverage details.

I agree with your characterization--anything "universal" is a new gestalt, and expensive...


i think what obama is doing is trying to put the US on the path towards a european style health care system. it wont happen during his tenure as president, but if the momentum is started, eventually it will become fact.

the other side benefit (if you are liberal) is that clearly the US cannot afford this kind of system along with what we spend on the military.. if you are philosophically anti-war (not saying it is correct or incorrect, just saying it)
it is the way you create a european style consensus way of international governance. we simply wont have a military that allows us to "cowboy" it alone. it will require pooling of resources by the international treaty groups to respond to anything more than a quick strike response..

in that sense it doesnt require a plebiscite to determine national choices--- the "people" have already decided by voting for national health care. the impact on our military, and thus our foreign policy is either collateral benefit, or collateral damage, depending upon your viewpoint.. essentially invalidating LBJ's "guns and butter" equation from the late 60's...

[Fathead]

agree.. but if you go into an ER with head trauma, a CT scan is the standard test they will do to look for bleeding

Yep. But sometimes you need an MRI to see the bleeding. And being on a waiting list for an MRI in France for 3 months is not much fun. Especially when you come back to the states and get an MRI within an hour of landing and find out that you are bleeding.

[fpickering]

I am no expert in health care and am not sure how the follow might factor into the discussion but here are my biggest complaints about the health care system:

1. The In network vs Out of Network debacle - On several occasions I have gone to an in network hospital only to receive a bill from an out of network provider operating within the hospital. This is unacceptable and leads to too much confusion which takes up more of my time, the provider's time and the insurance companies' time. Time = money. If I go to an in network hospital then all services provided there should be under some kind of umbrella in network clause.

2. As an owner of a small business, I am forced to go out and get my own insurance policy which results in higher premiums, pre-existing clauses, and other issues that otherwise would not be present if I were part of a group plan.

3. On too many occasions the onus has been on me to resolve provider/insurance problems. Why do I need to take time out of my day and my work schedule to make phone calls when they should just talk to each other?

[fpickering]

that is a straw man.. like gasoline additives
given super gas mileage .. once fully implemented it wont result in ANY substantial savings. that ispure poppycock.

what it will do is 2 things: make health history readily available, hopefully preventing mistakes AND open pandoras box as far as making medical records available to anyone who wants to snoop

any proposal that uses electronic medical records to balance the cost of the system is a sham and should be ignored..is is bogus. any savings will be eaten up by rising costs associated with the softwear, administration of the system, etc etc...


I hear what you are saying. If new software is implemented then you need to have persons to implement and support it which would result in costs.

However, there are definite efficiencies that can result from such systems. Any piece of my history and records are accessible at the fingertips of my Physician and they can find them using the software solution much faster. Also, pharmacies are integrated so prescriptions can be sent to my Pharmacy immediately.
I am sure there are more examples but I do not possess the applicable knowledge to talk about them. Thoughts?

[fpickering]

actually, i am pretty much immune since i left private practice... as long as there are lawyers, courts, arguments over injuries and work comp cases there will be a need for guys like me...

even the scandanavian systems, those most socialistic, have disputes. so i will probably have work for as long as i can drag myself to the office..

how drastic of a role do medical malpractice suits have in the costs of health care?

what can be done to curb this?

[shally]

Yep. But sometimes you need an MRI to see the bleeding. And being on a waiting list for an MRI in France for 3 months is not much fun. Especially when you come back to the states and get an MRI within an hour of landing and find out that you are bleeding.

part of choices that a society makes.. get used to it, that is what comes with
universal health care
there are always going to be priorities and compromises

unless you are part of the ruling elite.. no compromises on care for the ba****s who make the rules in congress. they get to go to bethesda naval, or anywhere they want to..

[shally]

I hear what you are saying. If new software is implemented then you need to have persons to implement and support it which would result in costs.

However, there are definite efficiencies that can result from such systems. Any piece of my history and records are accessible at the fingertips of my Physician and they can find them using the software solution much faster. Also, pharmacies are integrated so prescriptions can be sent to my Pharmacy immediately.
I am sure there are more examples but I do not possess the applicable knowledge to talk about them. Thoughts?

there is NO question your Doc will get better access to your medical records.

So will Docs in an ER who might not know you..

But, so will countless other individuals you might not want to have access to your information.. and anyone who says it will be kept safe is full of it.. just like your financial info.. how safe is it ?

and i am telling you, that in the end, it wont amount to any cost savings at all.
that is a huge lie that is being foisted on the american public. by the time everyone gets their little piece of the action, all those savings will disappear.
they are the same people who brought you the $479.00 hammer.. no one will have a clue as to where all those saving went..

[shally]

how drastic of a role do medical malpractice suits have in the costs of health care?

what can be done to curb this?

as a Doc i can tell you it has some.. but it is not so much as direct cost, as an indirect one..

look at it this way, if you are a neurosurgeon who has a premium of over $100,000, how many procedures do you have to do each year before you are earning money for yourself ?

or if you are an O.B. who has to decide if you want to deliver babies and it adds 100,000 to your yearly premium, do you continue to do so ?

or you are just finishing up your training and you have a couple of offers.
you have a choice of going somewhere your Med Mal is covered by a clinic and somewhere it isnt, where do you go ? or there are 2 states you are considering where the med mal policy costs 2 X in one versus the other.. where do you go ?

or you have been sued once because you could have ordered a specific test but didnt. you win the claim. but i bet you order that test and every other one you can think of for the next 30 years, whether it is needed or not..
bump your head and go to the ER ? 90 % of the time they will order a CT scan even though the yield is less than 1 %. Defensive medicine adds a lot to the cost overall.

i have been a doc now for over 35 years. i can tell you that medical students and residents are incredibly ethical as a rule.. they dont go into fields because of the med mal situation, they go into something because they are excited about that field of medicine

on the other hand, plenty of Docs leave certain fields, or leave certain states or cities because they cannot make the balance sheet work for them.

the statistics everywhere are that over 95 % of cases are won by docs even when claims are filed.. and yet insurance is very hard to find and expensive to keep. malpractice happens, and patients are injured by events. compensation should be made. but most of the time, it isnt the bad apples who are getting sued. and even defending a meritless claim costs the insurance carrier about $25,000. ultimately, that cost is passed onto the consumer

ultimately, i think the the answer is to separate out med mal from competency issues. the latter is an ongoing issue that is being dealt with, especially now that there are lay people on most state boards. the old boy system died a long time ago.

on the other hand, there are really smart, courageous docs who take on terribly difficult and complex cases. the ones that have the highest chance of going sour and resulting in a claim.. those are exactly the type of docs you HAVE to keep in the system.. if you run those people off because they cannot afford to keep practicing, we are all the losers because no one else in their right mind is going to want to take on those types of cases

if as a part of a universal coverage plan you make the government pick up the coverage of all med mal claims, the problem will go away pretty quickly.. docs who practice at the VA system have no headaches in this regard. why ? ever try to sue the federal government ? it is virtually impossible and takes a lot of expense. what you do is replace the tort system, which is in reality a lottery, with a schedule of benefits for the patient who gets harmed.

a hearing happens in front of an impartial arbiter and both sides get to present their cases. the arbiter decides how much the claim is worth by comparing it to a schedule of benefits. claim over. patient gets paid. think you didnt get enough ? you have the right to sue the government for an unjust settlement.

think the Doc is incompetent ? bring it up to another arbiter who has the power to suspend the doc's license. same thing happens. another hearing, another result.. due process all around.

the ultimate goal is to take the monetary incentive out of the process.
it should be a process that either results in better future care, removal of people who shouldnt be providing care or their education to provide better care, or compensation fairly given to someone who is injured.. once the Feds take over the system, it will likely happen,, how do i know ?? the incidence of med mal suits is so much higher here than any other country in the world.
why ? because it pays better here than anywhere else..

i will sum it up in a thought question for you.
a patient is legitimately hurt in a med mal case. they are offered 2 remedies

1. they are given a formal public apology by the Doc that is printed in the paper. if bad enough, or repetitive,the Doc is suspended for a period of time, and has to go on a period of supervised probation, and maybe isnt allowed to perform that procedure again.
they are compensated for their actual time lost from work, and if they cannot go back to work because of a legitimate reason (loss of eye, loss of hand, etc)
they are given a scheduled monetary award predetermined, and perhaps re training, or additional stipend for college, etc


or


2. there is no apology ever. little likelihood of any change in the practice pattern of the doc. but at the end of the case, there is the very high potential for a very large windfall of money based upon the sympathy factor and the skill of the representative presenting the case. basically, take the money, go away and shut up..

my own personal experience based upon review of hundreds of claims is that, public statements be damned, in this country NOT ONE OUT OF 100 CLAIMANTS WOULD OPT FOR PLAN 1... and you know i am right. because it is greed and the opportunity for financial windfall that drives this more than anything.. and it is greed on ALL sides that is driving this. take the monetary incentive out of the process and replace it with a fair and just system, and the problem goes away over night..

[ClubSandwichGuy]

the thrust has to be in early childhood. but how to do combat moms who feed their kids so much fat because fresh fruits and vege's cost more than processed crap ? or it is easy to prepare ? and dont even get me started onthe lack of exercise in our kids. we are going to see an absolute epidemic of hypertension, type 2 diabetes and cardiovascular diease inthe next 30-40 years.. very scary
I know very little about the health care system, but I can tell you that this is true. At my school (I'm 16) I see kids with the worst eating habits imaginable. Most kids buy lunch, which is just digusting-looking pizza, deep fried chicken, or other processed crap that's been sitting in a freezer for the last month. There is one kid who literally just buys cookies and brownies from the snack bar, and has that every day for lunch. I have friends who buy at least one soda from the various soda machines on campus every single day.

Most of these kids, aren't particularly unhealthy, but I have to wonder what some of them will look like in 20+ years if they keep up those habits.

This country is disgustingly unhealthy. And the worst thing is, most Americans think that science will cure them.
Are you fat? There's liposuction.
Have diabetes? There's insulin.
High cholesterol? They have meds for that.
Heart problems? The doctors will take care of you.

We have to wake up as a country and figure out that it just doesn't work that way.

Again, I know very little about the healthcare system, but I think that people who don't keep themselves healthy deserve to pay more for the care that ultimately won't cure them. I don't know how you would implement a system like this, but I shouldn't pay as much as someone who doesn't take care of themselves and is in and out of the hospital all the time.


Also, I like reading this thread. I've learned a lot.

[shally]

I know very little about the health care system, but I can tell you that this is true. At my school (I'm 16) I see kids with the worst eating habits imaginable. Most kids buy lunch, which is just digusting-looking pizza, deep fried chicken, or other processed crap that's been sitting in a freezer for the last month. There is one kid who literally just buys cookies and brownies from the snack bar, and has that every day for lunch. I have friends who buy at least one soda from the various soda machines on campus every single day.

Most of these kids, aren't particularly unhealthy, but I have to wonder what some of them will look like in 20+ years if they keep up those habits.

This country is disgustingly unhealthy. And the worst thing is, most Americans think that science will cure them.
Are you fat? There's liposuction.
Have diabetes? There's insulin.
High cholesterol? They have meds for that.
Heart problems? The doctors will take care of you.

We have to wake up as a country and figure out that it just doesn't work that way.

Again, I know very little about the healthcare system, but I think that people who don't keep themselves healthy deserve to pay more for the care that ultimately won't cure them. I don't know how you would implement a system like this, but I shouldn't pay as much as someone who doesn't take care of themselves and is in and out of the hospital all the time.


Also, I like reading this thread. I've learned a lot.

you have remarkable understanding for some one so young.. i cannot tell you how impressed i am with you and your comprehension of the system.
take care of yourself, you are off to a great start. you have only one body, and the way you treat it now, will have a profound impact upon you for the rest of your life..

my wife taught school and despite efforts to provide healthier snacks, kids just avoided them and went straight to the soda pop, cheetohs, and high fat items.. we are a nation in deep trouble because of the way our food supply is controlled by corporations who want to make vast fortunes by providing cheap crap for our citizens, especially young people to consume. the only solution is education in the home.. too many parents just give up and take the easy way out.

if you have any questions, or need answers for any medical issues, please feel free to send me a PM at any time and i will do my best to provide you with the best answer i know, or can research for you. it is my honor to do so, and part of my career mission to educate as well as treat.

you are welcome to participate and contribute to this discussion at all times.
your thought are well written and coherent. all the best to you in your future.

shally