Issues2004: Health care

Issues2004: Health care

: There can be no doubt that we are living in a health-care crisis in this country:

Too many are uninsured. Costs are too high at every level: doctor, hospital, drug, insurance. Insurance companies are trying to save money by making everyone’s life so miserable it’s just easier and cheaper to die. Paperwork alone is torture. Doctors are squeezed by malpractice suits and insurance — and paperwork. Hospitals are suffering. Employees who have insurance feel trapped by the jobs. Employers who offer insurance are seeing costs grow at incredible rates (40 percent in one year at one company I know). And on and on.

All the solutions proposed so far are inadequate and don’t begin to address the fundamental flaws, inequity, and illogic of the system. I’m not for nationalizing health care. But neither am I for letting the uninsured suffer.

This post is the first in a series on Issues2004. Remember that I am not an expert in any of these areas, nor did I report on them. I’m just a voter. And that’s the point. I want to learn more about these issues and want to have the forum to help push the candidates on these issues.

My wish list on health care:

: All citizens must be insured: If a prosperous society cannot help the sick among us, then what good is the prosperity?

Basic tenant: Every citizen (yes, citizen) of this country should be covered by health insurance and a prescription drug plan.

This also means that every citizen should receive the benefits of being part of a group. The serendipity of my getting insurance with my colleagues at one rate while my neighbor, who’s self-employed, gets higher rates is unfair, unjust, illogical, stupid, harmful, wrong.

And it’s expensive: Those who cannot afford insurance people end up going to hospitals and getting care that has to be paid for with higher rates for the rest of us, which means that insurance companies and employers and thus employees and consumers end up paying for the uninsured anyway. It’s broken. The only way to fix it is with the fundamental promise that all are insured. If we’re insured to drive, we should be insured to live.

: Insurance remains private: Who should run insurance? Government or industry. I say industry. The last thing we need is another inefficient and irksome government bureacracy. We need competition. We need choice.

: But who should pay? Think about it: By what logic should should employers have to be the ones who pay for health insurance? What started as a benefit of employment has become an entitlement for many, but then the rest are left out in the cold. Offering health insurance via work makes no sense.

My hope is that we all pay according to our needs with aid for those who need it. So I get a good group rate (see above). I earn a lot of money. I pay for my insurance. If I want, I can buy the deluxe insurance. If rates are fixed, most should pay for a good share of their own insurance (instead of paying taxes or higher product costs to indirectly subsidize their insurance).

Government support comes in a few forms: Those who help supplement insurance costs for employees or the poor get tax credits; that is one form of government support. Those who earn little and pay for their insurance get tax credits; that is another form of government support. Those who cannot afford to pay anything get on Medicare and Medicaid; that is another form of government support.

Who pays for that government support? We all do, of course, in the form of business and individual taxes. But run properly, this will end up being more efficient than the present system. And — pardon my lapse into supply-side social program economics — but the less companies have to build these costs into budgets indirectly, the better salaries and prices will be in the longrun. (Debate below.)

: Who should pay for R&D?: It is similarly illogical that through high drug costs, the sick underwrite R&D for new drugs to cure other diseases they don’t have. I don’t know how this system works today but it seems logical that government should help underwrite some cost of development — and then get the benefit for all of us of lower prices for the drugs that result.

I’ll say this again later, but I will add here: I support stem-cell research. I support science.

: The paperwork torture must end: Insurance companies are managing costs via harassment, in paperwork and in “managed care.” As I understand it, one great thing Canada did was standardize paperwork and bureacracy. With the Internet, it is now possible to standardize and modernize this entire system, from doctor to hospital to pharmacy to insurance company. It reduces the costs considerably for doctors and hospitals (and that should stop some of their complaining) and it reduces the hassle for us, the sick.

: Malpractice should be limited: But the threat of malpractice must remain over the heads of incompetent practitioners. We are still consumers of health care. We reserve the right to go after bad doctors — protecting fellow consumers from them — the way we can after bad contractors. And, yes, lawyers must stop being the primary beneficiary of the malpractice system.

: We must grapple with extreme care: I don’t want anyone unplugging me and letting me starve or choke to death. No thanks. And I hate seeing old people treated like the leftovers at garage sales. But I also recognize that some care is extreme and costs everyone a great deal of money for buying little hope. Who should set and enforce the standards of what is covered and is not? I don’t know. Debate below.

Here is Bush’s health stand. Here (with additional links on the side) is Kerry’s health stand. And what do you have to say?

: UPDATE: TB in the comments raises a good point: People who don’t take care of themselves cost the system and us. So how about higher rates for people who not only smoke but, what else?, get fat, don’t exercise, don’t get preventive tests on a set schedule….

: UPDATE: A previous post on this topic is here. It caused good discussion and I wanted to link to it … but disorganized mess that I am, I couldn’t find it. Thanks to Brett, here’s the link.

  • nyc_dr

    15% of our GDP is spent on health care; yet premiums rose 14% in 2003, and 40m people are uninsured. This is an emergency.
    All the suggestions made in your post are reasonable, but the biggest impact we can have on insurance costs and health care costs in general is a preventative, public-health oriented system of medicine. In the long run, not only is it far and away cheaper, but it’s makes us all healthier and happier.

  • Kat

    I believe in loving thy neighbor as myself. I believe in the good Samaritan–but I don’t believe in being a fool. If it’s free it gets abused. We have a huge illegals problem–free health care will only make it worse. I don’t want to pay for free abortions and I don’t think it’s right to kill a baby so you can live by taking its parts.Sure we pay to be insured to drive. Will we soon be expected to buy auto insurance for all?
    Canada has a problem. People die waiting for that free health care. It is abused because it can be. They have lotteries to pick who gets on a doctor’s list. Canadians pay half their salaries in GST, provincial taxes, and personal income tax to sustain an ailing system. And Canadian doctors flock south. Canada has to recruit for doctors in Africa, etc.
    I would like to see insurance more affordable–but not free. When you pay for something, you appreciate it more. I don’t know what the perfect answer is. I know being a welfare state isn’t it.

  • T-B

    Jeff, I think something else should be added to your list. As a health care worker, I see a lot of people who get admitted to the hospital that get sick because they don’t take care of themselves. I’m not just talking about the grossly overweight. There’s the people who smoke and don’t quit, who abuse drugs or alcohol, diabetics who don’t take care of their diabetes, people who contract STDs, trauma victims who find themselves on life support because of some stupid, crazy act they did. Etc.
    It’s frustrating beyond words because it seems that there’s way too many of these people who don’t take care of themselves and they also don’t have insurance or a way to pay the providers for treating them for the hospital stay that could have easily been avoided. Yet many of these same people are complaining about health care being too expensive or unaffordable. Or someone else should pay up for them. It blows the mind.
    If more people lived healthy lifestyles there would be less strain on a system that’s already stretched.
    We’re busy blaming other entities for the cost crisis in health care. Not that some of these entities don’t deserve the blame they receive (like the government and tort lawyers) but one group that gets a free pass is us as a nation. Some of this is OUR fault. It’s high time we start asking for greater accountability from ourselves.
    You’d figure that as expensive as health care has become people would think long and hard about protecting one of the most precious commodities that we posess; our good health. And realizing that by not taking care of our good health that we’ll end up not only feeling miserable but flat broke. But no.

  • Kat

    {UPDATE: TB in the comments raises a good point: People who don’t take care of themselves cost the system and us. So how about higher rates for people who not only smoke but, what else?, get fat, don’t exercise, don’t get preventive tests on a set schedule….}
    What about people who are gay and are at greater risk of contracting AIDS, people who have several abortions, etc. They should be considered health risks and pay more. A poor driving record makes you a risk for auto insurance.
    Problem is that people who are poor can’t afford eating 5 veggies a day, etc. Their lifestyle may not be healthy thru no fault of their own. And people who smoke contribute more to the government coffers than any other group already. I imagine they already pay for their habit in many ways. If they all stopped smoking, there’d be a huge void in tax dollars–billions. Same with alcohol,I think. So can we tax people for engaging in sexual practises which may be unhealthy? We know the risks of smoking and we know that gays are more likely to get AIDS. We also know about AIDS chasers–I have a real problem giving free healthcare to the latter idiots–let them jump off a cliff. It’s a slippery slope when you start penalizing peoples’ habits.

  • God, it’s great to see the ignorant debating the uninformed.
    For anyone interested in actual things that will work, here’s the abstract of the report of the AMA’s Physicians’ Working Group on Single-Payer National Health Insurance, which (in the full report) contains lots and lots of detailed proposals on how to get to lower-cost coverage and cover the entire population at the same time. You can google around for the full report; JAMA hides it behind a pay firewall.

  • Kat

    Mithras–what sounds good on paper isn’t always great in reality. If it was so easy, Canada could fix its system. They have closed thousands of hospitals, they now have centralized health care so they drive hundreds of miles to a city hospital because the town ones are all closed or have become seniors’ homes because the system can’t afford them. Sick people can’t get to see a doctor because the lineups are longer than those to a rock star’s concert. Doctors see hypochondriacs for free while sick people die. People get free sex change surgery while people needing a heart bypass wait. Women use free abortions as a means of birth control–some have 4 or 5.
    Easier and cheaper than being responsible for popping a little pill.
    Do you want quality care or quantity care?

  • jr543

    Doctors see hypochondriacs for free while sick people die. People get free sex change surgery while people needing a heart bypass wait. Women use free abortions as a means of birth control–some have 4 or 5.
    actually kat, i hear that those evil canadian fembots eat their babies, and that the crazy socialist government taxes them for the privilege to do so!

  • Kat

    And here I believed that they just flushed them down the sewer.

  • “God, it’s great to see the ignorant debating the uninformed.”
    Yeah, shut up, you peasants! Your Betters will decide for you.

  • Health plan published by Erskine Bowles, who is running for John Edwards’ Senate seat in NC.

  • Jeff,
    I’m thrilled to see you do this! A few points:
    – I am surprised that you started off with Health Care because we had that forum here in on your site already. That dialogue was terrific. Perhaps you could resurrect some of the more salient points from the comments in that thread.
    – Our society educates ALL children through tax payer subsidy for the betterment of society – because an educated workforce sustains the society (and young parents can’t afford the education of their children). If anyone agrees with that rationale, then they should agree to subsidizing the health care of children. After graduating from high school or a 19th birthday, private insurance kicks in.
    – I could not agree more that health insurance through work is wrong-headed. It’s not only a distraction for employers, but it also stifles small business startups as well, because they can’t compete for quality workers like the big companies can in terms of benefits.
    – I’m glad to see that you embrace choice and privatization, but to couple that with TB’s point about varying risks in the market takes us to a system that is not unlike today’s system. The only thing missing is the safety net for the uninsured.
    “If we’re insured to drive, we should be insured to live.” Consider that there are people who cannot drive because their insurance costs are prohibitive due to the risk factor of the individual. Since you’ve drawn the parallel, what do we do for people who have such behaviors in their lifestyle as to preclude them from affordable health insurance?
    Auto insurance is fairly unapologetic about behavior-induced high rates. But to do that with health begins to get into the tricky ground of underwriting morals.
    For example, driving my car recklessly threatens everyone and is therefore universally deplored and so my higher rate is okay with society – in fact, they might even like it if I can’t afford insurance to keep me off the roads. On the other hand, my habitual skydiving threatens no one. Should that personal choice prevent my ability to afford health insurance?
    Again, very cool that you’ve opened this up. You’re the man!

  • Jaybird

    Part of the problem with treating Health Care as a right is the problem of mortality. People die even if they take perfect care of themselves, eat right, don’t smoke, drink, or chew or dance with girls that do.
    And there will be a blurring between “a right to health care” and “a right to not die”.
    We can debate whether the former exists… but there ain’t no such thing as the latter.

  • Mithras:
    What did it add to start off with the snotty snark? Couldn’t you just contribute the link — as I invited you and everyone to do — without the gross insult? Restrain yourself, please.
    And why did you have to answer, snark for snark? As I tell my children: Ignore him; that is the best revenge.
    I start off with health care because (a) I think it’s important, (b) I didn’t deal with it as systematically before and wanted to tie up those ends, (c) it was on my mind, (d) order is not prioirity, (e) it’s a blog and such serendipity comes with the package.
    I’ll be blogging the other issues as I get to them and please don’t read into that some greater ranking. Thanks.
    Everyone: Thanks for the good links and discussion; keep it coming.

  • Jeff,
    Wasn’t trying to curb your effort – there was some great contribution in the previous conversation that I think would blend in well here, and it may be missed.
    Again, I’m thrilled that you’re doing this. I hope it starts a trend.

  • Jeff, it’s a little late in the day to complain. In case you haven’t noticed, scarcely any of your blog comment threads have gone more than two posts before the trolls leap in and hijack them. Mithras is one of the offenders. He can’t seem to make a single comment here without prefacing it with a “you stupids” sort of remark. If you’ll forgive me, you haven’t had a very good record of slapping down these trolls in the past, so those of us Mithras et al disapprove of have had to take care of ourselves. Now you are smacking virtual hands — huzzah. But I’m not psychic — I had no way of knowing you were going to come riding in on a white cyberhorse. However, since you have finally taken charge of your own blog you’ll find no more snark here from me.

  • Well, Andrea, I can start now. And I will. Stop the snarking.
    I do not read the posts by the snarkers. Life too short. Snarks too dumb. I know I’m not alone.
    If you prefer, I could come in and sanitize each post for stupid snarkiness. I choose not to. Don’t want to waste the time. Don’t want to cut off the discussion.
    I specifically asked in this post for contributions of value.
    I didn’t ask for snarks.
    I have no problem at all banning you and Mithras and Shark and others who love to snark for snarks’ sake.
    Is that what you’re telling me I should do in your latest post, because you choose to complain that I don’t kill the snarks.
    Snark gun ready, lady.
    Now please behave.
    And let’s get the discussion back to the topic at hand, please.

  • You might want to specify which stem cell research you support. I’m guessing you mean the controversial one – embryonic – which is also the less accomplished one, in addition to the uncontroversial adult stem cell research. For every news story I see about adult stem cell research, which is being used successfully in treatment now, I see five about embryonic stem cell research, which is still largely theoretical and has already done damage in trials because of the unpredictably of embroynic cells once implanted. We’re mostly arguing about ethical issues between the two instead of looking at which one has more promise for us right now, not 40 years in the future, which I think is sad.

  • Jessica

    We cure people so they can die of something else. Two statistics from an article in the NYT’s: Mr. Dillon’s age group, 65 to 74, 3 percent have Alzheimer’s; in the 85-and-over group, it is a staggering 47 percent, according to the National Institutes of Health. The number of afflicted will more than triple to 14 million by midcentury, according to health care experts and demographers.
    My father at age 74 has been diagnosed with Alzheimers. Does it make sense to continue to treat him for his high blood pressure and heart disease? Which death is the more merciful? Boomers in this country need to be at the forefront in rexamining the cost of their mortality.
    I tend to favor universal health care from pre-natal care up through the age of 25. After the age of 25, every employed American ought to be enrolled in a Health Savings Account where they budget and pay for their medical care with pre-tax dollarsfor the first $2,500 in expenditures. The HSA should be paired with a private insurer for catastrophic coverage. Insurance should be decoupled from employment.
    After the age 72, for those on medicare, health care should be rationed in the sense that we offer palliative care rather than agressive treatment for incurable diseases.

  • Anyone interested in an alternative viewpoint, written by someone who has lived under both systems,
    click here

  • Brett… The embarrassing thing is that I can’t find that particular post… If you can, please do pass on the link… And I didn’t think you were scolding; I just wanted to respond and make my lack of a system clear….

  • Kat

    Jessica–you want to play God. What right have you to determine that the life of a 72 year old is not as valuable as a 30 year old patient with Aids? He’s gonna die of aids which is incurable so why treat? That’s your theory. Why not institute universal euthanasia along with health care as you suggest? Then doctors can just kill patients requiring expensive procedures or incurable diseases. You are proposing selective care like Hitler proposed a selective race. That is just so wrong. A life of a 70 year old person is as precious to them as our lives are to us. How dare we decide to ration health care for them and yet ask them to help pay for such a system? I want to save my money so when I’m 70 I can afford insurance and won’t be bumped off by Jessica.

  • Jeff,
    You can find that former health care post here:
    You mentioned a while back the notion of content and delivery. I put this into the context of ideas – where I either create (content) or I pass along (delivery).
    Some blogs simply focus on delivery – they find an interesting post and link to it. Others focus on ideas (content). The harder of the two is the second, obviously.
    Between you and your less-snarky commenters, I find that your site one of the best content sites on the web. It’s the reason I’m hooked.

  • Andy Freeman

    > If rates are fixed,
    Then what are the odds that the rates are fixed correctly? And if they’re fixed correctly this year, what are the odds that they were correct last year or will be correct next year? (Feel free to define “correct”, but don’t be surprised to find that there are huge problems with every definition.)
    Govt price fixing tends to be below cost to provide service, so the service will be inadequate.
    > So how about higher rates for people who not only smoke but, what else?, get fat, don’t exercise, don’t get preventive tests on a set schedule….
    And if they don’t pay, what then?

  • How about a greater focus on prevention of problems rather than just treating illness, a penny of prevention worth a pound of cure or some such thing.

  • Rosemary

    the problem in a phraze is “first dollar coverage”. Health insurance is no longer “insurance”, ie coverage for the disaster. Stop the co-pays, stop the low deductibles and you will stop people walking into emergency rooms for the sniffles. People pay for their own normal healthcare maintenance costs but have insurance for the treatment of diseasees and hospital stays. They also pay for prescriptions unitl the high deductible is met ($5k-$10k). Prescription abuse is rampant by doctors and patients, and the drug companies are reaping millions. You won’t find everybody and there uncle on Prozac and getting an anti-biotic for just about anything unnecessarily, and don’t get me started on Viagra an the like. Drug R&D can be easily supported without the gouging that currently takes place, read their financial statements, I have(especially if they are not wasting their money on the next Viagra!! how may impotency drugs are there now?? watch an nfl football game and you will know.

  • Andy Freeman

    > It is similarly illogical that through high drug costs, the sick underwrite R&D for new drugs to cure other diseases they don’t have.
    Actually, it makes a lot of sense. Folks who have successfully produced valuable drugs in the past are far more likely to do so in the future than folks who haven’t.
    Also, the carrot and stick both work. People who are investing their money make better decisions than people who are merely directing public money, and I don’t care if people lose their money. People who stand to gain make better decisions than people who don’t.

  • Jarvis:
    You’re right. What you’re doing here is a good thing. I apologize for the snark.

  • Mithras:
    Thanks for that. A menschy moment. I appreciate it. Discuss on!

  • T-B

    I have liked the idea of higher premiums for people who put themselves at higher risk (by not taking care of their health) for developing health problems.
    The problem is that, and I could be wrong about this, is that people in the past have gotten upset about feeling discriminated against. Especially the overweight folks.
    I look at it this way. I have to pay a slightly higher car insurance premium because I’m a guy, I have racked up a few speeding tickets and had a fender bender. So the insurance company says I’m at a higher risk for more accidents and due to my driving history and they think I should pay more. Makes sense to me though I don’t like having to pay out more $$. Yet whose fault is all that? Mine and mine alone.
    I’m a pretty healthy guy, I don’t smoke, I don’t drink, I’m not a 500# couch potato. Why should I pay the same rate as the guy who does any or all of the above?
    BTW hear hear on not getting a health plan through one’s employer. We don’t go to our employer for home, car, or life insurance. Well, a lot of us don’t anyway.
    Another thing we could all collectively touch upon is the cost of health care that is given to illegal immigrants.

  • jr

    As a self employeeed non-insured person, I find that the 4000 to 6000 that Blue Cross pays for an appendectomy is far less then the 18000 I had to pay for what was basically one day of hospitializion.
    I have concerns with “deluxe insurance”. Will we soon have a separate private entrance for the deluxe patient?

  • Kat

    T-B, though I feel like you do,I truly don’t see a system that discriminates against smokers or fat people as one that can work. There are too many others that would have to be considered high risk. What about a criminal who gets shot, or gang shootings, or people smashing a beer bottle in each others’ faces. Do these immediately become high risk? I don’t think it should be run by government but it should be made affordable. I don’t care if it’s through the job or not, there should be a system where everyone pays an equal share and everyone gets equal care. There need to be family rates to cover kids. I want to be able to choose my doctor and I don’t want government in control of my life. Small businesses should pay the same rates as large corporations if it is a pay deduction.
    And yes, it is bloody time our government, present and past, did something about illegal immigration–that one issue is bankrupting California. Just apply the frigging laws.

  • Charlie (Colorado)

    Jeff, while grousing about the snark is fine, Mithras also had a point: a good bit of this is the ignorant debating the uninformed.
    I’ve done a fair bit of work for the insurnace industry, and do a lot of work that makes me a fair scratch actuary, even though I’m not a licensed one; as such, I suspect I’m a little less ignorant than most, and you know what? The more I learn, the more convinced that this is a hard problem. Hard in the sense that I’m nt at all certain that a satisfactory solution exists, or can exist.
    If you look back at the previous thread, you’ll see a number of questions about single-payer schemes. We can ask a pretty much analogous bunch of questions about this scheme:
    (1) Health care costs are growing at between 3 and 4 times the rate of inflation and about twice the rate of growth of GDP, last I saw any data. Unless, and until, you can propose a way to reduce that rate of increase to be not greater than the rate of growth of GDP, you will always and inevitably find that health care costs eventually exceed any scheme to pay for them. How can that rate of growth be reduced? What’s the root cause of the increase?
    (My own feeling is that the combination of liability costs and the Dr Welby mythology that a really really good doctor can cure everything from hives to glioblastomas and get the plain girl a date to the prom in his spare time leads to exceedingly high costs. But I don’t know that, and I don’t know of any data that can be trusted not to have a political slant.)
    (2) In every case I’m aware of — I’d be happy to hear counter examples, but I bet I don’t — “universal” health care has had two effects: the regular people get rationed, while the political elites and the very rich get whatever they want.
    This scheme seems certain to have the same problem. How will you manage the rationing, and will you be willing to accept a situation in which Senators get better health care than the proles?
    Even when a pretty nine year old girl is not getting the neutron-activated boron treatment for her glioblastoma that Bill Gates’ kids could fly to Japan for?
    (3) Drug discovery is an inherently hard problem. From what you wrote, it may be a surprise to you that a very large part of drug discovery, or at least the basic research that leads to drug discovery, is already government funded, via the NIH, NLM, and NSF. The R&D costs that are paid by the drug companies largely arise because of the costs of doing the studies that are needed to meet FDA requirements. In other words, they are regulatory costs.
    I don’t, frankly, see any way to dramatically reduce those costs — and if I did, I’d be way too rich and too busy to be blogging about it. I’m also very suspicious of the notion that the government could pay those costs and achieve the same results we already get, much less actually reduce the costs, without also reducing the stringency of the testing process.
    Are you willing to see the testing reduced, and accept the inevitable result that we’ll get more surprises than we do today? Will you accept the notion that the drug companies should be indemnifed, or their tort risks limited, as well?
    (It’s instructive to consider thalidomide in this respect: first it was an atractive non-habituating sedative, then it was the Spawn of the Devil, and now it’s an attractice “new” treatment for everything from leprosy (Hansen’s) to lupus to some cancers. Same drug, same risks. Why was it absolutely forbidden instead of being marked “do not use if you are pregnant or may become pregnant”?)
    (4) As I discussed in te previous note, a lot of the issues of health insurance have to do with the size and composition of the risk pool. A small, healthy, risk pool leads to low insurance costs, but a small pool is vulnerable to the occasional catastrophe. A large pool is less vulnerable to the random catastrophe — or rather, it’s more certain that the random catastrophe can be expected — but inevitably means that the costs of healthh care are tranferred from the health who overpay to the sick who underpay. They won the lottery.
    Is it really fair for the healthy young to pay health care costs for the sickly but relatively well-off elderly? Involuntarily?
    I’m sure I could think of more questions, but I’m tired and it’s kind of late. For convenience sake, I’m going to close this off, and tell you what I think might answer some of these objections in a separate post.

  • Jeff,
    I find it interesting that you started with a “right to health insurance” rather than a “right to health care”.
    I think some of the more creative economic solutions that decrease the amount of low-end insurance might be overlooked.
    I think that the economic ideal will occur when wealthy people find it less expensive to pay health costs out of pocket than to have insurance.
    This would indicate that insurance companies are appropriately compensated for spreading the risk of unanticipated health problems.

  • steve

    As tax payers (soon to be health insurance providers?) do we get to decide what we pay for? Hardly.
    We will pay for:
    Intravenous drug users who contract HIV/AIDS,
    Injured motorcyclists who don’t wear helmets,
    Automobile drivers who become injured due to reckless driving,
    Excessive Smokers,
    Excessiver Drinkers,
    Couch potatoes,
    People who eat pasta at every meal,
    People who don’t exercise,
    How would a government health care system make this less expensive?
    Isn’t it simply punitive to charge a higher premium for those that partake of the above listed behaviors? How will you compel them to pay? Will you deny them treatment if they don’t?
    What benefits, in terms of lower cost and higher service, will be achieved by a government run health care system?
    Or is providing health insurance to the 40 million people who aren’t already covered (regardless of why) the primary goal?
    Would it be cheaper to have the government simply subsidize a private insurance policy for the uninsured? Or how about just giving them a check and let them spend it how they wish?

  • Charlie (Colorado)

    Okay, it really isn’t fair to just ask hard questions, so here’s another scheme.
    (1) Let the self-employed, the unemployed, and people who don’t receive insurance as a benefit, buy health care using pre-tax dollars. (There is an approach to this now, with medical savings accounts; I hope to move to that kind of coverage myself next year.)
    Alternatively, make all health care coverage optional, part of taxable income, and a line item in a pay statement.
    (2) Put a responsible upper bound on malpractice tort awards, and forbid contingency-percentage fees.
    A hot new topic in the medical world is “going naked”: not buying malpractice coverage at all.
    Given that an OB/GYN is sued for malpractice, on average, every other year, this may sound nuts, but it actually makes some sense. It not only eliminates the amazing costs of malpractice insurance, it also protects you against most malpractice suits: with no deep pockets to empty, the ambulance chasers respected trial attorneys can’t make millions off a big award; there’s a real incentive to find a solution that makes sense. (Of course, if you make an oopsie, it could impoverish you, but the answer to that is to try not to make any oopsies.)
    When the costs of lawsuits are accounting for thirty to fifty percent of the costs of the good, there’s something wrong somewhere.
    (3) Set up very high deductible catastrophic care policies, or rather, make them more commonly available than today. Catastrophic care coverage can be very much less expensive than the “first dollar” coverage we’ve started to expect, because catastrophes are relatively rare.
    If you really want it to be universal, then you have to find a way to make it compulsory to have coverage. There are a spectrum of tradeoffs to be made, from a “single payer” catastrophic program to simply allowing people to buy catastrophic care insurance if they want it. If you don’t nationalize it, then you’ll probably have to set up an “insuror of last resort” to cover the people who are otherwise not good actuarial risks.
    (I’m not necessarily arguing for this last: these schemes haven’t been all that successful in car insurance.)

  • Walter E. Wallis

    If some judge were to decide that since you need gas for your car to go, your car insurance must buy that gas, what would happen to car insurance premiums?
    The tax free benefit, including health care should be taxed as ordinary income. You should be able, as I was for over thirty years, to buy a high deductable policy that requires you to pay for ordinary medical and dental costs but takes care of the big bills when they occur. You should, equally, be allowed to buy cadillac, first dollar coverage if you want to pay the cost. Any medical care that is mandated by law must be paid by the mandating agency. Southern California hospitals are going broke because they cannot bill the Mexican government for care given to indigent Mexicans. Judges have added birth control pills and erection pills to ordinary coverage, and California’s workman compensation insurance treats pregnancy as an on-the-job injury. Judges should be required to respect contracts.

  • Andy Freeman

    > I don’t care if it’s through the job or not, there should be a system where everyone pays an equal share and everyone gets equal care.
    How are you going to make folks pay?
    Equal as in equal amount? The progressive tax folks are going to eat you alive.
    Want to bet that the various forms of health nazis don’t go for punitive charges for things that they don’t like? (Frankly, they’re enough to drive one to drink and they make slow suicide seem like a good idea.)
    > There need to be family rates to cover kids.
    As in you want a subsidy for your kids?
    If I’m paying, I’m going to ask for control….

  • Kat

    No, I want to pay for my kids on my plan–I don’t want you or anyone else to pay for my kids. If I am paying, my primary interest is providing the best that I can for my own kids. I already pay for health, dental, pharmacare, Blue Cross. I was thinking of an affordable plan for those who don’t have insurance. I don’t think a National plan is feasible. I was thinking out loud. I want to make the decisions for my kids–not some bureaucrat. I would like to see affordable insurance for everyone and I like the idea of doctors not buying insurance and thus no big payout. I’m for affordable insurance not free health care where one size fits all.

  • To Mithras’ and (sort of) Charlie’s point about “the ignorant debating the uninformed”…
    Are we ignorant? Sure. Uninformed? Sure. But does that mean that we shouldn’t discuss all of this? You and I, we choose the leader of the free world. Based upon what – gut feeling? Good looks? Party label? Plan? Team and leadership?
    A good debate can inform with great insight like yours, Charlie. We need to be informed.
    But even if we are uninformed, life isn’t rocket science. There are principles that apply to pretty much all of life.
    – People do better for all society when something is expected of them. If we can agree that this is true, then it’s an argument for everyone paying something for their own health care.
    – People tend to fare better when there is less chaos in their life. If we can agree that this is true, then it’s an argument for portability in health insurance, independent of employment.
    – Courts should not be not lotteries and doctors should not be expected to be errorless or omniscient. If we can agree that this is true, then it’s an argument for caps on lawsuits. (I’d also argue for visibility in a doctor’s/nurse’s/hospital’s legal history.)
    Pick other principles… I’m sure they apply. If I apply these principles that I know to be true to the decision of what plan makes sense, then it’s not really “the ignorant debating the uninformed.” We should discuss this. A lot.
    What I find difficult in debate is the absence of principle driving decisions or beliefs.
    For example, some people say, “Everyone should have a right to health care.” That becomes their first and final assertion, as though it can’t be debated. You’re horrible if you don’t agree with it because how in the world can anyone disagree with providing health care to the sick?
    The problem with the statement is that “health care” is a service, which requires someone else’s time and expertise. I don’t have a right to take anything from anyone else without their permission or without fair compensation (another principle).
    The next argument from those who assert “a right to health care” is that in a rich democracy like ours, can we not provide this? Which is very close to (or the same as) Jeff’s statement: “If a prosperous society cannot help the sick among us, then what good is the prosperity?”
    I ask: what principle?
    It wasn’t long ago that Hillary Clinton said: “Many of you are well enough off that … the tax cuts may have helped you. We’re saying that for America to get back on track, we’re probably going to cut that short and not give it to you. We’re going to take things away from you on behalf of the common good.”
    What’s the principle? Is she right?
    I think this is where we can all debate, without ignorance.

  • Equal care for equal pay? That’s communism. It doesn’t work.
    All citizens must be insured? Whatever, health care is NOT a right.
    Insurance remains private? Absolutely.
    But who should pay? Everyone who can afford to.
    Who should pay for R&D? All of us to some degree.
    Malpractice should be limited. You can’t limit that. What’s the price of a lost human life?

  • For what it’s worth, I wanted to learn how employers came to be the chief providers of health care in America.
    Here’s a PDF link to a paper by Laura Scofea, economist for the US Bureau of Labor Statistics.
    It’s a pretty interesting read, covering the genesis of health insurance, employer provision, and HMO’s.

  • And a health care timeline, courtesy of PBS.

  • Greifer

    I’m really looking forward to the day that the govt wants to know if I’m a gay man so that they can tell me my chances of contracting HIV mean my insurance premium should be higher. I’m really looking forward to the day when the govt wants to know my sexual history for the same reason. I’m really looking forward to the day when the government has a vested interest in finding correlations between my spending habits and my health patterns.
    You cannot make services cost nothing; you will only incur the cost somewhere else. And when the costs appear to be free, people will use more of those services. not sure if you’re sickness warrants seeing a doctor? if it’s free, go anyway. not sure your aches and pains are cancer or just old age, but you want to be sure even though you have no reason to suspect the worse? if it’s free, you’ll go anyway.
    catastrophic insurance is something reasonable people can argue about. but your attempts to make things “more fair” result in all of us suffering more.
    answer this: would you prefer that everyone–EVERYONE– had an objective improvement in their quality of life over their quality today, but those best off had their quality go up more than others? or would you prefer the worst off to have their quality of life decline if you could ensure that the best off were closer relatively, to the bottom?
    your ideas lead to the latter case. be careful about this “fairness” you wish for: the only time everything is fair is when we are all dead.

  • Raspil

    “If we’re insured to drive, we should be insured to live.”
    that’s beautiful and it makes sense.

  • Robert Brown

    ***”Equal care for equal pay? That’s communism. It doesn’t work.”****
    No it isn’t. “Care to those who need it, paid for by those who can afford it” would the communist philosiphy.

  • Kat

    “If we’re insured to drive, we should be insured to live.”
    The government doesn’t pay for our auto insurance. If we are high risk, we pay for it. If we are low, we reap the benefits. If we are going to equate the two, then risk must be a factor for health insurance And there we start slipping down that slope.
    Maybe a two tier system could work–public and private.

  • Charlie (Colorado)

    Are we ignorant? Sure. Uninformed? Sure. But does that mean that we shouldn’t discuss all of this?
    Of course not. Next, let’s discuss de Bruges’ proposed proof of the Riemann Hypothesis.

  • Kim

    I started googling information about 2 weeks ago to see if anyone had put out a proposal to change health care in the US. (Your 9/11 memorial proposal gave me the idea to search this way) This Doctor has written a really good proposal that might be worth a look. If you click on the site overview you’ll see he put a lot of time and effort into it. The only thing he didn’t address is non citizens.
    All American citizens would have health insurance – each selects their insurance company each year from among all insurers operating in their region. Patients are responsible for paying a percentage (? 20%) of all services they receive with a maximum amount per service and a maximum amount per year. Those with low income pay a smaller percentage (? 2%) and have lower maximums. Funding for the premiums comes from an income tax and employer payroll tax dedicated solely to health care – this replaces all current health care funding methods (employer and individual purchasing of insurance policies, state and federal taxes including the Medicare payroll tax). A quasi-governmental over-seeing agency (which is not an insurance company) supervises the system including establishing uniform billing procedures and developing / distributing (for free) / maintaining software for billing and medical records. What is covered in the basic insurance plan is decided by votes of the people – the more covered the higher the tax rates.

  • Cute, Charlie.

  • slim

    Your Issues2000 post on health care had me turning purple … again. Anytime I hear discussion about this particular topic, it makes me go apoplectic.
    Let me see if I can understand this. You say:
    We are in a health-care crisis because “too many are uninsured.” Did you mean that we are in a “under-insured crisis?” Because you have defined the problem as an insurance problem, rather than a health care problem.
    Let me expound: Are people NOT BEING CARED FOR? This is what you suggest when you say that there is a health CARE problem. You suggest that, because people don’t have insurance, that, somehow, they aren’t receiving care … prove this to me please. Demonstrate that people are being turned away from our hospitals and clinics because they do not have health insurance.
    I’ll be open-minded to hear your evidence, however, I haven’t noticed 40 million people milling around the nation’s hospitals moaning and nursing their broken arms all the while being told to get off the property until they can show proof of insurance. Seem’s like I’d notice if 40 million people without health insurance MEANT that there were 40 million people who couldn’t get into a hospital.
    You equate INSURANCE with CARE. You say: “All citizens must be insured: If a prosperous society cannot help the sick among us, then what good is the prosperity?”
    Let me rephase you without changing your meaning: “A prosperous society cannot help the sick among us unless it provides them with insurance.”
    Shouldn’t you be saying this instead: “A prosperous society cannot help the sick among us unless it provides them with (free) health care.”
    Insurance is just a collective agreement from everyone to split the cost of something. That’s all it is. Insurance is about SPREADING COSTS … not about PEOPLE GETTING HEALTH CARE. Insurance is JUST about how we’re gonna pay for it, not whether we’re getting it.
    You seem to admit later on (although I don’t think you meant to) that there really isn’t a health CARE problem: “Those who cannot afford insurance end up going to hospitals and getting care that has to be paid for with higher rates for the rest of us …” I snipped there to demonstrate my point. You as much as ADMIT that, even without insurance, health care is provided to ANYONE in our society, and you’d be right. Having had in the past the benefit of free health care, I can tell you, it’s great – no forms to fill out (heh).
    Hey, I have an idea … what if everyone who went to the hospital paid their own bill … kind of like what happens in a restaurant. After all, I have to eat to live, don’t I? Why aren’t you helping to pay for my dinner?
    Finally, let’s look at the nation’s TOP health insurance companies … uh well, this information seems to be missing. How bout some facts: please report back with the top 10 health insurance companies by the revenues they generate and the profits they had in the last 10 years; typical profit margins in this industry; and quote some economists on what the likely effect of those profit margins would be if 40 million people are suddenly forced to pay for health insurance whether they want it or not.

  • Andy Freeman

    > I was thinking of an affordable plan for those who don’t have insurance.
    What if they don’t want to pay?
    BTW – Insurance schemes that require cross-group subsidies soon discover that folks who think that they’re on the wrong end won’t cooperate.

  • Jack Tanner

    Slim – Agree with you 100%
    “A prosperous society cannot help the sick among us unless it provides them with (free) health care.” – It’s not f’ing FREE! Paid for by someone else doesn’t mean it’s free.
    ‘I haven’t noticed 40 million people milling around the nation’s hospitals moaning and nursing their broken arms all the while being told to get off the property until they can show proof of insurance.’ – absolutely right – the advocates for the plight of the uninsured need to acknowledge the reality of this – and the reality that they are really just trying to come up with a subsidy – not judging morality of this but they need to acknowledge why the uninsured are uninsured and that any sort of buy in program should be a supplement to private insurance and the indigent are already covered by Fed programs.
    Lastly more gov’t programs > better health or healthcare. If the objective is to provide an insurance card to everybody, fine say it but personal health is complex and affected by many factors and coming up with any sort of single payer system is going to little or nothing to change that.

  • First, Jeff, you’re the greatest! This is the discussion we need to be having—not just health care but all of the issues. You go!
    Second, I’ve given my response at (probably too great) length on my own blog here to use my own space and bandwidth rather than yours.
    One word, however, on the subject of blaming the patient. No doubt some health problems are due to smoking, overeating, doing drugs, riding a motorcycle without protective equipment, not wearing your seatbelt, and not looking before crossing the street. I don’t want to diminish the misery of people with serious health conditions brought on by any of these means but what in the world is anyone going to about all of the possible lifestyle issues that may cause serious health problems? Ain’t going to happen, folks.
    And how do you know that this particular case of obesity is caused by overeating rather than genetic abnormality? That this particular condition is self-inflicted? If you don’t know without any possibility of doubt, what’s the difference between claiming bad lifestyle brought on the problem and claiming that evil spirits brought on the problem?

  • It’s pretty clear there’s not a lot of understanding of health care costs and financing:
    “The last thing we need is another inefficient and irksome government bureacracy. We need competition. We need choice.”
    This is flat out wrong. HMOs, on average, spend 11% of their budgets on paperwork (with the deviation being between 8-25%). Medicare, an “irksome government bureaucracy,” runs at 2-3% administrative costs, and Medicaid runs at 6%. Canada is down around 2-4% as well.
    On TB’s point: risk analysis is a slippery slope. We all take risks in life. If we have some sort of national system, it would encourage voters and politicians to support healthy policies and legislation.
    Unless we’re planning to risk-adjust all these groups to make things more even, the way it’s done in Germany, there will always be cherry-picking and risk avoidance, and the sicker will always be at risk of having sub-standard care, which defeats the whole purpopse of providing health insurance for everyone.
    We need single-payer national health insurance.
    What Is Single-Payer?

  • Sandy P

    Our “allies” need to start paying their fair share.
    Frasier Institute in CA covers Canadian HC. And Canucks are dumping $41 Billion Loonies into improving their care, see Daimnation and Colby Cosh.
    If people want to grab 1/6 to 1/7 of the US economy, you’d better be able to discuss Canada, Britain, Scotland and Australia at minimum. Their papers are in English. All have massive problems.
    Marginal Revolution also had some interesting posts around 12/4 or 12/ll/03 as to who the uninsured are.
    And until we realize we’re all going to die, we’re never going to move the conversation forward.

  • Don Mynack

    Single payer is not only a dog, it’s a dog with fleas. What health emergency is prompting this call to suddenly pick up the health costs of every citizen of the country? An epidemic of some sort? A natural disaster? I choose to purchase health insurance because I believe that I need it for myself and my family. There have been times in my life that I have voluntarily had no insurance – the cost/benefits didn’t work for me.
    I think a simple, workable solution to the “health care crisis” would be an expansion of the medical savings account plan in size and length, making it revolving on a 5 year basis and raising the amount of tax free money one can contribute. This would allow workers and/or employers to purchase higher deductable policies that would substantially reduce costs. Workers would benefit from the negotiated hospitalization rates and drug discounts that insurance companies receive, yet also benefit from the discount that doctors give for prompt payment – payment that could come directly from the worker’s Medical Savings Plan. These plans would use a debit card account system (no more clumsy reimbursement paper system) to authorized providers. Also, insurance for the self employed should continue to be 100% deductable, as it was made in the 2002 tax reform bill. I was self-employed for most of last year and that reform alone was of great assitance come tax time.

  • Jack Tanner

    ‘If we have some sort of national system, it would encourage voters and politicians to support healthy policies and legislation.’
    It would encourage voters and politicians to take more of other people’s money for what they want.

  • Inspector Callahan

    In response to Graham’s post:
    I’m someone who has worked in the “administrative” cost part of healthcare for the past 15 years (health care finance departments). What you said about HMO’s spending 11% of their budgets on paperwork is misleading.
    What creates that paperwork? Who requires it? Answer: the governments, be it federal, state or local. When I worked at the HMO, we had entire departments set aside for government compliance – medicare, medicaid, etc. We estimated that as much as 35% of all administrative costs were for government compliance issues – HIPAA, benefit coordination based on government guidelines, etc.
    If the government takes over healthcare, as in your single-payer system, what makes you think that paperwork will go away? Doctors still fill out claims forms, charts, etc., hospitals still have to do transfers, track patient data, etc.
    Regarding Medicare and Medicaid – these agencies shift their administrative burdens onto the providers and the insurance companies. That’s why their admin costs are low.
    TV (Harry)

  • Jeff, I would also like to suggest putting Elder Care on the table. Many elderly are being cared for by family members at home and not in old-age homes as some would assume. Those of us who are family elder care providers get little support from either the State or Federal governments. We save millions of dollars in saved healthcare professional wages yet lack the training or support structures (including, for example, antidepressants to help us deal) that are required for us to do our jobs.
    I recently came to realize this after reading an article (NY Times?) article on a family going through a similiar situation as they care for the family patriarch who is suffering from Alzheimers.

  • AvatarADV

    We need to understand one thing about costs, right up front.
    We -cannot- pay for unlimited medical care for everyone under the current system. The money just isn’t there, through taxes or through individual insurance payments. There must be some method of limiting costs or services, or you’re not talking about a real plan of action.
    Socialized medicine attempts to restrain costs by eliminating profit as a motive – by moving the entire thing into a bureaucracy, you can mandate that care be provided for below its actual costs and share the shortfall over the entire populace. You can make it -free- if you want to. On the other hand, if you do that, you’re going to face some pretty wicked quality-of-care issues… bureaucracies are not known for their compassion for the individual any more than insurance companies are, and you can’t just go with a different one. If your insurance company denies you care, at least there’s the possibility that another one won’t; if the government denies it, you get no care.
    But if you reduce the quality of care, people die. There’s no way around that – one of the reasons that medical care is so bloody expensive in the US, and that it keeps getting more expensive, is that it’s extremely, extremely good (assuming you’re one of the insured, naturally.) People routinely die of diseases, disorders, and various other health problems in other countries, whereas here those problems can be treated. That part works, and if we tinker with it such that it stops working, then that itself will cause people to die who otherwise would not have died.
    What I’m saying is that any… ANY… rational distribution of health care will inevitably entail telling people that they will not, or cannot, be treated and that they will die. A socialized system favors making care available to everybody, with the cost that people with extremely difficult medical problems will die. The current US system favors making medical care available to those who can pay, which means some people get life-saving care but others who cannot afford it will die.
    It’s a terrible choice, no? I’d like to think that the current market solution isn’t bad – insurance available to most people, emergency care for those who can’t afford insurance, and my dad didn’t die of cancer five years ago from a cancer that would have killed him ten years earlier, without fail.
    But at the same time, socialized medicine might be a bit easier and a lot cheaper in the long run… saying “we cannot treat your problem” is easier on the conscience than saying “we can treat your problem, but you can’t afford to have it treated.” Then again, the person ends up just as dead, no?

  • Charlie (Colorado)

    You can find my uncomfortable questions about single-pay systems back at Jeff’s previous post, so I won’t repeat them, but I will repeat the most primary question that strikes me: I would be a lot more inclined to listen seriously to single-pay advocates if they could name even one example that works.
    I’ve lived in Canada, and it doesn’t work; I know plenty of people in England, it didn’t work; and there are even more amazing examples, like when the Belgians tried to draft all doctors into the Army because they kept leaving the country rather than work for the National Health.
    With no good example, and so many counter-examples, it’s hard to take single-pay really seriously.

  • Charlie (Colorado)

    Speaking of drug discovery, this article explains in great detail what the differences between different areas of drug research are, and why it’s both hard and expensive.

  • Kat

    The National Post says:
    {Canadians less likely to survive heart attack
    Canadians are significantly less likely than U.S. patients to be alive five years after a heart attack, according to new research that suggests this country’s ”conservative” approach to treatment may cost hundreds of lives a year. }
    So are US citizens willing to pay for those who don’t, and compromise their own care?

  • h0mi

    “The last thing we need is another inefficient and irksome government bureacracy. We need competition. We need choice.”
    This is flat out wrong. HMOs, on average, spend 11% of their budgets on paperwork (with the deviation being between 8-25%). Medicare, an “irksome government bureaucracy,” runs at 2-3% administrative costs, and Medicaid runs at 6%. Canada is down around 2-4% as well.

    Much of those administrative costs of HMOs have to do with complying with Medicare or other government regulations. The HMO I work for had to introduce an emergency enhancement to their computer system that cost the company ~1-2 million in 2000 when California required parity between Mental Health and “regular” co payments due to Medicare regulations that affected the way benefits may be sold to medicare patients who are part of employee groups vs off the street medicare patients. CMS introduced new “reply codes” and adding them to our system will cost us tens if not hundreds of thousands for a relatively simple change.

  • Eric Blair

    I can only echo the commenters who actually work in the health insurance industry.
    Government compliance: HUGE amount of time and treasure devoted to this.
    Malpractice: Don’t even get me started. Sure there are bad doctors, but the awards are out of control.
    Fraud: How’s $30 Million in insurance fraud in 18th month’s time grab you?
    I can’t even imagine what a single payer structure would be like.

  • IKreil

    As a nursing home administrator of 16 plus years, I would like to share some thoughts on the topic as my perspective might be a bit different from individuals who work in the hospital or insurance setings.
    Many years ago, when I went to graduate school in 1979, all students were given a book title ” Who shall live?”( I don’t remember the author) which focused on the very issues that we are talking about today. This was before HMOs and CONs and the like. Simply put, health care was going to get to the point where there would not be enough money to cover needed expenses.
    As to who should run healht care, I strongly agree
    that health care should not be run by the government. There are many examples out there of
    programs in other countries that do not work well and not really any that do that would be satisfactory to our citizens.
    As for tor reform and insurance reform, they are two key issues that seriously need to be looked at. However,I have been unable to find any studies that specifically address what insurance rates would do if it was enacted and how much more coverage would be available. Same goes for insurance reform. It’s worth getting statistics to get a reasonable debate.
    Regulations come from the government because of what we the constituents demand. Nursing homes tend to be one of the most regulated industries in the country and although the care is much better, the costs because of the increased paperwork have gone up. I seriously doubt you will see a decrease in the amount of regulations. That would come about from public opinion demanding it and from my time in the field,I have never been asked once by any media to talk about the good things that happen in the field.
    Regulations have their place but you have to learn from the good ones and use them elsewhere.
    In nursing homes, any medication without a diagnosis is considered unnecessary and it removed via a physician’s order. in 1988, my residents averaged 13 meds a day ( including PRNs ) today they average 7.5 ( including PRNS)
    That’s a lot of money saved but that regulation doesn’t exist in hospitals. Why I don’t know.
    There are other examples but the point is getting better coverage for all of us doesn’t require us to pay more- just to understand why we have what we have.

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