The U.S. Health Care Debate

[jabarto]

jabarto, you gotta get hip to the [ex] tag when you post long texts. Example:

VERY LONG ARTICLE

Does wonders for your readers.

Meanwhile, hat tip to Slashdot for turning me on to a systems designer's perspective on HR 3200. Very eager to read the upcoming part 3.

-edit-


I should introduce the author to a couple of people I know. One guy, in particular, believes that the U.S. Military is a socialist boondoggle best replaced by well-trained mercenaries. He even argues that roads should be privatized. Admittedly, he's a kook, but he calls himself a libertarian.

Oops, I forgot all about the spoiler tags. I'll edit my post accordingly.

It's really funny what you posted, though, because one of the chief arguments against libertarianism is "How would you feel if roads/police/firefighting services/whatever were privatised?" That someone would honestly agree to that, though...wow.

[Lemur]

He's a hoot. I told him that his vision for the U.S.A. sounded like an extra-cruel version of 1700s London, with the East India Company replaced by Blackwater. His response: "Is that bad?"

[Xiahou]

Blaming our low stats on deaths is blowing crime and accidental deaths out of proportion.

Maybe not.

Spoiler Alert, click show to read: 

When they standardized life expectancy by taking fatal injuries into account, the US had the longest life expectancy of any nation.

[Strike For The South]

Does anyone think by simply allowing you to buy health insurance across state lines we could mitiagate allot of this craziness.

[Lemur]

Does anyone think by simply allowing you to buy health insurance across state lines we could mitiagate allot of this craziness.

I'd certainly be interested to see a study on what sorts of savings we could expect.

But frankly, at this point I'm in a state of advanced despair over either the Dems or Repubs getting serious about cost containment. The Dem plan, from what I can understand of it, does little to cap costs. And the Repubs have made a vow to never cut Medicare, which is insane.

I read a math geek this morning saying that Medicare D was actually five times more expensive than HR 3200. Maybe we could all agree to scrap Medicare D? Could that be a start?

[Strike For The South]

I'd certainly be interested to see a study on what sorts of savings we could expect.

But frankly, at this point I'm in a state of advanced despair over either the Dems or Repubs getting serious about cost containment. The Dem plan, from what I can understand of it, does little to cap costs. And the Repubs have made a vow to never cut Medicare, which is insane.

I read a math geek this morning saying that Medicare D was actually five times more expensive than HR 3200. Maybe we could all agree to scrap Medicare D? Could that be a start?

Well if we end up with a public option doesn't medicare becomre redudant?

Right now a few companies are holding states hostage, if it was eaiser to start an isurance company or move into another state they would simply get undercut.

Also for people who don't have insurance, they should actually have to pay. Give them the care they need but hunt them down and make them pay or at least take collatrol. Right now we have this limbo and the gov't usually foots the bill. I don't want to mandate insurance becuase I think you should have that choice. I also think you should live with your decisons.

[Lemur]

Well if we end up with a public option doesn't medicare becomre redudant?

Nope. Under Medicare, if you're over a certain age you get taxpayer-funded medical treatment. The public option would be an entirely different animal.

Also for people who don't have insurance, they should actually have to pay. Give them the care they need but hunt them down and make them pay or at least take collatrol.

Um, that's what we do now. Unless they file for bankruptcy, we expect people who have had medical treatment to pay. And the amusing thing is that they pay much higher costs than people with insurance. For example, let's say a hospital asks for $800 for an operation. An insurer will probably pay somewhere between $200–$500 for it, while an uninsured Joe off the street will be billed for the full $800.

Or if you have my insurance, they bill $800, then the insurer decides what they think the operation ought to cost in their private fantasyland, pays that (or doesn't), and then you get stuck with the remainder. Worst of both worlds.

[Strike For The South]

Nope. Under Medicare, if you're over a certain age you get taxpayer-funded medical treatment. The public option would be an entirely different animal.

So we have an NHS for old people? And I wasn't informed? Why do old people get all these sweet deals!

Um, that's what we do now. Unless they file for bankruptcy, we expect people who have had medical treatment to pay. And the amusing thing is that they pay much higher costs than people with insurance. For example, let's say a hospital asks for $800 for an operation. An insurer will probably pay somewhere between $200–$500 for it, while an uninsured Joe off the street will be billed for the full $800.

Or if you have my insurance, they bill $800, then the insurer decides what they think the operation ought to cost in their private fantasyland, pays that (or doesn't), and then you get stuck with the remainder. Worst of both worlds.

That's good to know

The bolded part is the problem. Dare I say we need more regulation? If the insurance company can screw you when it's convienet for them or when you need exspensive treatment then is the really any point to do buisness with them in the first place?

This is what I don't understand. In any other buisness if you pulled these kind of tricks you'd be run out of town but why can isurance companies get away with it?

[Lemur]

So we have an NHS for old people?

Yep, and they love it. Not sure they understand what they're getting, though; more than one protester at the town halls was shouting about "Keep government away from my Medicare." Um ...

Why do old people get all these sweet deals!

Because they vote in large numbers, and they like their entitlements. That's why we (as a nation) allow large numbers of children to go without health coverage, even though the slightest common sense would tell you that healthcare for kids is far more economically important than healthcare for 90-year-olds.

[Banquo's Ghost]

I'm getting confused now.

If you have an "NHS" for old people, and this is sacrosanct to the Republican Party - and the world has not so far come to an end, God is in His Heaven and Liberty Reigns from Sea to Shining Sea...

...why does the Soviet Union win if this principle is extended to all age groups?

[Lemur]

I'm getting confused now.

Oh, it gets even more confusing. The biggest legislative accomplishment under Bush 43 and the all-Republican congress was Medicare Part D, in which the government promised to buy full-retail-price pharmaceuticals (no discounts! no generics!) for everyone on Medicare.

As I said, the cost of this boondoggle is estimated to be five times greater than any of the bills being evaluated now for healthcare reform.

Apparently neither party has the guts to talk seriously about cost control, 'cause that would mean rationing. Heaven forefend we discuss that.

Oh, and because of the politics of hysteria, now we won't even advocate end-of-life counseling to those pampered seniors, 'cause that would be a death panel. So even if a senior citizen wants to die peacefully, without multiple medical interventions, we aren't helping them get it done. 'Cause we don't want death panels.

Idjits.

-edit-

Here's the sales video for the Seniors' Bill of Rights, in which the Repubs declare that no cuts can be made to Medicare. Madness.

[Xiahou]

Or if you have my insurance, they bill $800, then the insurer decides what they think the operation ought to cost in their private fantasyland, pays that (or doesn't), and then you get stuck with the remainder. Worst of both worlds.

It could vary from state to state, but I only know of one way that could happen. If your plan is part of a network and you went outside the network to get your treatment.

My insurance would have pre-negotiated rates with all providers in their network. Therefore, when I saw a doctor, they would get reimbursed the preset amount by my insurance company. Now, if I went to a provider outside the network they could charge whatever they wanted, but my insurance would still only pay what their network rate is. It's a way of keeping premiums down.

I actually had the pleasure of telling an office's billing dept to go to hell when they tried to bill me for the difference between the network rate and what they would've liked to charge me. When I called their office, they tried to tell me that I was responsible for the difference. I told them they were in my network and were not allowed to charge me more- he persisted. I then asked for the guys name and contact information, called my insurance company and told them they were trying to bill me beyond the network coverage. Once I explained everything, they said they'd call him and take care of it. I never heard from them again- it was a pretty satisfying experience.

[Tribesman]

...why does the Soviet Union win if this principle is extended to all age groups?

You should understand that by now.

It is simple to understand

The whole reason is because its the democrats not the republicans

[Seamus Fermanagh]

You should understand that by now.

It is simple to understand

The whole reason is because its the democrats not the republicans

Well, there a some who do view things through exactly that lens, along with others from the other party who have the mirror position. I envy them their clarity, in a way. I've never been able to look at politics and truly think "My guy is perfect your gal is a twit" since I hit double digits in age.

Current US healthcare consumes more than 16% of the GDP. While it can be argued that the therapeutic treatments available are the best, or among the best, on the planet, it is also readily apparent that we've got the worst hybridized system in the world to pay for it.


I oppose a national health system (or the "public option" which will beget it) because I:

1. Don't want government managing health care as I think it's extraneous to the purpose of government in general and of our federal government in particular,

2. Don't want the federal government involved because the federal government is bloated and overly involved in the lives of all Americans and should be pared back, not enhanced,

3. Don't want the federal government involved because of their miserable track record in terms of efficiency, and

4. Believe that ANY such effort by the federal government exceeds their constitutional mandate and therefore believe they have no standing to make such laws (of course, I'm one of the 12 remaining people who also thinks the 10th ammendment is still part of the Constitution, so what do I know).


I believe we would be better served by a system of private insurance and fee-for-services, regulated by the government ONLY to the extent necessary to prevent fraud. Under such a system, not all will receive medical care (some by choice, others by circumstance).

Life cannot be "legislated" into fairness. Attempting to do so is well-intentioned utopianism.

[Lemur]

It could vary from state to state, but I only know of one way that could happen. If your plan is part of a network and you went outside the network to get your treatment.

You're assuming I'm on an HMO, which I am not; it's a PPO, and they change what is in and out of network on an arbitrary and daily basis.

Also, you clearly don't understand how they figure the deductible. I don't hit my limit until I have spent X dollars, but they figure X by what they think procedures ought to cost, not by what they actually do. So you could very easily need to be $10,000 out of pocket before you hit their $2,000 deductible limit. It's a total scam.

Life cannot be "legislated" into fairness. Attempting to do so is well-intentioned utopianism.

Given how many real-world examples there are of national health systems that work adequately, I don't think you need to be a starry-eyed idealist to say that those systems deserve serious consideration. Empiricism, to my way of thinking, is the opposite of utopianism.

[Xiahou]

You're assuming I'm on an HMO, which I am not; it's a PPO, and they change what is in and out of network on an arbitrary and daily basis.

No, I've never been in an HMO and I didn't assume you were either. The situation you described sounds exactly like what could happen if you got a procedure outside of your provider network. Generally speaking, out of network HMO care is just flat out denied coverage. All non-emergency care must go through the HMO. When you're talking in-network and out of network coverage, you're talking about PPOs.

Also, you clearly don't understand how they figure the deductible. I don't hit my limit until I have spent X dollars, but they figure X by what they think procedures ought to cost, not by what they actually do. So you could very easily need to be $10,000 out of pocket before you hit their $2,000 deductible limit. It's a total scam.

Nope, I understand deductibles, but I think you're talking about the out of pocket maximum. Again, being in network or out of network makes all the difference. My max out of pocket for a family was $2500 in network and it jumped to $10,000 for out of network service. When you're part of a PPO type plan, it's just a bad, bad idea to go to a provider who isn't part of the network. Whenever I was thinking of moving, I would get on my insurers website and make sure there was an in-network hospital nearby (there always was). To be put in the position of going to a non-network hospital for treatment could end up costing thousands of dollars.

I'm not saying it's perfect, but I don't think it's accurate to say that they screwed you over with some sort of bait and switch. I'm sure had you called and told them that you were having procedure A done out of network, they would've told you how much they'd reimburse for it. Out of network coverage is always expensive, and in my opinion, best avoided.

For anyone interested, here's a description of HMOs, PPOs, and POSs. I've had experience with the last two, but never an HMO.

[Lemur]

A "hospital" that was in newtwork? ORLY? Are you quite sure?

A girl I used to work with did just as you described, made sure the clinic where she was getting the procedure was in-network. Turns out the radiologist was not. So the surgeon was fine, the nurses were fine, the pharmacy was fine, but the radiologist was not. And she got stuck with a really nice bill. Last I talked to her, she was still paying it off.

Normal people can't compete with that kind of bureaucratic opacity. Most of us have jobs and lives. The status quo is untenable.

[jabarto]

1. Don't want government managing health care as I think it's extraneous to the purpose of government in general and of our federal government in particular

See my response to bullet point #4 of this post.

3. Don't want the federal government involved because of their miserable track record in terms of efficiency, and

People trot this line out all the time. But really, how many things has the government messed up with? Last I checked, the Interstate Highway System and USPS were resounding successes. And it's worth mentioning that we already have nationalized medicine for our government, military personnel AND their families, and the elderly. It's pretty obvious that the government can handle UHC.

4. Believe that ANY such effort by the federal government exceeds their constitutional mandate and therefore believe they have no standing to make such laws (of course, I'm one of the 12 remaining people who also thinks the 10th ammendment is still part of the Constitution, so what do I know).

Doesn't the constitution explicitly state that the government is responsible for the welfare of its citizens?

I believe we would be better served by a system of private insurance and fee-for-services, regulated by the government ONLY to the extent necessary to prevent fraud.

Why would you want ANY private insurance? Do you really want the industry to be (mostly) regulated by the people who will profit from it? Besides which, the insurance companies have proven themselves unable to render the services for which they're being paid, over and over and over again. They're worthless and should have been out on their asses years ago.

Under such a system, not all will receive medical care (some by choice, others by circumstance).

And that's why such a system would merely be a band-aid over a gushing artery.

Life cannot be "legislated" into fairness. Attempting to do so is well-intentioned utopianism.

I know a little group of people called "every industrialized nation on the planet except for this one" who would like a word with you.

[drone]

Doesn't the constitution explicitly state that the government is responsible for the welfare of its citizens?

Do you realize how dangerous this connection would be? It's bad enough with the abuse of the interstate commerce clause. Making this a precedent would nanny-state us to death.

Now that I think of it, does that statement occur outside of the preamble? The preamble itself does not give the government any powers, it just puts the rest of the Constitution into context for judges.

Edit-> Seamus, will you marry me?

[Louis VI the Fat]

I know a little group of people called "every industrialized nation on the planet except for this one" who would like a word with you.

Nononon!!

We are quite happy the way it is. Big Pharma consists of many European corporations. They are perfectly happy to have the US as a playground. They love the American allergy to protecting the interests of civilians against corporations.

The US federal government is a perfect tool for our interests. The average US citizen is a perfect tool too. Erm..I mean, a perfect tool in the global struggle against healthcare communism!



Many European companies are a member of the largest and wealthiest lobby group in Washington, that of Big Pharma. See link below.
Please don't kill European profits by insisting Washington protects the rights of American citizens over our rights to suck you dry? Please?
http://www.statemaster.com/encyclope...ers-of-America

(Note that the PhRMA is a lobby group representing the pharmaceutical industry in, not of, the US )

[Azathoth]

Here are some of the notes I took if you prefer a quick summary to an hour-long speech:

Spoiler Alert, click show to read: 

Introduced members of the cabinet first

Black secret service guy looks tough

President came in 8:12; took 5 minutes to start

He looked pissed off at the applause (he said be seated twice hah)

Mentions situation of last winter (ie. recession)

Reminds recovery is still far away

Says he wants unemployed to have jobs

Claims his administration has helped economy recover greatly

Thanks Congress and American people

Wants to build future (ie. healthcare)

Wants to do something decisive on the issue

Attests to history of healthcare reform (since Theodore Roosevelt)

Puts listeners on defensive by talking about failure of insurance and lack of coverage for many, compares US to world

Describes cases of insurance failure where people died, says US is better than that

Talks about how current insurance problems lead to greater taxes and Medicare and Medicaid costs

Says health care is most important problem

Tries to take middle ground, describes both sides; wants to improve current system

Talks about massive support for health care reform that exists; mentions bipartisan support

Censures most ardent opponents for "scare tactics"

Three points: Slow growth of health care costs, insurance for those who don't have it, security for those who do

Places responsibility on all Americans

The plan will not require those with existing health insurance change their plan; illegal for denial of customers over preexisting conditions or drop coverage during illness; no arbitrary limit on amount of coverage and insurance companies must cover routine checkups and preventive measures

For those who don't have health insurance create marketplace for insurance companies for competitive prices, including non-profit government insurance; if not enough money, government tax credits based on need

Wants all Americans to have same opportunities as politicians in healthcare

Low cost coverage for those really in need or with terminal illnesses

Not having health insurance when it is affordable is irresponsible; basic health insurance a requirement, and business must cover healthcare or help employees with health insurance; small businesses exempt and very poor people exempt

Stresses benefit to economy and all Americans

Talks about the controversy; dismisses "death panels" as lie and says that the reforms don't (sorry, I meant don't) apply to illegal immigrants (lots booed at this) and federal money won't fund abortions

Defends state-sponsored insurance as more choice in competition, playing to Republican capitalists; talks about insurance monopolies

Wants to hold insurance companies accountable

Wants the government insurance company to be self-sufficient and not supported by taxpayer money

Mentions public and private school systems

Often says that he won't back down on basic issues

Says the plan will not add to deficit

Reminds viewers of the source of the deficit (Bush administration)

Pay for plan by finding saving in existing health care system (Medicare and Medicaid) by limiting waste and abuse; a commission of doctors and adminstrators will identify this

No money from Medicare trust fund used to pay for plan; Obama will protect Medicare

Some sort of medical malpractice reform that Republicans like

Plan will cost $900 billion over 10 years, which he claims is a relatively small amount; once again says that wasted money will mostly pay for it

Ends with letter from Ted Kennedy about his support for health reform and the moral issue at stake in the health reform controversy

Talks about American ideals and how great Ted Kennedy was

Tries to endear people to Ted Kennedy by talking about him as a caring father

Says ability to help others is also an American ideal and that government is sometimes necessary to do it

Talks about historical examples (Roosevelt, Social Security, Medicare) to rally support for the present initiative

Ends with a lot of "I still believes" and some nice-sounding rhetoric

Uses colloquial often

Tries to take middle ground constantly, “seek common ground”

Often dismisses most zealous adversaries as pranksters and opportunists

[Papewaio]

In Aus we have private & public healthcare.

If you earn a lot you either get private healthcare or pay more tax to cover your healthcosts.
If you don't get private healthcare by age 30, then for every year above that age (-1 year in total for lapses) your Private Healthcare rate goes up by 1%.

So if you are 61 years old and decide to join private health then the provider can charge you a 30% loading.

There is also a 30% rebate from the Government on all private health cover.

[ICantSpellDawg]

Since we already provide food stamps to some, why don't we just buy everybody food?

[Tribesman]

Since we already provide food stamps to some, why don't we just buy everybody food?

You already do.

[ICantSpellDawg]

You already do.

Oh, In that case, lets just pool all of our money together and see which one of us can spend it the fastest.

[Lemur]

Best comment of this morning:

Moreover, Obama's proposals are within the center of rational debate, and he is open to persuasion. As he said last night, he's happy to back tort reform, or McCain's catastrophic insurance idea. He has also bent to the Clinton position on mandates. His proposal, one should recall, is to massively increase the markets for private insurance companies and drug companies. If David Cameron, the British Tory leader, were to propose this, he'd be called a Thatcherite radical. But in the world of Fox News, this is tantamount to government "take-over". Piffle. Claptrap. Bollocks.

[Xiahou]

A "hospital" that was in newtwork? ORLY? Are you quite sure?

A girl I used to work with did just as you described, made sure the clinic where she was getting the procedure was in-network. Turns out the radiologist was not. So the surgeon was fine, the nurses were fine, the pharmacy was fine, but the radiologist was not. And she got stuck with a really nice bill. Last I talked to her, she was still paying it off.

Normal people can't compete with that kind of bureaucratic opacity. Most of us have jobs and lives. The status quo is untenable.

Yeah, a hospital. Which isn't a clinic. In a clinic, individual doctor's can and often are treated as separate practices. You need to make sure the specialist that you're there to see is in network.

The flip side of that is if the provider is in-network, but the clinic itself is not. If the provider orders up tests and you get them performed at the clinic, which is out-of-network, you can quickly find yourself in billing hell. That's a definite sore spot for PPOs. Luckily, most of us will never encounter that- the examples I've seen of it involved people with rare diseases or conditions who need care at very specialized facilities. Unfortunately, people in those situations are going to have a difficult, expensive future ahead of them no matter what insurance they have.....

The question is, should the entire system be changed to accommodate these cases? If the government forces insurers to allow people specialized care at any facility of their choosing, what will happen to everyone else's costs? It's not hard to find stories of maltreatment for chronic disease sufferers in countries with government-run healthcare, so I don't think it's a panacea either.

From my perspective, I kind of like the way HMOs look. My wife and I are both fairly young and healthy so we don't need specialized care and an HMO would offer comparatively low premiums and offer near total coverage for any common medical services we'd be likely to have. Plus, pretty much all non-emergency care has to be referred thru your primary physician and pre-approved, taking the guess work out of what's going to be covered where. Unfortunately, there just aren't any available to me due to the tangle of rules and regulations that cover the insurance industry.

If the government must meddle in health coverage, I think the most helpful things it could do is separate medical coverage from employment, improve transparency, and break down barriers to insurance competition. Of course [I]something/I] is going to have to be done about medicare/medicaid too. Those are the 500lb gorillas that everyone is afraid to look at- Im afraid no one is going to have the courage to fix those until it's too late.

[ICantSpellDawg]

Best comment of this morning:

Moreover, Obama's proposals are within the center of rational debate, and he is open to persuasion. As he said last night, he's happy to back tort reform, or McCain's catastrophic insurance idea. He has also bent to the Clinton position on mandates. His proposal, one should recall, is to massively increase the markets for private insurance companies and drug companies. If David Cameron, the British Tory leader, were to propose this, he'd be called a Thatcherite radical. But in the world of Fox News, this is tantamount to government "take-over". Piffle. Claptrap. Bollocks.

All of that sounds very good. Remember, the more you lump us individually with Fox News, the more enemies you make. It has been demonstrated rather well that we have our own opinions on the subject. Those who would confound and hamper resolution are always present on both sides - when you don't have a message that can cut through the peanut gallery it is easy just to place the blame on the immortal unmoving jerks (who can sometimes be entertaining.)

Find a real middle ground instead of rhetoric and the rational and skeptical center will buy it. Fox news and limbaugh woun't be enough to obfuscate real moderation. The problem is that the only moderate approach thus far has been "the potemkin moderate approach". If you search, there are plenty of Republicans who want and will vote for reform. They don't all have ideologically puritan conservative suggestions either.

[Ariovistus Maximus]

Generally I think the anti-Obamareform side hasn't really brought up the core issue:

We dislike strong government! I mean, sure you can argue dollars and cents, but quite frankly I don't want to sell myself to the feds to make a buck, and I think it's a legitimate issue!

[Seamus Fermanagh]

People trot this line out all the time. But really, how many things has the government messed up with? Last I checked, the Interstate Highway System and USPS were resounding successes. And it's worth mentioning that we already have nationalized medicine for our government, military personnel AND their families, and the elderly. It's pretty obvious that the government can handle UHC.

Tricare works well, though it does help to minimize costs when well over half of your client base is under the age of 40 and a large minority of the recipients are required to pass physical fitness tests periodically or risk losing their jobs.

Medicare has a raft of problems and is NOT noted for its efficiency. It is noted for encouraging a number of the better physicians to forgoe working with medicare patients at all. Even adjusted for inflation, Medicare is so grossly over the costs predicted for the program at its outset as to be laughable.

My fear is not that the government can't handle UHC, but that it will do so according to its own glorious standards.

Doesn't the constitution explicitly state that the government is responsible for the welfare of its citizens?

No, the preamble to the Constitution states that WE THE PEOPLE are establishing this Constitution to "provide" for the common defense and "insure" domestic tranquility, but only to "promote" the general welfare. Government was meant to encourage that welfare, and to establish conditions that would allow everyone the chance to better themselves. It was never meant to underwrite the whole thing. Our founders would likely to have deemed such a notion preposterous.

Why would you want ANY private insurance? Do you really want the industry to be (mostly) regulated by the people who will profit from it? Besides which, the insurance companies have proven themselves unable to render the services for which they're being paid, over and over and over again. They're worthless and should have been out on their asses years ago.

I think you'd be surprised at the quality of coverage provided if the health insurers were allowed to craft their own policies and provide the insurance needed by the individual themselves. Instead, there are more mandates and "must includes" than you can comfortably list. All such must be paid for and it is impossible in many places for insurance companies to establish substandard ratings and underwrite risk fairly.

I do thank you for your clear expression of a sentiment that I believe DOES underly a segment of the support for UHC in the United States -- a loathing for corporate capitalism. Whether intended or not (and mostly I think it is) the 'public option' will eat private insurance alive. It is impossible to out-compete an entity that can lose money endlessly without ending up bankrupt.

I know a little group of people called "every industrialized nation on the planet except for this one" who would like a word with you.

A foolish opinion, held by thousands, is still foolish.

Still, since many of them can vote, we will very likely see UHC in my lifetime and I will have to learn to cope with life in a Socialist Democracy. Franklin's quip about liberty and safety falls on deaf ears.

I breathe, therefore you are required to feed me, clothe me, entertain me, and keep me healthy to the maximum extent possible. My existence trumps all! Is that not what government is for?