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Re: US Healthcare Expensive and Inefficient
Old 05-15-2007, 05:10 PM   #21
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Re: US Healthcare Expensive and Inefficient

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Originally Posted by mykidslovedogs
You bet it would, but nationalizing healthcare isn't necessarily going to have any affect on fixing that part of the equasion.

I really wasn't advocating nationalizing health care. I was afraid that was the response I would get.

I was just pointing out the irony that the chief defense of our system in many of these conversations is that there are these mysterious socioeconomic differences among our population.

FWIW, I think we need to get more creative and devise a third way to solve this thorny problem. First step is for everyone, left and right, to get off their ideology and do some real thinking.
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Re: US Healthcare Expensive and Inefficient
Old 05-15-2007, 05:20 PM   #22
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Re: US Healthcare Expensive and Inefficient

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Originally Posted by mykidslovedogs


Yes, we have a LOT of uninsured people, but remember, too, that approx 1/3 are uninsured by CHOICE (can afford and qualify for it, but choose not to buy it), and another 1/3 would qualify for child programs or Medicaid, yet they have not been signed up for it yet. That leaves about 15 million people uninsured against their will. Still, a HUGE number of those folks are only temporarily uninsured (in-between jobs, etc.)
I have questioned these numbers which you have posted before. I won't go through each one this time. For example, I agree that there are roughly 45 million uninsured, but a 2004 study from Families USA found that 81.8 million lacked health insurance at some point in 2002 and 2003 and most were uninsured for more than 9 months. These are the temporarily uninsured, a much bigger number than the uninsured number. Adding to these numbers, the Commonwealth Fund has found 16 million adults as under-insured in 2003.

Well, I gotta give this a rest.

As far as doing real thinking, I believe a number of proposals had been advanced that show real thinking. Some of these have been discussed here. One is Senator Wyden's plan. Do a search and you will find discussions about his plan. Many are working on the issues but get shouted down by the politics. Retired Senator Dave Durenberger, a moderate republican from Minnesota, has been working on health care system issues. Specifically issues as to why health care costs so much in the United States and what we can do to change it. So good ideas can come from republicans or democrats or whatever. Let us pick one and try it.
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Re: US Healthcare Expensive and Inefficient
Old 05-15-2007, 05:31 PM   #23
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Re: US Healthcare Expensive and Inefficient

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Originally Posted by Martha

As far as doing real thinking, I believe a number of proposals had been advanced that show real thinking. Some of these have been discussed here. One is Senator Wyden's plan. Do a search and you will find discussions about his plan. Many are working on the issues but get shouted down by the politics. Retired Senator Dave Durenberger, a moderate republican from Minnesota, has been working on health care system issues. Specifically issues as to why health care costs so much in the United States and what we can do to change it. So good ideas can come from republicans or democrats or whatever. Let us pick one and try it.

I agree and I applaud politicians who are brave enough to come up with alternative ideas. We need to find a way to overcome the chief weakness of the free market model (IMO access is the biggie) and the weakness of the wholly socialized model (IMO efficiency).

Affordable access to efficient, high-quality care is the holy grail. Hopefully we can approach something reasonably close. It will take all of our creatvity and political will to do so.
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Re: US Healthcare Expensive and Inefficient
Old 05-15-2007, 05:33 PM   #24
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Re: US Healthcare Expensive and Inefficient

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Originally Posted by Martha
So good ideas can come from republicans or democrats or whatever. Let us pick one and try it.
I don't think so. I'll go back to my ancient theme (unclemick and webtv days). You get some good kids, 8th or 9th graders, some hand held calculators, population data and a copy of Deming's Red Bead Experiment.

Ask them to raise taxes and figure out how to reward people to be healthy.

Shot any adult who comes near them till they are finished.

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Re: US Healthcare Expensive and Inefficient
Old 05-15-2007, 05:33 PM   #25
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Re: US Healthcare Expensive and Inefficient

Calif - I am totally in agreement with you....I just lean a little bit further to the right in the types of solutions I would offer. Here is one I posted a few days ago:

Gov't mandates all Americans must carry at least the most basic health insurance plan (kind of like liability car insurance). This plan design would be standardized and required that all insurance carriers must offer it in their mix of healthplans. The plan should be a high deductible (say maybe $2500 single/$5000 family deductible) HSA compatible plan. It would be the ONLY plan that insurance carriers would be required to offer on a guaranteed issue basis. The plan would have to cover preventive care (nationally recommended cancer screenings and immunizations) NOT subject to the deductible. The plan would offer a copay of around $15 or less for generic drugs, and brand prescription coverage AFTER the deductible is met and 100% coverage for all other services AFTER the deductible is met. It must cost no more than what the average working class American could afford to pay, and no less than the cost to administer the plan and pay claims. Premiums could perhaps be offered on a sliding scale based on income(The gov't will determine the maximum premium.) The insured would be required to use the private carrier of their choice's networks or be penalized with a higher deductible if they choose to go outside of the network. The standardized plan would be portable from state to state because it is a guaranteed issue plan.

Although it might be hard for some people to afford the deductible, at least the health care providers will still get reimbursed for balances above the deductible, so their write-offs won't be nearly as hefty, and there won't be as much of a need for health care providers to come after private insurance carriers for lost profits, like they do today when someone with a $100,000 claim or higher is uninsured. This will help bring down premiums for everyone, overall, over time.

Medicaid and Medicare remain in force as is, however, if someone over the age of 65 wants to buy the cheaper, basic plan, they would be allowed to do so, and NOT be required to go on the gov't Medicare plan if they don't want to.

Employers are prohibited from providing medical benefits, but they would be allowed to have flexible spending plans or health re-imbursement arrangements, whereby people could have tax-deductible income and/or employer contributions set aside for use to pay premiums for personal health insurance coverage or for deductible health insurance expenses, if the employer wants to offer such a benefit. Employers should not be forced, nor taxed to provide subsidies for the basic plan.

Whoever is not eligible for Medicare or Medicaid, and does not purchase this minimal level of coverage voluntarily must understand that they could be turned away for medical care with NO legal consequences to the physician for turning them away. Any physician who wants to treat the person on a pro-bono basis has the perogative to do so, provided they don't try to recapture the lost profits from the private sector.

In addition, insurance carriers will still be allowed to medically underwrite products that have more bells and whistles than the basic plan design. People who want to buy up have all the freedom in the world to do so, provided that they can medically qualify.
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Re: US Healthcare Expensive and Inefficient
Old 05-15-2007, 05:50 PM   #26
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Re: US Healthcare Expensive and Inefficient

MKLD, some good food for thought there.

One concern I would have as a buyer of the upgraded policy would be my ability to maintain coverage somehow, somewhere if the private insurer goes out of business or limits coverage in other states. Transferability, I suppose, could be a feature of the policy.

Another real world concern would be the ability of those currently covered by their employer's policy to be able to jump to the new system without having to worry about pre-existing conditions.
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Re: US Healthcare Expensive and Inefficient
Old 05-15-2007, 05:50 PM   #27
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Re: US Healthcare Expensive and Inefficient

Why an HSA? Those that are not able to buy on the individual insurance market are going to have chronic diseases or be poor. An HSA is not what they need. If you have a chronic disease, you will chew through deductibles and not be able to stash money for the future. If you are poor, you can't afford to fund an HSA. The Kaiser family foundation has published studies on how HSAs do not work for these two populations. They are great for the young and healthy though.

I don't know how to make the insurance model work unless we:

--require people to have insurance
--subsidize the poor and uninsurable or bar underwriting much as in Wyden's plan.



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Re: US Healthcare Expensive and Inefficient
Old 05-15-2007, 05:52 PM   #28
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Re: US Healthcare Expensive and Inefficient

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Originally Posted by Freein05
The insurance even covers a stay at a health spa. That may change in the future. For employed people the cost is 13% of your gross salary.
So if you are a single 25 yr old, and you are employed, and you make $100,000/yr, your cost of insurance is $13,000?! Wow. How much of what's left of your income do you have to pay for other gov't sponsored programs? Just curious.
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Re: US Healthcare Expensive and Inefficient
Old 05-15-2007, 05:57 PM   #29
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Re: US Healthcare Expensive and Inefficient

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Originally Posted by Martha
Why an HSA? Those that are not able to buy on the individual insurance market are going to have chronic diseases or be poor. An HSA is not what they need. If you have a chronic disease, you will chew through deductibles and not be able to stash money for the future. If you are poor, you can't afford to fund an HSA. The Kaiser family foundation has published studies on how HSAs do not work for these two populations. They are great for the young and healthy though.
Martha, you couldn't be more incorrect. I have a chronically ill client who was paying literally thousands in out of pocket costs for prescription drug and office visit copays on a traditional plan. She switched to an employer-sponsored HSA, which provided 100% coverage for all costs after deductible and she ended up saving about $10,000/yr in out of pocket costs (in premiums plus copays and co-insurance expenses). In my plan design, employers would be able to subsidize the cost of the deductible for a lot less $$ than paying premiums for health insurance, so there would still be incentive for employers to provide benefits. Those who are on the basic plan could potentially have 100% coverage if their employers subsidized their entire deductible as a benefit each year. The HSA would provide tax incentives for people to save for future healthcare costs and incentives for people to use their deductible $$ wisely.


Plus, with EVERYONE being required to have insurance, that will drive premiums down tremendously, so it might not be that hard for lower income folks to save towards their HSA....especially if their employers kick in a little bit towards the deductibles.

The Kaiser Foundation is biased towards a nationalized system, because they think they are going to be the administrator if it all happens. I imagine that their stats are somewhat correct, but HSAs are only beginning to become more and more understood. I think when people really get the just of how they work, we are going to be seeing a lot more participation. Many of the people who have signed up for HSAs were previously uninsured.
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Re: US Healthcare Expensive and Inefficient
Old 05-15-2007, 06:07 PM   #30
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Re: US Healthcare Expensive and Inefficient

How would they plan on funding universal health care? Tax rate across the board increase? The working middle class will be the ones who take it on the chin. The rich wont give a **** and the poor well they already have nothing and were getting free health care anyways.
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Re: US Healthcare Expensive and Inefficient
Old 05-15-2007, 06:10 PM   #31
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Re: US Healthcare Expensive and Inefficient

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Originally Posted by califdreamer
MKLD, some good food for thought there.

One concern I would have as a buyer of the upgraded policy would be my ability to maintain coverage somehow, somewhere if the private insurer goes out of business or limits coverage in other states. Transferability, I suppose, could be a feature of the policy.

Another real world concern would be the ability of those currently covered by their employer's policy to be able to jump to the new system without having to worry about pre-existing conditions.
Calif - notice in my plan that the basic plan is standardized and guaranteed issue, so people wouldn't have to worry about portability if they moved. True, we could still be faced with portability issues on upgraded plans.

To address your second concern - notice that my plan prohibits employers from providing insurance to their employees, so there would be no need to worry about pre-existing conditions. Instead, employers would be allowed to have something like a flexible spending account or health reimbursement arrangement, whereby they would be allowed to subsidize up to 100% of the employee's deductible AND even premiums if they wanted to, a tax deductible basis. This gives employers plenty of incentive to still provide benefits, while it also still gives employees the discretion to shop around and use their deductible dollars wisely, because if they don't use the money, they will get to keep it, and allow it to grow, tax free, year after year.
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Re: US Healthcare Expensive and Inefficient
Old 05-15-2007, 06:19 PM   #32
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Re: US Healthcare Expensive and Inefficient

I agree that if you have high drug costs, an HSA can be cheaper than a plan with copays. In fact, for the chronically ill some employers are dropping or reducing copays to get people to buy their drugs. In the long run, they figure it is cheaper. Saving for future health care costs is pretty much a non-issue for this group.

So if you want an HSA option for the chronically ill, that is fine with me. Minnesota's risk pool offers either a standard insurance plan at various deductible levels or an HSA plan. So Minnesota does this already, at a price equal to 125% of what a healthy person would pay on the individual market. How about poor people who can't afford the deductible or premiums because they are unemployed or underemployed?

Also, how would you force people to have insurance? Wyden does it simply by forcing everyone to pay through the tax systems.


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Re: US Healthcare Expensive and Inefficient
Old 05-15-2007, 06:25 PM   #33
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Re: US Healthcare Expensive and Inefficient

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How would they plan on funding universal health care? Tax rate across the board increase? The working middle class will be the ones who take it on the chin. The rich wont give a **** and the poor well they already have nothing and were getting free health care anyways.
Look at Wyden's plan. http://early-retirement.org/forums/i...?topic=11033.0

It is a myth that the poor get free care anyway.

Also, people in the middle class can be impoverished by health care costs.
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Re: US Healthcare Expensive and Inefficient
Old 05-15-2007, 06:26 PM   #34
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Re: US Healthcare Expensive and Inefficient

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Originally Posted by Martha
I agree that if you have high drug costs, an HSA can be cheaper than a plan with copays. In fact, for the chronically ill some employers are dropping or reducing copays to get people to buy their drugs. In the long run, they figure it is cheaper. Saving for future health care costs is pretty much a non-issue for this group.

So if you want an HSA option for the chronically ill, that is fine with me. Minnesota's risk pool offers either a standard insurance plan at various deductible levels or an HSA plan. So Minnesota does this already, at a price equal to 125% of what a healthy person would pay on the individual market. How about poor people who can't afford the deductible or premiums because they are unemployed or underemployed?

Also, how would you force people to have insurance? Wyden does it simply by forcing everyone to pay through the tax systems.
The way I would force people to sign up would be for them to have to pay for it in the form of a tax penalty if they chose not to buy it. Therefore, there would be no incentive for them not to buy it, because they'd have to pay for it anyway in the form of a tax if they couldn't prove they bought it. (you would have to submit a certificate of creditable coverage to the IRS when you file to avoid the penalty.)

As far as poor people go (and this would only be people who couldn't qualify for Medicaid), all I can say is that, yes, in my system, there might still be a little inequality. My plan would allow them to get a catastrophic plan for practically free. Their only worry would be the deductible. At the very least, this will help reduce cost shifting, because instead of these people being uninsured, providers of healthcare will still be paid above the deductible amount. You have to figure that not all poor people are going to need to be heavy users of their deductibles. It will only be a very small amount of people left with financial issues. They would still have coverage above the deductible, and that will do wonders to hinder cost-shifting to other markets and bring down premiums for everyone.

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Re: US Healthcare Expensive and Inefficient
Old 05-15-2007, 06:30 PM   #35
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Re: US Healthcare Expensive and Inefficient

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Originally Posted by unclemick2
You get some good kids, 8th or 9th graders, some hand held calculators, population data and a copy of Deming's Red Bead Experiment.

Ask them to raise taxes and figure out how to reward people to be healthy.

Shot any adult who comes near them till they are finished.
Sort of reminds me of the 1st graders who they tested on the Florida "butterfly ballot" after the 2000 election. Seems the kiddies had no problem figuring out how to vote it properly and the way they intended.
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Re: US Healthcare Expensive and Inefficient
Old 05-15-2007, 06:42 PM   #36
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Re: US Healthcare Expensive and Inefficient

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As far as poor people go (and this would only be people who couldn't qualify for Medicaid), all I can say is that, yes, in my system, there might still be a little inequality. My plan would allow them to get a catastrophic plan for practically free. Their only worry would be the deductible. At the very least, this will help reduce cost shifting, because instead of these people being uninsured, providers of healthcare will still be paid above the deductible amount. You have to figure that not all poor people are going to need to be heavy users of their deductibles. It will only be a very small amount of people left with financial issues. They would still have coverage above the deductible, and that will do wonders to hinder cost-shifting to other markets and bring down premiums for everyone.

But you cost shifted to the providers. If a person can't afford the deductible, (1) they could go without care (2) they could get the care and owe money for it or (3) the provider could eat the cost. If they can't afford the premiums, not only would they not have insurance, but they would owe a tax penalty. Better to have a sliding fee system. Or properly fund medicaid and allow people to enroll on an income basis alone, with sliding fees up to a certain income and asset level. (I don't like that idea because the poor is always the first to lose out).

You mentioned waiting lists. I know a young woman who has no money and is not eligible for medicaid (not disabled, no children). She has no dental insurance. Heck, I don't either. She is on a waiting list to get a bunch on necessary dental work done. In a year or so maybe she will get to the top of the list. Or never.



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Re: US Healthcare Expensive and Inefficient
Old 05-15-2007, 06:50 PM   #37
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Re: US Healthcare Expensive and Inefficient

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But you cost shifted to the providers. If a person can't afford the deductible, (1) they could go without care (2) they could get the care and owe money for it or (3) the provider could eat the cost. Better to have a sliding fee system. Or properly fund medicaid and allow people to enroll on an income basis alone, with sliding fees up to a certain income and asset level.
Actually, my plan DID call for a sliding fee on the premiums for the catastrophic plan. Go back and take another look.

Right now, we have a large number of uninsured people. When they have a huge medical expense, providers eat the cost and shift the balances to the private sector in the form of higher premiums. If everyone had at least catastrophic coverage, providers would not have to eat the costs above the deductible amount. This will help to reduce cost shifting, because providers won't have to inflate prices so much to people who are paying for better coverage by choice. Coverage will be much more affordable for the great majority of the population. Employers will likely gladly pick up deductibles in the form of a company benefit if they don't have to pay for premiums anymore.

Yes, there may still be a few people who unfortunately will choose to forego treatment for deductible items. On the other hand, in a nationalized system, eventually, everyone will have to forego treatment until they get to the top of the waiting list. Isn't it better to have only a small number of people having to forego treatment or get the care and owe money unwillingly than eventually having EVERYONE be forced to wait on waiting lists for services?
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Re: US Healthcare Expensive and Inefficient
Old 05-15-2007, 07:00 PM   #38
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Re: US Healthcare Expensive and Inefficient

With regard to Senator Wyden's plan, I have heard very little discussion of it. I read the Loewen study of it, and IMO it's the best thought out and most complete plan that has been presented. I have to take his numbers at face value and don't know if they are correct. But he seems to arrive at 99% coverage at a reasonable cost and with essentially no change in the healthcare delivery system, only how the insurance works. I am astonished that the Democratic Presidential candidates haven't rallied around it. I guess their egos force them to each have their own plan. Edwards said in the debate that he is in favor of forcing businesses to provide insurance or pay into a pool. I think this is completely out of step with current thinking which is that we should be cutting the tie between jobs and insurance, and tying insurance to the individual, which will allow one to maintain his insurance forever so long as he files a tax return.

Martha, do you have any idea why Wyden's plan has gotten so little press or open Democratic support?
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Re: US Healthcare Expensive and Inefficient
Old 05-15-2007, 07:09 PM   #39
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Re: US Healthcare Expensive and Inefficient

I guess I stirred things up a bit.

MKLD - here is the link to the complete 40-page study I referenced in the original post.

Commonwealth Study

If you look through it, infant mortality and longevity are only 2 of the metrics they use. They also look at: Quality of Care, Access, Efficiency, Equity, and Healthy Lives (where the infant mortality stats are included). There are detailed tables that indicate all the different criteria that were used. Under Quality of Care, for example, they looked at things like: Prevention (where the US does very well), Chronic Care (where we don't do as well), Safe Care (wrong meds, e.g.), Coordinated Care, and Patient Centeredness. The MSNBC article does not do the study justice. In short, they looked at things that have nothing to do with socioeconomic conditions.

Also, we spend almost double per capita than the next country. 51% of our spending is by or for the government (Medicaid, Medicare, SCHIP, VA, taxes used for government employees insurance, etc.) and that doesn't include the lost revenue from the tax deductions. Theoretically, if we rationalized our current system, we could provide the same level of spending as the next closest country without having to raise taxes.

I worked in healthcare for 15 years. We don't have a healthcare system. We have an expensive and inefficient hodgepodge that does some things right, but a lot of things wrong.
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Old 05-15-2007, 07:22 PM   #40
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Re: US Healthcare Expensive and Inefficient

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With regard to Senator Wyden's plan, I have heard very little discussion of it. I read the Loewen study of it, and IMO it's the best thought out and most complete plan that has been presented. I have to take his numbers at face value and don't know if they are correct. But he seems to arrive at 99% coverage at a reasonable cost and with essentially no change in the healthcare delivery system, only how the insurance works. I am astonished that the Democratic Presidential candidates haven't rallied around it. I guess their egos force them to each have their own plan. Edwards said in the debate that he is in favor of forcing businesses to provide insurance or pay into a pool. I think this is completely out of step with current thinking which is that we should be cutting the tie between jobs and insurance, and tying insurance to the individual, which will allow one to maintain his insurance forever so long as he files a tax return.

Martha, do you have any idea why Wyden's plan has gotten so little press or open Democratic support?
Fire'd - Did you see how rich the benefits were on Wyden's plan? (very low deductible and low low copays - no much incentive there to prevent overutilization). I have a feeling he is greatly underestimating the cost on that. That's just IMO. At least he's trying to do something, but I really do think he is greatly underestimating the cost.

Getting rid of brokers and adminstrators, IMO, is not going to cut back costs that much to keep the family rates as low as he hopes it will. Our commissions are minimal in comparison to the overall costs to administer private health insurance. The biggest admin costs I think are in billing and claims, and you aren't going to get rid of those costs by eliminating brokers. In fact, you might make claims admin worse by providing such a rich plan (giving incentive for people to overutilize) and eliminating brokers who typically pick up a lot of claims admin work for free as part of the cost of doing business and keeping clients happy.

Wyden's plan shifts admin/enrollment costs to the gov't, which I can't imagine will be more efficient than it is in the private sector. Is the gov't going to step in and help out with difficult claim issues, too?
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