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Old 03-10-2009, 06:02 AM   #281
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Old 03-10-2009, 07:52 AM   #282
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An interesting article showing how America might want to model it's health care system in a similar manner to the French system. They're not so un-alike already as one may think.

France's model healthcare system - The Boston Globe

"That's because the French share Americans' distaste for restrictions on patient choice and they insist on autonomous private practitioners rather than a British-style national health service, which the French dismiss as "socialized medicine."


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Old 03-10-2009, 08:01 AM   #283
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... but the problem will come because the insurers' profit on the spread between what they collect and what they pay out. This will ineluctably lead to denials/limitations of coverage to those who believed they were insured. I would prefer that my health not be sacrificed for someone else's profit.
I understand your point, but can you explain this info:

Socialized Medicine



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If we can specify that someone will be paid to administer the system for a fixed fee, like any other service provided to the government by private industry, that might solve the problem.
IMO, that would make the problem worse. No motivation to contain costs at all. Then we are back to Tragedy of the Commons where "everyone else" will pay.

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As far as investing in the health care companies, that only works for those of us (like most on this board) in the rentier class. The vast majority of people will be unable to benefit.
I don't know about "vast majority", a lot of people have 401Ks or pensions that are invested in the market.


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Old 03-10-2009, 02:51 PM   #284
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the problem will come because the insurers' profit on the spread between what they collect and what they pay out. This will ineluctably lead to denials/limitations of coverage to those who believed they were insured. I would prefer that my health not be sacrificed for someone else's profit.
How is having a private company trying to control costs to maximize profit different than the current situation with Medicare (our Universal Health Plan for folks over 65) which routinely denies coverage (length of hosp stay limits, max payments to docs, procedures allowed, etc.,) based on wanting to control costs to meet their budget?

Public or private coverage, it will not be possible to pay for all possible treatments. This is already manifesting itself in Canada, USA Medicare, Australia and others.

It seems to be a matter of deciding whether we want a govt/private coalition or a 100% govt decision based situation determining our fate. For example, I'm more comfortable being able to choose a Medicare supplement to my liking as opposed to having my future Medicare based treatments determined 100% by a govt committee with no private supplement possible.

I understand others may feel differently.
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Old 03-10-2009, 03:34 PM   #285
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Exactly. That is why I prefer to give a voucher to everyone, pauper and millionaire alike. It is an equation that needs to be balanced, so do it the simplest way possible. Put the "means test" on one side of the equation (the payment of taxes), not *both* sides (the payment of taxes *and* the distribution of vouchers). To do both sides adds complexity, which always results in additional inequalities, unintended consequences, loopholes, and added administration costs. None of which goes to helping people get better health care, which should be the goal. The KISS plan.



I understand your point, and I'm struggling with it too. It would appear that the ins cos are just an added layer, sucking up costs. The only reason to consider them is if the competition helps control costs over and above their profits. That is a net benefit to consumers, even though the ins cos did rake some off the top..

-ERD50
Have you tried to calculate the additional taxes needed to provide everyone a voucher? I think the FIT "taxable income" (after deductions) is about $5.2 trillion. If we're going to provide a voucher for all middle and upper income people under 65, what's the total cost? How much does that add to our FIT bill? I'm asking partially because you've said in other places that you're already concerned about high tax rates acting as a disincentive to work.

I think you are correct about gov't vs. private - it's always a matter of looking at trade-offs in specific circumstances. The argument for private is that competition forces firms to find efficiencies. The argument for public is that private firms have additional costs in sales/marketing, duplication (between firms) and profits. "Private" has additional advantages in more innovation and customization, but those advantages disappear if we mandate a few forms (which I think is correct for the format that Samclem described).

It's hard to know in advance which wins. We can look at other countries that have gov't monopolies on health insurance. We can compare Medicare vs. private in the US.
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Old 03-10-2009, 03:48 PM   #286
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Samclem:

My problem is not with the profit motive per se. If private companies can administer the health care system more efficiently than the government, then we should probably go that route. You assert that there will be competition that will lower premiums. That may be true, but the problem will come because the insurers' profit on the spread between what they collect and what they pay out. This will ineluctably lead to denials/limitations of coverage to those who believed they were insured. I would prefer that my health not be sacrificed for someone else's profit.

If we can specify that someone will be paid to administer the system for a fixed fee, like any other service provided to the government by private industry, that might solve the problem.
I agree with the general point that we're arguing for private insurer's because they may have lower cost administration, but private insurer's have many more dollars at stake in controlling claims costs.

I tend to see the issue in terms of "high risk" individuals. It's simple to say "no underwriting, insurer's have to take all applicants". But I can imagine the numbers working out so that getting one less high risk person in 100 insureds can double profits. While getting one extra can wipe out profits entirely. The incentive for finding some way to duck those high risk people, or nudge them out of the group (maybe by providing poor claims service to certain high cost people) seems pretty high.
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Old 03-10-2009, 03:48 PM   #287
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In Canada, we have universal health care. We need to go to the doctor - make an appointment and go. In an emergency, we're treated in the emergency room of the hospital. Emergency surgery or treatment for life-threatening condition - immediate attention. Elective surgery -- you are prioritized and yes, there will be a wait time ( no queue jumping in Canada). I don't think the quality of health care differs significantly between our countries. I understand that per capita health care costs are much less in Canada than in the U.S. Of course, we pay more in income tax for health care. But most Canadians proudly consider our universal health care coverage as one of the most important benefits our citizenship and something we would never give up.

Rob
I have family in Canada....and the elderly ones who have lately needed some care are not getting it very timely. My cousin who had symptoms not severe enough for an emergency room visit, was referred (its manditory to be referred - you cannot just go to a specialist) to a heart doctor ordered who ordered a sonogram (or similar) and now has to wait 2 months for a follow up visit to the specialist to get the results. Another close relative did have a heart attack (she discovered) after calling for an ambulance and was taken right away to in the emergency room, then the next day did get a stent put in....that all was good. Unfortunately, her first follow up visit wasn't available for 1-1/2 months..and she suffered a fatal heart attack in the meantime. She did have indications that something was wrong...went to an emergency room, but the on duty staff found nothing wrong and no specialist called. This was in a prosperous city (Calgary). This is exactly what I hope doesn't happen to the very good care we get where I live. I did live in Canada when I was younger, but was healthy and didn't really require any special or much medical care...my relatives tell my the system now has almost completely broken down...not enough equipment, doctors, nurses, hospitals, etc. My intent with this is not to put the Canadian system down....don't know if its really the system that is to blame....could be just too many people for too few resources (ie not the payee system)....and I do know from personal knowledge...that many of the good doctors move to the US from Canada to make more $$. But if volume and lack of resources is a problem in Canada with just 22-24 million (or whatever #)...imagine what its going to be like in the US. But something needs to be done. Just my 2 cents!
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Old 03-10-2009, 03:56 PM   #288
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I truly believe that if all of the social programs, and welfare, and free medical treatments went away, people would not wonder about aimlessly and die on the street. I sincerely believe they would find ways, and the market would adapt itself to find more ways of treating people. But if this is never tried... it will always be the way it is right now. ...
I think it "has been tried" for much of history, and over much of the world. For example, I expect that Bangladesh doesn't try to provide appendectomies for anyone who needs one, or bypass surgery, chemo, ...

I think the accurate statement is that most "rich" modern countries provide "free" medical treatments.
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Old 03-10-2009, 04:10 PM   #289
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I tend to see the issue in terms of "high risk" individuals. It's simple to say "no underwriting, insurer's have to take all applicants". But I can imagine the numbers working out so that getting one less high risk person in 100 insureds can double profits. While getting one extra can wipe out profits entirely. The incentive for finding some way to duck those high risk people, or nudge them out of the group (maybe by providing poor claims service to certain high cost people) seems pretty high.
Is that risk any higher than the risk of the govt committee in power at the time deciding that we can't afford the cost of treating certain high risk people? The decisions are either going to be profit based or populist/political based and I'm just not sure which would be better.

I'd like some choice to remain. If I've worked hard and saved hard and can afford to buy a supplemental policy or pay out of pocket, I'd like to have some say regarding my own or my family's fate regarding medical treatment without having to leave the country for the treatment.
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Old 03-10-2009, 08:00 PM   #290
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Have you tried to calculate the additional taxes needed to provide everyone a voucher? I think the FIT "taxable income" (after deductions) is about $5.2 trillion. If we're going to provide a voucher for all middle and upper income people under 65, what's the total cost? How much does that add to our FIT bill? I'm asking partially because you've said in other places that you're already concerned about high tax rates acting as a disincentive to work.
Good question. Well, I have not run any numbers, but I have thought about the balances and tradeoffs. So I think we can take a very rough stab at whether it is a large net gain or net loss. Lets' see if I can hit the major points:

Well, a significant number of under 65 *are* currently paying for their health insurance, either privately or in combo with their employer (so that is largely coming out of their salary). So we can very roughly assume that the cost to them in total taxes would be about what they are paying out-of-pocket. That makes the assumption that the govt actually pays for the vouchers out of current taxes rather than pushing the cost forward, but let's do that for now for simple accounting. So, give me a $x,xxx voucher and increase my taxes by $x,xxx - it's all the same on average.

Now, for the poor. Well, we end up paying for them out of our taxes anyhow, right? Or from cost shifting by hospitals (we can't collect from Indigent Joe, so we WILL collect from Insured Joe). So no real change there either. In fact, there is a big opportunity for cost cutting. Eliminate some of those ER visits, because a doctor will see them. Get some proactive health measures in place which could possibly reduce the overall health care cost. Potential Win-Win.

Am I missing any big piles of expenses? If not, then I don't think those vouchers will cost us much if anything net-wise. So no, it shouldn't drag the economy down with extra taxes. Lotsa guess work there, but that's about all we can do. See anything you strongly disagree with?


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Old 03-11-2009, 05:20 AM   #291
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Is that risk any higher than the risk of the govt committee in power at the time deciding that we can't afford the cost of treating certain high risk people? The decisions are either going to be profit based or populist/political based and I'm just not sure which would be better.

I'd like some choice to remain. If I've worked hard and saved hard and can afford to buy a supplemental policy or pay out of pocket, I'd like to have some say regarding my own or my family's fate regarding medical treatment without having to leave the country for the treatment.
I'd much rather take greed over ideology. Greed is predictable and therefore easier to work with. Ideology changes with each person elected.
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Old 03-11-2009, 10:12 AM   #292
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Now, for the poor. Well, we end up paying for them out of our taxes anyhow, right? Or from cost shifting by hospitals (we can't collect from Indigent Joe, so we WILL collect from Insured Joe). So no real change there either.
There are plenty who do not get care because of inability to pay. They put off going to the doctor and things get worse. They run up against insurance limitations and end up either not getting the care that they need or selling their home and all their assets. They don't get care for chronic conditions, like mental illnesses, diabetes, and heart disease. We may pay more in health care costs to take care of these situations. However, there may be other cost savings as a healthy population is a productive population.

I know a few years ago about 18,000 people were dying a year in the US solely because they were unable to pay for health care and who were uninsured. Many more limp along, not dying but certainly not healthy. I recently heard that the study was updated and will have to poke around and see what the numbers are now.
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Old 03-11-2009, 10:56 AM   #293
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There are plenty who do not get care because of inability to pay..
Yup. Like the man I literally saw an hour ago who stopped his blood thinner injections at $2700 a month because he couldn't afford them, and was not a candidate for the cheaper oral type because of medical reasons. Risk of recurrent pulmonary embolism rises from 5% to 35%+ if he doesn't take it.
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Old 03-11-2009, 11:25 AM   #294
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An interesting article showing how America might want to model it's health care system in a similar manner to the French system. They're not so un-alike already as one may think.

France's model healthcare system - The Boston Globe

"That's because the French share Americans' distaste for restrictions on patient choice and they insist on autonomous private practitioners rather than a British-style national health service, which the French dismiss as "socialized medicine."
Looks like France has at least three things going for them, good food, a decent health care system, and a tolerance for nuclear power plants. Maybe they can learn how to fight wars now.......
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Old 03-11-2009, 12:34 PM   #295
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I have family in Canada....and the elderly ones who have lately needed some care are not getting it very timely. My cousin who had symptoms not severe enough for an emergency room visit, was referred (its manditory to be referred - you cannot just go to a specialist) to a heart doctor ordered who ordered a sonogram (or similar) and now has to wait 2 months for a follow up visit to the specialist to get the results. Another close relative did have a heart attack (she discovered) after calling for an ambulance and was taken right away to in the emergency room, then the next day did get a stent put in....that all was good. Unfortunately, her first follow up visit wasn't available for 1-1/2 months..and she suffered a fatal heart attack in the meantime. She did have indications that something was wrong...went to an emergency room, but the on duty staff found nothing wrong and no specialist called. This was in a prosperous city (Calgary). This is exactly what I hope doesn't happen to the very good care we get where I live. I did live in Canada when I was younger, but was healthy and didn't really require any special or much medical care...my relatives tell my the system now has almost completely broken down...not enough equipment, doctors, nurses, hospitals, etc. My intent with this is not to put the Canadian system down....don't know if its really the system that is to blame....could be just too many people for too few resources (ie not the payee system)....and I do know from personal knowledge...that many of the good doctors move to the US from Canada to make more $$. But if volume and lack of resources is a problem in Canada with just 22-24 million (or whatever #)...imagine what its going to be like in the US. But something needs to be done. Just my 2 cents!
I agree that access to care can sometimes be a problem in Canada. But when I lived in the US I saw many instances of access problems too. For example, a colleague's son put his hand through a glass door. He had to be trucked around to five hospitals, bleeding, with a severed nerve, before he could receive the emergency plastic surgery that he needed, because the HMO had such specific requirements.

As far as physician migration goes, it is true that a significant number of Canadian physicians migrate to the US The Canadian contribution to the US physician workforce -- Phillips et al. 176 (8): 1083 -- Canadian Medical Association Journal but the pattern has begun to reverse since this study was published.
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Old 03-11-2009, 08:17 PM   #296
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Good question. Well, I have not run any numbers, but I have thought about the balances and tradeoffs. So I think we can take a very rough stab at whether it is a large net gain or net loss. Lets' see if I can hit the major points:

Well, a significant number of under 65 *are* currently paying for their health insurance, either privately or in combo with their employer (so that is largely coming out of their salary). So we can very roughly assume that the cost to them in total taxes would be about what they are paying out-of-pocket. That makes the assumption that the govt actually pays for the vouchers out of current taxes rather than pushing the cost forward, but let's do that for now for simple accounting. So, give me a $x,xxx voucher and increase my taxes by $x,xxx - it's all the same on average.

Now, for the poor. Well, we end up paying for them out of our taxes anyhow, right? Or from cost shifting by hospitals (we can't collect from Indigent Joe, so we WILL collect from Insured Joe). So no real change there either. In fact, there is a big opportunity for cost cutting. Eliminate some of those ER visits, because a doctor will see them. Get some proactive health measures in place which could possibly reduce the overall health care cost. Potential Win-Win.

Am I missing any big piles of expenses? If not, then I don't think those vouchers will cost us much if anything net-wise. So no, it shouldn't drag the economy down with extra taxes. Lotsa guess work there, but that's about all we can do. See anything you strongly disagree with?


-ERD50
That's a solidly rational way of looking at it. I'm thinking about the future when people look at their tax bills and see that marginal rates which used to be 25% plus FICA are now 35% plus FICA (and the current 35% goes to 45%). I suppose they can also look at the $5,000 per person voucher (or whatever it will be) and feel they are at least getting something tangible for their taxes.
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Old 03-11-2009, 08:28 PM   #297
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Is that risk any higher than the risk of the govt committee in power at the time deciding that we can't afford the cost of treating certain high risk people? The decisions are either going to be profit based or populist/political based and I'm just not sure which would be better.

I'd like some choice to remain. If I've worked hard and saved hard and can afford to buy a supplemental policy or pay out of pocket, I'd like to have some say regarding my own or my family's fate regarding medical treatment without having to leave the country for the treatment.
With all the various opinions floating around, I want to clarify that I'm not a person who thinks that gov't funding of all health care is a good idea. If we had some mandatory system, I'd also want to have the option of getting purely private care above the gov't mandate (and I'd want a substantial deductible at the bottom).

I'm not that afraid of a gov't "board" of some sort. Medicare already pays for a significant chunk of our total medical expense. I'm sure there are some bad stories somewhere, but I don't remember seeing anything about denying treatment that scares me.

I honestly would take my chances with a public board, knowing that any savings they get goes to taxpayers, rather than private companies where the profit motive may push harder.
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Old 03-11-2009, 10:23 PM   #298
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With all the various opinions floating around, I want to clarify that I'm not a person who thinks that gov't funding of all health care is a good idea. If we had some mandatory system, I'd also want to have the option of getting purely private care above the gov't mandate (and I'd want a substantial deductible at the bottom).

I'm not that afraid of a gov't "board" of some sort. Medicare already pays for a significant chunk of our total medical expense. I'm sure there are some bad stories somewhere, but I don't remember seeing anything about denying treatment that scares me.

I honestly would take my chances with a public board, knowing that any savings they get goes to taxpayers, rather than private companies where the profit motive may push harder.
Given your assumption of the option of allowing purely private care above the govt mandate and the existance of private supplemental medical insurance policies, having a board or committee setting policy, guidelines, rules, etc., might be acceptable. But I'd find it hard to accept zero private care allowed and a govt committee calling all the shots leaving you with no alternatives.

My experience with govt and govt control may not be typical. I'm from Chicago, home of Dem Machine Politics. Please understand my fear of having my family's health possibly being under the direction of a govt group like this with zero alternatives allowed! "Pay to Play" and my grandchildren's health aren't a very acceptable combination!

I could accept Medicare for all. It's already in place, we're experienced with it - tens of millions are already using it and private supplemental policies or out-of-pocket payments are allowed. It would just be a matter of determining how to spread the cost across the population in some humane way.
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Old 03-12-2009, 01:36 AM   #299
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It would just be a matter of determining how to spread the cost across the population in some humane way.
We have a way already being applied in other areas by the new admisitration. Responsible, frugal and productive people pay, all others party on.

Ha
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Old 03-12-2009, 02:29 AM   #300
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Looks like France has at least three things going for them, good food, a decent health care system, and a tolerance for nuclear power plants. Maybe they can learn how to fight wars now.......
Hey, they're fully rejoining NATO. Be careful what you wish for.

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