Socialized Medicine

[Martha]

I'm not certain that this is a good analogy. In fact, the insurers' profit motive largely explains what happened. They leaned on government to mandate auto insurance, thereby increasing demand for their product. Then, they reneged on the promise they used entice the government to take action, citing yet another excuse for their high rates. This is precisely why I think insurers should not be part of the solution -- they are in it solely to make money for themselves, not to ensure that you or I have adequate health care.

I agree, but we are in a minority, even among democrats. The problem with insurance company competition is that they are competing for the healthiest. You can buy a good low cost non-group plan from a private insurer if you are perfectly healthy and young. They bet that you will not stay with them for long and most don't. They compete to cover large groups where a few large claims aren't going to break the bank, unlike for small groups. And they have lifetime caps so you or your premature infant probably won't cost them more than a million or two anyway.

They don't want the small employers. They don't want the chronically ill. They don't want the old. The model is a cherry picking model where insurance companies make a lot of money. A huge amount of money. The government ends up picking up the tab for the old and disabled. And many fall through cracks.

 

[ERD50]

Has anyone addressed that if "the current American system currently results in groundbreaking advances" where does the world go for that in our system is changed?

Hey, isn't that the theme of this book that I had to put a hold on as my library had every issue out?

http://www.early-retirement.org/forums/f28/just-picked-up-my-old-atlas-shrugged-book-42940.html

-ERD50

 

[youbet]

When someone who is not a citizen comes to live in Canada legally, e.g. on a work permit, or is a landed immigrant, their province or territory of residence begins covering their health care (IIRC) within three months of arrival and registration.

.

How about long term illegal (undocumented if you wish) folks living in Canada? If someone from that class of people has cancer, how would it be handled?

BTW, I've generally heard good things about the Canadian system. But never having experienced it myself, I'm just curious how it would handle some of our situtions. For example, we tolerate millions of non-citizens being here long term and currently provide education and minimal health care. Including them in a universal medical plan would be an issue in the minds of some people. I'm not sure Canada has to cope with that issue, but I'm curious how you do, if you do.

 

[youbet]

The government ends up picking up the tab for the old and disabled.

I'm curious, who will pick up the tab for the old and disabled in a govt univeral health care plan?

 

[Martha]

Has anyone addressed that if "he current American system currently results in groundbreaking advances" where does the world go for that in our system is changed? Sure, there are and will be break troughs but will it be at the same rate?

Insurance doesn't pay for experimental treatment anyway. That gets done with other money, being parts of studies, etc.

My grandniece was born without much of an intestine. She was on SSI so the government paid for her care, which amounted to well over a million dollars before she died at one year old. They did a surgery on her that had only been done seven times before, with two or three successes. She was not a success. She died a few months later. I had mixed feelings about the whole thing. Should this kind of surgery be even done when the odds are so bad? How long should that poor baby and her parents suffer? The experts really did a pitch for the procedure. In retrospect, all I can say is that I hoped they learned something.

 

[Martha]

I'm curious, who will pick up the tab for the old and disabled in a govt univeral health care plan?

Is this sarcasm? We all pay for it now and we all will pay for it with universal care. You and I contributed to the medical bills of my grandniece.

 

[FIRE'd@51]

I'm curious, who will pick up the tab for the old and disabled in a govt univeral health care plan?

My [-]fear[/-] guess is that the treatment to older people will be greatly limited as cost-benefit analysis is applied in order to keep down the cost for the entire plan. Things like bypasses for 75 year-olds will be considered not worth doing since their life expectancy is lower than say, a 50 year-old.

 

[ERD50]

They don't want the chronically ill. They don't want the old. The model is a cherry picking model where insurance companies make a lot of money.

But isn't that problem fixed if everyone is required to have insurance, and ins cos have to take all who apply (as in samclem's outline)?

It would also seem to promote more preventive healthcare approaches, since all the companies would be "stuck" with any/all applicants for as long as the applicant wanted to stay with that company. It might take something to help keep the ins cos focused on long term results though. If they are looking to make this Quarter's numbers look good, preventive techniques are going to get the short end. But again, the govt might specify the minimum preventive techniques that must be covered.

-ERD50

 

[Meadbh]

Meadh, what does Canada do to promote population health?

For people unfamiliar with population health, here are a few links:

Population health - Wikipedia, the free encyclopedia

Population Health - Public Health Agency of Canada

Canadian Population Health Initiative

Basically, population health aims to improve the overall health of the population, thereby reducing the need for healthcare over time. (An apple a day keeps the doctor away, hence the apple on the PHAC website). In real terms, in Canada this translates into public policy. For example, provincial governments (who fund health care organizations) usually conduct, or cause to be conducted, population health assessments every 5 years or so. This helps to determine where the needs are. They can then incorporate those needs into a set of deliverables for the organizations they fund. In recent years, rather than funding individual hospitals and clinics that may not talk to each other, governments have been amalgamating them into health regions or similar clusters. A health region will be responsible for the health and health care of its entire geographically defined population, so it's in its interest to look at the big picture. Some provincial governments have specific indicators that they require health regions to improve, e.g. the number of diabetics getting screened for eye or kidney problems or the number of kids who get their immunizations on time. Another way to address the determinants of health is to get agencies and ministries to work together (e.g. health, housing, education) on policy making and programs. Also, health systems accreditation (Accreditation Canada) incorporates population health into its standards and now has specific sets of standards aimed at specific populations (e.g. child and youth, older people, mental health population). At the frontlines, care plans designed for patients now usually incorporate secondary prevention measures; for example, a care plan for myocardial infarction may include a stop smoking program, exercise and rehabilitation, and a visit to the psychologist in case of depression; a care plan for acute asthma will include family asthma education.

One further step that I would like to see taken is that the money follows the patient. Currently it's allocated to facilities and programs.

 

[Martha]

Crap, I lost my post with a bad signal. Briefly, I would accept SamClem's solution as a compromise. There are issues and always will be issues. One in enforcement of requiring insurance. Wyden's plan addressed that issue by collecting payments through the tax system, yet still kept insurance companies. Another issue is that the care focus is driven by insurers, so prevention and chronic care may get short shrift as it does now. "What, you check your blood sugar 6 times a day? That isn't usual, the insurance company will only pay for test strips to check two times." Who cares if there is substantial health benefit to increased checking. The other issue is the administrative layer resulting from multiple insurers each with their own paperwork and other requirements. Major PITA for providers. "Now who is your insurer? Lets see, they only pay for this inhaler, not that inhaler."

 

[Martha]

For people unfamiliar with population health, here are a few links:

Population health - Wikipedia, the free encyclopedia

Population Health - Public Health Agency of Canada

Canadian Population Health Initiative

Basically, population health aims to improve the overall health of the population, thereby reducing the need for healthcare over time. (An apple a day keeps the doctor away, hence the apple on the PHAC website). In real terms, in Canada this translates into public policy. For example, provincial governments (who fund health care organizations) usually conduct, or cause to be conducted, population health assessments every 5 years or so. This helps to determine where the needs are. They can then incorporate those needs into a set of deliverables for the organizations they fund. In recent years, rather than funding individual hospitals and clinics that may not talk to each other, governments have been amalgamating them into health regions or similar clusters. A health region will be responsible for the health and health care of its entire geographically defined population, so it's in its interest to look at the big picture. Some provincial governments have specific indicators that they require health regions to improve, e.g. the number of diabetics getting screened for eye or kidney problems or the number of kids who get their immunizations on time. Another way to address the determinants of health is to get agencies and ministries to work together (e.g. health, housing, education) on policy making and programs. Also, health systems accreditation (Accreditation Canada) incorporates population health into its standards and now has specific sets of standards aimed at specific populations (e.g. child and youth, older people, mental health population). At the frontlines, care plans designed for patients now usually incorporate secondary prevention measures; for example, a care plan for myocardial infarction may include a stop smoking program, exercise and rehabilitation, and a visit to the psychologist in case of depression; a care plan for acute asthma will include family asthma education.

One further step that I would like to see taken is that the money follows the patient. Currently it's allocated to facilities and programs.

Great stuff Meadh, thanks. One place where I see we have a big problem with population health is with mental health. I really have seen that in the homeless population and in the young runaway population. They end up hospitalized in emergencies and booted out quickly as no one pays, with no good followup. Some are mentally disabled but don't get classified as such because their care is so sporadic and no one is in charge of seeing if they are eligible for disability. Their drug compliance is poor. For example, Wisconsin charges a $10 copay for their "free" drug program for the very poor. So, you sell you blood. What you are going to buy? Cigarettes or Risperdol? You need the cigarettes.

 

[Rich_by_the_Bay]

By the way, "break through" discoveries are no longer the sole domain of the US. Western Europe, Russia, France and other places have an equal or better research presence in specific areas than we do. We may be a powerhouse, but it is no longer a one-country world. Even in stem cell research we have fallen behind because of funding and political/ethical issues. Pharmaceutical companies support research and clinical trials which are driven by their commercial interests, and yes, occasionally we get a break through. Universities are weakly funded and now proudly accept drug company support which automatically makes the interpretations hard to assess objectively ("I wonder how many other studies they chose NOT to publish.").

So I am not convinced that research and breakthroughs are necessary a product of our current insurance system. Under a more universal system, the NIH, CDC, etc. could prioritize the research support they grant based on noncommercial factors.

 

[ERD50]

Briefly, I would accept SamClem's solution as a compromise. There are issues and always will be issues.

No doubt - the question is which system is likely to have the best outcome overall.

One in enforcement of requiring insurance. Wyden's plan addressed that issue by collecting payments through the tax system, yet still kept insurance companies.

Maybe I'm being over simplistic here, but I fail to see a problem. Everyone gets a voucher, they are in the system. Period. The vouchers are paid out of the general taxes, which is no different from most programs.

One problem would be getting all people to comply with the preventive care. Not much you can threaten a poor person with. But yet, that is no different today, so that isn't a net negative.

Another issue is that the care focus is driven by insurers, so prevention and chronic care may get short shrift as it does now. "What, you check your blood sugar 6 times a day? That isn't usual, the insurance company will only pay for test strips to check two times." Who cares if there is substantial health benefit to increased checking.

I guess that is where the govt would be mandating minimal "best practices". Yes, all sorts of room in there for problems, but wouldn't we have similar problems if it was all govt provided? Or maybe the problems would be from the other end - overpaying for unneeded procedures?

The other issue is the administrative layer resulting from multiple insurers each with their own paperwork and other requirements. Major PITA for providers. "Now who is your insurer? Lets see, they only pay for this inhaler, not that inhaler."

Much of the paperwork could be standardized. Businesses do this all the time. I don't look to see who manufactured my Thumb/Flash drive before I stick it in the USB port - it's standardized. Yes, ins cos will try to differentiate themselves in some ways, but I would think the majority of costs could fit some standard procedures. I'll bet the Pareto principle applies, 20% of the procedures are responsible for 80% of the cost.

-ERD50

 

[youbet]

The US is the most independent society in the world; Canada is more collectivist. The real question is: which solution will work best for your society's value system, and is that value system subject to change?

Been thinking about Meadbh's statement (above).

Assume we go ahead with a plan for universal coverage. Say it's the plan that would provide Medicare for all, regardless of age. Good. But based on who we are there would be a bunch of interesting questions to be answered.

Like:

Medicare for all would require a chunk of new tax money to pay for it. OK. How would we structure the taxes? Just increase the current Medicare payroll tax? Increase income tax rates? Invent new taxes on citizens? On businesses?

Who would be included? All citizens? Plus folks with greencards? Plus undocumented long term residents (also know as "illegals")? Plus fresh undocumented arrivals? My cousin Kieran living near Dublin?

What would be covered? Who would make the decisions? Would those folks be elected or appointed? With our always rapidly changing outlooks on issues, could/would we have enough policy consistency?

We're having a hard time deciding whether to do it or not (although we did get Medicare going which is covering many). How will we get these details ironed out? Can we trust our form of govt to make decisions many Americans are typically happier making for themselves?

 

[Meadbh]

How about long term illegal (undocumented if you wish) folks living in Canada? If someone from that class of people has cancer, how would it be handled?

BTW, I've generally heard good things about the Canadian system. But never having experienced it myself, I'm just curious how it would handle some of our situtions. For example, we tolerate millions of non-citizens being here long term and currently provide education and minimal health care. Including them in a universal medical plan would be an issue in the minds of some people. I'm not sure Canada has to cope with that issue, but I'm curious how you do, if you do.

Illegal immigrants are not covered. That can become a serious problem for public health if they have contagious diseases.

 

[Martha]

Much of the paperwork could be standardized. Businesses do this all the time. I don't look to see who manufactured my Thumb/Flash drive before I stick it in the USB port - it's standardized. Yes, ins cos will try to differentiate themselves in some ways, but I would think the majority of costs could fit some standard procedures. I'll bet the Pareto principle applies, 20% of the procedures are responsible for 80% of the cost.

-ERD50

Yeah, but look at those damn camera and phone chargers. Everyone is different.

 

[Martha]

Maybe I'm being over simplistic here, but I fail to see a problem. Everyone gets a voucher, they are in the system. Period. The vouchers are paid out of the general taxes, which is no different from most programs.



-ERD50

I thought that the idea was you would go and buy your own plan, no underwriting, and if you are poor you get a voucher. (sorry, I haven't back tracked to read all that was said before). There are people who won't buy a plan and they get sick or hurt anyway. Young people for example can feel invulnerable. That is why you have pre-existing condition waiting periods if you are uninsured. Otherwise, who would buy insurance. You need some way to force them into the system. This has been a problem with MA.

 

[Martha]

There's nothing sacred about the construct I've laid out there (and I'm sure there's not an original thought in it), but for it to work there needs to be no underwriting (not just excluding folks from coverage, but also no price differentiation based on health factors). If Prudential sells the "A" plan in Vermont, anyone who lives in Vermont can buy the "A" plan at the stated price. If better deals are available through employers, clubs, etc then there would be a significant opportunity to get de facto underwriting--since those who are employable are, as a whole, healthier than those who are not. You could form a club of 10K runners that requires all members to complete one 10K event per quarter, and then buy insurance as a group, thereby "cherry picking" and forcing higher rates on the public pool.

Isn't that the problem though? More and more pools are created to cherry pick the healthy and all that is left in the "public" pool are the unhealthy, making it very very expensive. Look at state risk pools. Most people can't afford them. And they are already subsidized.

 

[youbet]

Illegal immigrants are not covered. That can become a serious problem for public health if they have contagious diseases.

I'm sure the issue of whether to cover illegals or not is a significant stumbling block for us in making a decision on what to do. It's a huge number and growing constantly. Opinions are all across the board.

If we don't cover them, they will use emergency rooms for basic care anyway as they do now.

If we do cover them, their numbers would add significantly to the bill and the coverage would be another reason for millions more to come.

Tough questions.

I believe Canada takes a much tougher stand on illegals than we do so it may not be as much of an issue.

 

[youbet]

all that is left in the "public" pool are the unhealthy, making it very very expensive. Look at state risk pools. Most people can't afford them. And they are already subsidized.

But the costs of the unhealthy will be included in any universal system we come up with, no? Adding young and healthy folks to the risk pools would not make them less expensive. It would make them more expensive. The costs of the unhealthly would still be there plus you are adding the costs of the young and healthy folks.

I think you making be thinking in terms of "per person." But the bill we have to pay as a country is the aggregate bill for everyone.

 

[Meadbh]

I believe Canada takes a much tougher stand on illegals than we do so it may not be as much of an issue.

It's estimated that there are somewhere between 35,000 and 100,000 illegal immigrants in Canada. Most Canadians would like to see illegal immigrants deported. However, the Auditor General last year criticized the Federal Government for losing track of 40,000 of them.

 

[ERD50]

Yeah, but look at those damn camera and phone chargers. Everyone is different.

http://www.early-retirement.org/for...-have-same-charging-port-by-2012-a-42569.html

-ERD50

 

[Martha]

But the costs of the unhealthy will be included in any universal system we come up with, no?

Well, it depends on the extent you want to have the unhealthy pay for their own care. With risk pools, the unhealthy pay a lot and many can't afford it. I was responding to SamClem who suggested that group buying could be allowed to reduce the cost of the group. The problem is then how much will people who are not in a group going to have to pay?

If you have a voucher or subsidy system based on how much you can afford, what will the cut offs be? For example, if you are retired on a pension, that likely would be be the income that is looked at. But if you are retired on a million in assets, but no pension, would you get a subsidy or would you have to spend down your million? Most people are not overly sympathetic to millionaires. And who would review each person's finances to see what kind of subsidy they would get?

If you are going to have insurance companies in the mix with the ability of people to form groups you will have an adverse selection problem for people who do not fit in a group. If you allow for group formation you will need to have price regulation. Look at the guaranteed issue states, the prices are outrageous because of adverse selection.

 

[Martha]

http://www.early-retirement.org/for...-have-same-charging-port-by-2012-a-42569.html

-ERD50

I remember, just joking with you.

 

[ERD50]

I thought that the idea was you would go and buy your own plan, no underwriting, and if you are poor you get a voucher. (sorry, I haven't back tracked to read all that was said before). There are people who won't buy a plan and they get sick or hurt anyway. Young people for example can feel invulnerable. That is why you have pre-existing condition waiting periods if you are uninsured. Otherwise, who would buy insurance. You need some way to force them into the system. This has been a problem with MA.

Well, I'm sure there will be many proposals. I believe in the KISS principle. Just give *everyone* a voucher. Done. Everyone is in.

Why bother trying to figure out who can pay and who can't? The ones that can pay will pay - through their taxes. Cuts the administration of that aspect of it down near zero.

-ERD50