single-payer system ... singled out

[The_Animus]

I now sit humbly awaiting the meme defense mechanisms of single payer to arrive. I will "have no evidence" or "am wrong", in spite of the hundreds of experiments done last century.

Well of course people will say you have no evidence as you didn't provide any.

Single payer does not exclude the possibility of buying greater additional coverage. It doesn't even necessitate a sole provider of insurance or complete government control.

Dr. Ezekiel Emanuel's UHC plan:
http://www.pbs.org/now/news/315.html
This is only a very brief description of it, for more information you'd have to find the actual outline of his plan.

PBS Frontline Sick around the world:

Can the US learn anything from the rest of the world about how to run a health care system? Five Capitalist Democracies and how they do it.

http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/

With UHC you would save maybe 1/3 to 1/2 of the countrys healthcare expenses. So there is plenty room/money for goverment sponsored research.

This is wishful thinking.

Ziggurat is correct. This is very wishful thinking. There would be lots of money saved by switching to a different system. The profit motive could be taken out, administrative overhead could be reduced , and current healthcare systems such as medicare and schip which are subject to fraudulent claims or inefficiency could be slowly phased out. All of this would save a significant amount of money. However, you also have the 40 million or so Americans who don't have health insurance at all that you now need to cover. This is why a UHC plan will not cut costs overall. Dr. Emanuel believes with his plan that we can spend roughly the same amount of money as we do now but cover everyone in the country.

If any of you take the time to thoroughly read and go over Dr. Emanuels entire plan I think you'd find it is a really good option.

 

[Rolfe]

I would certainly agree that for the same expenditure, you ought to be able to provide cover for everyone. Good cover, too.

So what would be the objections to that?

Rolfe.

 

[ARubberChickenWithAPulley]

Insurance companies have a duty to their stockholders, and alot to lose. Lobbying against UHC is an expected reaction from them. And it would be foolish not to try to affect the public debate as well as politicians.

And yet doctors, hospitals, and pharmaceutical companies outspend them by a large margin when it comes to lobbying.

The fact is, there are quite a few major players in the system who would have a lot to lose in a government-run system, and who regularly lobby the government to oppose it. Including the AMA, the AHA, the AARP, Pharmaceutical companies, etc.

In other words, almost all of the major groups involved in the system are against it for various reasons.

 

[Rolfe]

Sure. In the USA a great deal of money is spent, to deliver healthcare that is mediocre (on a whole-population basis) by international standards. This money is going somewhere. And those who are receiving the large chunk of it that isn't being spent directly on patient care, don't want that to change.

Rolfe.

 

[ARubberChickenWithAPulley]

Sure. In the USA a great deal of money is spent, to deliver healthcare that is mediocre (on a whole-population basis) by international standards. This money is going somewhere. And those who are receiving the large chunk of it that isn't being spent directly on patient care, don't want that to change.

Odd way of phrasing things. The AMA represents physicians, the AHA represents hospitals, and Pharma companies are obviously the people who research and develop the medicine that people take. Even AHIP (the insurance trade group) represents both for-profit and not-for-profit insurance companies. As such, the first three are providing patient care.

Besides, how do you define money "spent directly on patient care" anyway? At what point is a physician's profit considered not "directly on patient care"? At what point does a pharmaceutical company's profit equal "not directly on patient care"? Ultimately, unless you remove profit from the entire system, there's going to be quite a bit of money that it is not spent "directly on patient care."

The Pharmaceutical industry, for example, is one of the most profitable in the country (something like a 17% margin on over 300 billion in revenue).

The hospital industry, prior to the recession, was pulling in profit margins of 6+%.

The health insurance industry was around 3.9% on 280 billion of revenue.

Why not get rid of profit everywhere?

 

[Rolfe]

Mmmm, I wasn't thinking much about pharmaceutical companies at all since I don't know of any universal healthcare system which includes them. They remain as they are, and are paid for their product. However, thinking about that point, I understand that in the USA you pay significantly more for your medicines due to being unable to negotiate the price down. So there would be that bit.

Medical professionals' profits or salaries would, in my view, be money directly spent on patient care. You have to pay your staff. On the other hand, shareholder profits from hospitals?

I was thinking of the insurance companies, all their advertising and staff costs and overheads, and their profits, and all the money spent deciding who is entitled to what and all the administration involved at both ends in processing the claims and shunting money around. There seems to be an inordinate amount of this.

Some universal healthcare systems remain insurance-company based, and this apparently works so I'm not knocking it. But frankly, if you simply declare that anyone whom a doctor decides is sick and needs treatment, gets that treatment, you cut out an awful lot of paper-pushing.

Rolfe.

 

[ARubberChickenWithAPulley]

Mmmm, I wasn't thinking much about pharmaceutical companies at all since I don't know of any universal healthcare system which includes them. They remain as they are, and are paid for their product. However, thinking about that point, I understand that in the USA you pay significantly more for your medicines due to being unable to negotiate the price down. So there would be that bit.

"Negotiate" is one way of putting it. They get some lower prices from negotiation on volume. A lot of it, though, they get not from "negotiating" prices down, but by essentially regulating and fixing prices at a certain level. For example, Brazil didn't like Merck's price for an anti-AIDS drug so it simply threatened to break their patent. Canada and France also hold drug prices down through government price controls. Arguably, this is on the back of the U.S. consumer, who is making up the difference, since we don't have those price controls, and the pharma companies have to make up the difference somewhere.

Medical professionals' profits or salaries would, in my view, be money directly spent on patient care. You have to pay your staff. On the other hand, shareholder profits from hospitals?

Okay, so no hospital profits. Got it. And what about physician salary control? What is an "acceptable" physician salary? Should that be decided by the market, or do we regulate it? Some doctors make some pretty hefty salaries.

I was thinking of the insurance companies, all their advertising and staff costs and overheads, and their profits, and all the money spent deciding who is entitled to what and all the administration involved at both ends in processing the claims and shunting money around. There seems to be an inordinate amount of this.

Probably. The U.S. "system" likely doesn't help much. I mentioned it earlier in the thread, but the fact is, even insurance companies don't truly operate nationally. Every state has its own unique regulations and laws that insurance companies have to follow. Every state mandates coverage for certain things and not others, every state has its own requirements for pharmacies, oversight of insurance companies, etc. There's a lot of additional overhead just to stay on top of each state's regulations, laws, etc, not to mention the difficult in being able to pool risk.

Some universal healthcare systems remain insurance-company based, and this apparently works so I'm not knocking it. But frankly, if you simply declare that anyone whom a doctor decides is sick and needs treatment, gets that treatment, you cut out an awful lot of paper-pushing.

I'm with you there. If the U.S. simply nationalized its health insurance market, that would be possible, I think. Insurers could truly pool risk and operate under one national system, and actually compete with one another for business. And they could probably do it without denying coverage due to pre-existing conditions.

 

[Blue Mountain]

Medicaid.

I think (and correct me if I'm wrong) that somewhere after $7.00/hr you make too much to qualify for Medicaid.

It's called planning. You don't need to be making $75k a year in order to save enough to pay for COBRA coverage, or even individual insurance. I saved enough when I was a grad student to do exactly that sort of thing. Hell, I still don't make that kind of money, and I've always made sure I could cover my own health insurance if I ever lost my job.

First, are you saying it's possible to save money when you're working for wages that are just above the poverty line, raising kids and paying rent? Does the term "working poor" say anything to you?

Second, take a look at your savings right now. Assume you go into work tomorrow and are handed a pink slip and ten weeks severance pay. Regardless of your optimism of finding a job in the near future, how long will your savings last under these two scenarios:
1. You elect not to pay COBRA and take your chances with your health and your family's
2. You pay the COBRA

Here in Canada, I don't even have to worry about option 2. My savings will go that much further.

Further to you comment about savings: I see this much so among people with your mindset: Because I can do X, everyone else should be able to do X as well. Not everyone can do X, for a variety of reasons. Some of those reasons are bad, such as laziness and a willingness to pursue pleasure before basics. Sometimes they're neutral: some people just plain can't get interested in some things. For example, that's why I don't run a business: I am simply not interested in all the minutia required to keep a business healthy. And other times it's circumstances, such as string of bad luck or even a decision that reduces your savings just before your employment is terminated.

Exactly. So why would you think that the stories which make headlines in the US are any more representative?

Because I can see the words "X million Americans don't have any health insurance." The value of X varies, probably depending on how the person compiling the numbers decides who to include: under-insured, the uninsured who prefer to not to pay the premiums when they could, and persons living in the US illegally all can be used to inflate the number.

To me, the fact that health insurance is tied so closely to employment is the real downside of the American system. Unless they're making really good money, individuals don't seem to be able to pay for their own insurance because the premiums are so high. And when people lose their jobs, they lose their health insurance. All too often people lose their jobs because of chronic illness, and now they have a multiple whammy: not healthy enough to work, not poor enough to get Medicaid, and not rich enough to afford insurance. Sucks to be them, I guess.

And I'll throw another wrench at you: denial of insurance for pre-existing conditions. Here in Canada you're still covered even if you've had cancer and are now showing symptoms of diabetes. Would you be able to get insurance at any price if you had a medical history like that?

 

[balrog666]

I'm pretty sure there's more than few fellow skeptics here who check out the blog Denialism (prominently linked to by Novella and others), but he's had a few posts on health care in America and given we were talking about satisfaction with health care in different systems around the world I thought this recent post would be useful for our discussion:

[qimg]http://scienceblogs.com/denialism/upload/2009/05/whats_health_care_like_in_aust/commonwealthfigureII8.jpg[/qimg]

[qimg]http://scienceblogs.com/denialism/upload/2009/05/are_patients_in_universal_heal/HFA2.gif[/qimg]

Oh, I see! Your intent is to reduced discretionary spending on medical services! Isn't there an easier way to do that?

 

[balrog666]

? Are they loosing money faster than european railroads?
Not enough goverment regulation?
Not your best examble of private efficiency.

?
Last I heard they made good use of what money there were.

All countries have horror stories of goverment waste.
That is not something unique for the US.

Sorry if I exceeded your Google-fu.

And you heard wrong. Buy a few clues. Please.

 

[Ziggurat]

I think (and correct me if I'm wrong) that somewhere after $7.00/hr you make too much to qualify for Medicaid.

Not if you've got kids.

First, are you saying it's possible to save money when you're working for wages that are just above the poverty line, raising kids and paying rent? Does the term "working poor" say anything to you?

Yes, I'm saying exactly that: it is indeed possible. And people do it.

Second, take a look at your savings right now. Assume you go into work tomorrow and are handed a pink slip and ten weeks severance pay. Regardless of your optimism of finding a job in the near future, how long will your savings last under these two scenarios:
1. You elect not to pay COBRA and take your chances with your health and your family's
2. You pay the COBRA

More than a year. Because I've saved aggressively. Which many more people can than do.

Further to you comment about savings: I see this much so among people with your mindset: Because I can do X, everyone else should be able to do X as well. Not everyone can do X, for a variety of reasons. Some of those reasons are bad, such as laziness and a willingness to pursue pleasure before basics. Sometimes they're neutral: some people just plain can't get interested in some things. For example, that's why I don't run a business: I am simply not interested in all the minutia required to keep a business healthy.

I don't have pitty for people in the first condition. The second condition doesn't make sense when it comes to your savings: you don't do it because you're interested, you do it because it's stupid not to.

And other times it's circumstances, such as string of bad luck or even a decision that reduces your savings just before your employment is terminated.

That happens sometimes. And when it does, you typically end up qualifying for medicaid.

To me, the fact that health insurance is tied so closely to employment is the real downside of the American system.

I'm not a fan of that either. But there are plenty of ways to change that besides having government take over the industry.

And I'll throw another wrench at you: denial of insurance for pre-existing conditions.

Cannot be done unless you let your coverage lapse (did you know this?). So don't let it lapse. Most people caught by this get in that position because they screwed up.

Here in Canada you're still covered even if you've had cancer and are now showing symptoms of diabetes. Would you be able to get insurance at any price if you had a medical history like that?

Yes. If you let your coverage lapse, the providers will typically not cover expenses for a preexisting condition for some period of time (IIRC something like 18 months), but will after that period. And if you haven't, then you get covered from day 1, and yes, you can get insurance even with serious pre-existing conditions.

 

[Matthew Best]

I don't have pitty [sic] for people in the first condition. The second condition doesn't make sense when it comes to your savings: you don't do it because you're interested, you do it because it's stupid not to.

You seem to think that stupid people deserve whatever bad stuff comes their way. But half the people in the US are of below average intelligence - why is that their fault?

 

[Rolfe]

I'm still wondering what "freedoms" US citizens have with their present system that citizens of countries with universal healthcare don't have.

From where I'm sitting, I think I'm the one with the greater freedom.

Rolfe.

 

[martu]

I'm still wondering what "freedoms" US citizens have with their present system that citizens of countries with universal healthcare don't have.

From where I'm sitting, I think I'm the one with the greater freedom.

Rolfe.

They have the freedom to die of treatable diseases if they aren't rich enough to afford medical care.

 

[Architect]

Let's be quite clear here. Despite the hand-waving, despite soundbites, where we've covered medical standards in other threads - just a selection of the threads are linked above - then it's been shown that universal socialised healthcare systems sucha s those found in the UK do, in fact, produce better standards of healthcare based on key performance indicators such as infant mortality. Likewise it's been shown that it's far cheaper than the American system once we factor in the costs of both Medicare/Aid and private cover.

Is there any chance that Balrog, Zugggarat, and others might address these, rather than be all vague?

 

[martu]

Let's be quite clear here. Despite the hand-waving, despite soundbites, where we've covered medical standards in other threads - just a selection of the threads are linked above - then it's been shown that universal socialised healthcare systems sucha s those found in the UK do, in fact, produce better standards of healthcare based on key performance indicators such as infant mortality. Likewise it's been shown that it's far cheaper than the American system once we factor in the costs of both Medicare/Aid and private cover.

Is there any chance that Balrog, Zugggarat, and others might address these, rather than be all vague?

Government = bad mkay?

That's all it is. Putting ideology above doing what will result in better care for the overwhelming majority of the population at less cost.

 

[Rolfe]

You seem to think that stupid people deserve whatever bad stuff comes their way. But half the people in the US are of below average intelligence - why is that their fault?

So many of the reactions from US posters dislpay a hard and unsympathetic attitude.

• If I can be smart enough to ensure I'm covered by the system, everyone else should be.
• If I can make huge financial sacrifices to tie up a lot of my money to meet possible future healthcare needs, everyone else should be able to do that.
• And if you're virtually destitute, then Medicaid is the answer.

One of the things I really appreciate about the NHS is not having to worry about any of this. I don't have to think about whether my health-care plan is good enough. I don't have to lock away my savings with the thought that I might need to pay for a big-ticket item some time in the future. I don't have to think at all about healthcare coverage if I decide to change jobs. I can decide to give up my job and spend some time doing something else without worrying about healthcare coverage.

If I had to do these things, I'd do them. But it's really, really nice not to have to. At the moment I'm planning some alterations to my house. (Architect knows all about this!) If the NHS wasn't there, I'd probably feel I had to keep the money that will cost, just in case. And Architect would lose a little bit of income. It's nice to feel that I can do something else with my savings other than lock the money away in case I need a triple bypass.

And I like the knowledge that all my fellow-citizens have the same freedom from worry. I don't feel resentful that nobody else has to plan and scrimp and save to provide for possible future healthcare needs either. This isn't just general approval either. I very much like the fact that I'm not constantly assailed by charity appeals for donations for healthcare needs. In particular, I know that if a close friend or relation develops a big-ticket healthcare requirement, they won't be scraping their savings dry, and so I won't be tortured by my conscience into scraping my savings dry too, to help them. (Yes, there are charity appeals, don't get me wrong, but they're mainly for research, or for extra provision such as hospices - not, our neighbour George desperately needs a kidney transplant and can't pay for it.)

Of course, anyone in Britain is entirely free to take out private healthcare insurance, and/or pay for private treatment out of their savings. And some choose to do that. There are advantages, mainly that non-emergency treatment will be done at a time of your own convenience (the NHS cuts patients a limited amount of slack in this respect), and you'll get a lovery private room in a swanky upper-class hospital. But how many people do this? Not a lot. In spite of all the horror stories you might find in your web searches about waiting times and so on, the underlying confidence in the NHS to look after you when you need looking after is very high. Most people have many friends and relatives who have had major interventions done on the NHS with no complaints whatsoever. Few people have personal experience of the sort of thing that hits the papers - these things hit the papers precisely because they're uncommon. And because they represent a denial of patients' basic rights.

I honestly don't understand why US citizens seem to like all this worry and scrimping and saving and tying up large amounts of income and/or capital in just-in-case healthcare provision.

I'm going back to measuring up my roof for these new windows. Architect, I'll email you.

Rolfe.

 

[ARubberChickenWithAPulley]

Let's be quite clear here. Despite the hand-waving, despite soundbites, where we've covered medical standards in other threads - just a selection of the threads are linked above - then it's been shown that universal socialised healthcare systems sucha s those found in the UK do, in fact, produce better standards of healthcare based on key performance indicators such as infant mortality. Likewise it's been shown that it's far cheaper than the American system once we factor in the costs of both Medicare/Aid and private cover.

It just depends on what you consider a system "like those found in the UK." I think a universal system is absolutely necessary. I also think all the focus on single-payer and blaming the "evil" insurance companies for all of the problems is misplaced. A system similar to what the Netherlands uses, or even Germany, would work. Have the government "referee" the system at a national level, but not necessarily run it.

 

[Rolfe]

I don't necessarily disagree with that. We all tend to talk about the system we're familiar with, and in my case and Architect's, that's the one where the government pays for the hospitals and the doctors and so on, and we get to access that resource at need. We don't think much about how it works in other European countires, because there, just as here, we don't hear stories about people being denied necessary healthcare because of the lack of the means to pay for it.

As an aside, we also know that if we show up in another European country requiring healthcare, and present our European Healthcare entitlement card, we will be treated in the same way as a citizen of that country would be treated. And we know that while that may mean some modest payment, we're basically covered.

The fact that insurance companies are involved in the delivery in these countries doesn't seem to interfere with the delivery of healthcare (free or at least easily affordable at point of need) to all their citizens. So yes, there's no reason why the USA shouldn't adopt a system like that. In fact, I would think it much more likely that they would go down that route, considering the starting point.

The important thing is that all citizens should be able to access whatever healthcare they need, without this being denied due to lack of ability to pay for it. How this is accomplished is only important insofar as practicalities and workability are concerned.

Rolfe.

 

[Rolfe]

And what about physician salary control? What is an "acceptable" physician salary? Should that be decided by the market, or do we regulate it? Some doctors make some pretty hefty salaries.

They do here,too. Nobody really disputes that people as highly-trained and highly-skilled as doctors are entitled to excellent remuneration. In fact, the BMA (the doctors' "trade union") negotiated so well recently that the doctors ended up with quite a lot more money than the government had really wanted to give them.

Now that the weather is so nice, I'm hoping that my medical friends (general practitioner married to a consultant surgeon) will once more invite me to spend a weekend on their yacht.

Rolfe.