It’s just not enough for our own Dr. Paul DeMarco to solve our education problems. Now he’s fixing health care. I like what he says, anyway. Who am I to argue? He’s the doctor, after all. In case you don’t know what I’m talking about, check out his op-ed piece that was in the paper today. An excerpt:
It is a complex issue, but it comes down to whom to trust: an industry
that deals with patients at arm’s length and is ruled by the almighty
dollar; or physicians, who deal with you face-to-face, who suffer with
you when you are unable to access essential care and whose oath calls
them to service, not just to higher income.
Unlike some people I could mention, Dr. DeMarco doesn’t just talk; he acts. To wit:
That’s why I am eager to announce the formation of a new group devoted
to creating a single-payer plan for our state and country. The
organizational meeting for a South Carolina chapter of Physicians for a
National Health Program will be held at 2 p.m. Saturday at Thorny’s
Steakhouse, 618 Church St. in Conway. The national group was founded in
1987 and now boasts more than 14,000 members (everyone is welcome; you
need not be a physician to join).
Dr. DeMarco is doing his bit. What are the rest of us going to do?
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“It is a complex issue, but it comes down to whom to trust: an industry that deals with patients at arm’s length and is ruled by the almighty dollar; or physicians, who deal with you face-to-face, who suffer with you when you are unable to access essential care and whose oath calls them to service, not just to higher income.”
Just whom is the good doctor trying to kid here? How will the physician “suffer with [me]” when I’m in pain in the hospital or laid up at home? I’ll bet you $100 to a donut that as soon as the physician is off duty he’ll be heading for the golf course or whatever else strikes his/her fancy while I’ll still be suffering. Far from being some sort of saint, most doctors are just as much after the buck as the insurance companies are.
Personally I don’t trust either the insurance companies or the physicians. Both are there to provide a service and both are trying to make money. The adage ‘trust but verify’ applies to both equally. When my man Paul points his finger at the insurance companies I hope he’ll notice that his other fingers are pointing right back at him.
I fervently hope that Americans will never fall for the socialist snakeoil he’s trying to sell us. For the predictably bad results, just check out the travails of the British and Canadian single-payer schemes. There’s a reason why the Brits and Canucks come here for medical treatment when they face waits of many months for treatment of painful conditions and just can no longer stand the pain. Hint: it’s not because their socialist schemes are better than our system.
“A single-payer system will change the debate in a fundamental way, from who we are going to cover to what we are going to cover.”
You betcha! But who will decide what gets covered? Unfortunately I don’t think those super-efficient folks who gave us the DMV and 49th-in-the-nation public education are in any way qualified to make those decisions, much less better qualified than we are ourselves.
The problems with our medical system are precisely because the government got involved in the first place and made the situation worse and worse every time they “improved” and “fixed” it. Our best chance for real improvement (just as with public education) is to privatize the whole shebang.
BTW, Brad, I’m slightly mystified at your some people I could mention/a> link. There’s nothing on that page about medical care. Are you suggesting that you want Fred Thompson to fix the state’s medical system?
BTW, Brad, I’m slightly mystified at your some people I could mention link. There’s nothing on that page about medical care. Are you suggesting that you want Fred Thompson to fix the state’s medical system?
The PNHP website claims that when it comes to healthcare in the U.S.: “The reason we spend more and get less than the rest of the world is because we have a patchwork system of for-profit payers.”
I’m less inclined to believe that the primary reason is due to essentially too many payers/insurers than other factors like: exhorbitant malpractice insurance and “defensive” medical practices to prevent lawsuits; Medicare paying below-market prices for healthcare which in turn must be subisidized by for profit insurers – ask a few surgeons whether they are happy with Medicare negotiated fees; Big Pharma relying more and more on marketing pills for every malady (should any insurance company pay for Viagra?); A general shift in the American culture due to that marketing that assumes the answer to every problem (physical, mental, sexual) is to take a pill? Parents (the same ones whose kids have never done anything in school that wasn’t the teacher’s fault) who demand antibiotics for every sniffle or doctor shop until they find one who will diagnose little Johnny with ADHD so he can be doped up all day; Too-long patents for new drugs that reward drug companies with monopolized profits at the expense of the general public welfare; and you may be shocked to learn that there are many doctors and surgeons who are doing pretty well financially… they are just as “for profit” as the insurance companies.
There are a myriad of problems… I’m skeptical that a single payer will make any difference. I’d like to see limits on malpractice awards except in cases of extreme negligence; cut drug patent lengths; go back to the good old days where drug companies did not advertise prescription medications on TV; reward people for healthy lifestyles and making rational decisions about healthcare;
Anyway, I’m confused. If a doctor is the best person to trust when it comes to healthcare, how come a legislator or doctor (and not a teacher) is the best person to trust when it comes to education? Using Mr. DeMarco’s own words:
It is a complex issue, but it comes down to whom to trust: educrats and legislators who deal with students at arm’s length and are ruled by the almighty dollar; or teachers, who deal with your children face-to-face, who suffer with you when you are unable to access the best educational opportunities and whose oath calls them to service, not just to below market incomes.
Lex, you sure have simple answers to some complex questions. Just privatize the whole thing, eh? You sure have a lot of faith in the unfettered goodness of individualism. Understandable, in a way–our country was founded by the pioneer spirit. Still today we are individualists to the core. But modern life is a little more complex than that, especially with microscopic surgery and MRIs.
I can’t say that don’t have some reservations about Dr. DeMarco’s proposals, but leaving the situation as it is doesn’t seem to be a good idea. And turning it over to unfettered capitalism–well I’d say that the job of the shepherds is to take care of the sheep. True, it isn’t to primarily spend time playing golf (but most physicians I have been to don’t have much time for playing golf, anyway) but neither is it to feed the sheep to the wolves.
You point out Canada and Britain, and you have a good point there, but there are other models than these. It is not a good argument to take the two worse scenarios and hold them up for ridicule while ignoring other possibilities.
I think we should probably welcome physicians themselves working on the problem, which makes more sense than having politicians fix it. And if the physicians don’t, then I’m pretty sure that the politicians will, sooner or later.
In the doc’s own words:
His solution, however, does not put you face-to-face with medical professionals, but puts an agency like the US Postal Service between you and the pros. So, just stand in line and make sure your parcel is the correct size, properly wrapped, and doesn’t rattle.
If we do want to put the patient in charge and minimize the role of third-parties, we need to do change the financing system and make folks assume more responsibility for their healthcare decisions. Is it fair that an obese, alcoholic smoker get all the healthcare that Brad and I can afford?
We have a single-payer system now for the elderly. It’s called Medicare. It is constantly beset by cost woes and it overpays for many services. Physicians are constantly begging Congress to put more money into it. The problem is that there is no perfect system, and Dr. DeMarco’s suggestion has an element of “if we only created the Tooth Fairy, we’d all have money under our pillows” mentality to it.
Wake up all you conservatives. We already have socialized medicine in the U.S. It exists today. The system we have is simply awful. It’s very expensive. Waits at the emergency room are extensive. The system we have is based on the conservative model of how to do things: allow a few corporate entities to control everything with approval from the government. Then soak everyone else. The current system we have is probably the worst in the world.
Worst in the developed world, you mean. There’s no reason to dip into hyperbole when the truth is bad enough.
I read Dr. DeMarco’s full editorial in the dead-tree edition of The State and found his comparison of the medical industry to public education to be nearly scandalous.
His contention was that the current status of the high costs of medical care is the fault of the insurance industry’s “profit motive,” and that because we (as the public) readily accept the “notion of public schools” we should just as readily accept “public health care.” He further contends that “Big Insurance” and its “shareholder profits and outrageous CEO compensation” is the root of the problem.
Dr. DeMarco conveniently forgets the history and principle of public education lies in neighbors and communities voluntarily banding together to build schools and hire teachers as the solution to collectively educating their children and improving their communities. However, medical care has always been the purview of the private, for-profit practitioners who moved to those same communities and established medical practices only when demand insured business.
The current state of the high costs of medical care is a direct result of the descendents of those same early doctors seeking ever-increasing profits from the care that they provide over generations of patients. The medical insurance industry has only emerged as doctors priced their services out of the reach of normal persons, and those same patients had to turn to insurance as the only way to pay for decent care. The medical insurance industry exists to pay for the high profits of the medical industry and its doctors, not the other way around.
Dr. DeMarco and his MD peers continue to seek their profits with their Physicians for a National Health Program, only now they hope to guarantee a universal pool of potential customers. And don’t be fooled by arguments that their high salaries are only necessary to pay for their high business costs (to include education). Don’t forget that their credentialing and schooling is established and conducted by doctors for doctors. As to the ever-higher costs of medical malpractice, once again, the professional medical community shares as much of the blame as the legal and insurance industries.
While Dr. DeMarco might, as an individual, be truly motivated by his concern for our fellow citizens who don’t receive the quality medical care that they sometimes need because of its too high cost, the blame for that high cost lies more with the medical industry than anywhere else. Universal government health care insurance will only feed the demand for higher profits by the medical industry and its doctors at everyone’s expense.
Mike Roof –
You’re talking around a part of the problem. Employer-provided health insurance in the US today functions to insulate folks from the real costs of medical treatment. (Extracts below are from Arnold Kling’s Insulation vx. Insurance:
. It’s been a good deal for those so insulated as well as for the providers, but has bred inflation and greater demand for extravagant (high-cost, low-benefit) care. Those without insurance are kept out thanks to the high prices.
Kling points out that even if one eliminated the overhead introduced by insurance companies, overall healthcare spending would decline from about 15% of GDP to 14%.
The supposed advantages of single-payer are that everyone would be covered, overhead associated with the multiple insurance companies would be eliminated, and overall costs could be reduced to an affordable level.
It’s interesting to consider the measures inherent in such a top-down, closed system.
First, Kling points out that even if one eliminated the overhead introduced by insurance companies, overall healthcare spending would decline from about 15% of GDP to 14%. Hey, a point is a point, we’ll take it.
Next, medical personnel would be salaried (in some way) and a cap put on the number of practitioners. This is where things get interesting because of the way in which folks will react. Why would a doc spend extra years mastering a specialty like brain surgery or heart/lung transplants if there’s no real financial incentive to do so? The same is true of all categories of healthcare workers.
What will be covered? Okay, physicals, breaks, mammograms, are easy. Do annual colonoscopies for folks over 50? (Canada doesn’t think so.) Aromatherapy? Transplants? Chiropractic adjustments? We’re starting to get into real money here as we balance the treatments covered and number of practitioners permitted.
And I was not joking in an earlier response about limiting coverage to abusers of alcohol, food, and tobacco. What else shall we put on the national healthcare taboo list? Sexually transmitted diseases?
There are many interesting facets for cool-headed discussions.
Here’s something that should be much food for thought:
Why Nationalizing Health Care Will Make Us Less Free
In the debate over health care, many people support the idea of a government-run, single-payor system that will supposedly guarantee equitable distribution of treatment. However, in granting government the authority to ration all medical care, we grant them the power to withhold it for whatever purpose they see fit. The British have begun to discover this dynamic, as the Daily Mail reports that the National Health Service will begin denying smokers access to medical care until they prove they have quit — through a blood test.
Undoubtedly this is only the beginning of the slippery slope. Even Herb has admitted that I have a point about the horrid socialized systems the Canucks and the Brits have inflicted on themselves but the undeniable fact is that ALL socialized medical care systems will inevitably wind up like the above.
No matter how much we might like to be able to afford all the best medical care in the world, unfortunately we can’t because our resources are limited. There has to be some way of prioritizing medical care. In our admittedly imperfect system that is accomplished by a price mechanism. If a patient can raise the money – either out of pocket, from insurance or from voluntary charitable contributions by others – the necessary care will be delivered. In addition, everybody is guaranteed emergency treatment by law.
By contrast, in socialized systems unaccountable bureaucrats decide whether you should get care for what ails you, and when that care will be delivered. Since they can’t use price as a rationing tool, they will use other methods such as long waiting lists, severely restricted approved drug lists, and denial of treatment simply because you use nicotine or alcohol or are overly fond of Big Macs, among other things. In other words, the only way to get “free/affordable” medical care is to surrender your freedoms to the bureaucrats.
In many such systems you can’t get needed treatment even if you do have the necessary funds to pay for private treatment. They prohibit citizens from paying for their own treatment, forcing them to either suffer for months/years or to come to the US for treatment. Just another prime example of how socialism never solves a problem by raising people up but inevitably only makes everybody equally miserable.
Rudy dropped a bomb during last night’s debate. On healthcare:
The columnist goes on to cite the Kling column I linked to above.
I heard that also and just for that comment I can easily forgive Rudy a couple or three of his more liberal stances.
This everything-plus-the-kitchen-sink approach to health insurance is a major part of the cost pressure. If car insurance were run like health insurance we would all be paying several times as much and the Pauls of this world would be clamoring for a single-payer car insurance scheme.
We absolutely need to get back to the notion that most people (only exception: the truly poor) should pay for routine medical care just the same way they pay for a brake job or new tires. Instead we have people who see no problem with paying $150/month for the “monster” all-channel cable package or paying $300 for some Barbra Streisand concert or sports event, or $3,000 for a huge-screen TV. Yet they scream bloody murder when they are asked to co-pay $10 for their $200 miracle drug prescription, a drug which may cure or at least manage conditions which would have killed them 20 or 30 years ago. They will spend $150+ on some sneakers but $50 or $100 for a doctor visit is too much. How did people go so wrong in their priorities?
>Those without insurance are kept out
>thanks to the high prices.
Very true, Mike. When my father had complications after surgery in December, he spent 12 days in a coma in ICU. Looking back, it seems pretty apparent that the quality of care he received was enhanced by the fact that he had both Medicare and private insurance. The prognosis was very dim from the beginning and we were told the best outcome would be that he would be blind and in a nursing home for the rest of his life. Adding to the confusion was that his condition resulted in doctors from a variety of specialties (cardio, renal, pulmonary) weighing in with their own diagnosis and treatment options. The cardio guy was cautiously optimistic, the renal guy said there was little chance of survival. We were never informed of the cost of any of the variety procedures that were ordered. I’m assuming that was because they had already done an analysis of his insurance coverage to determine what would be allowed. My mother got the bill a month or so after my father died… $120,000 of which she had to pay less than $3000.
How would his treatment been impacted if he didn’t have the insurance? How would it be impacted by a single payer system?
The Scandinavian healthcare system works. Scandinavian Social Democracy works as well.
The Scandinavian Model
“The argument generally goes like this. Nowadays, every nation faces a stark but straightforward choice: It can admit that globalization demands a fluid economy–in which people will lose jobs frequently and incomes are bound to be more volatile–and adapt by slashing taxes, government benefit programs, and trade barriers. Or it can try to hold on to old-fashioned notions of lifetime job security and guaranteed incomes by blocking out trading partners, closely regulating business activity, and maintaining a generous welfare state–a formula sure to produce sluggish growth, chronic unemployment, and crippling government debt….
But… Scandinavia and, especially, to Denmark. Over the last decade, the Danes have turned the conventional wisdom on its head by boasting not only one of the world’s most expansive welfare states, but also one of its most robust economies. Given the way average American workers’ wages continue to stagnate even as their burden of risk–of losing a job, of losing medical insurance–continues to rise, it looks increasingly as though the conservative triumphalism has been misplaced….”
Lex,
You said:
“Even Herb has admitted that I have a point about the horrid socialized systems the Canucks and the Brits have inflicted on themselves but the undeniable fact is that ALL socialized medical care systems will inevitably wind up like the above.”
Well I’m glad you and Herb have decided that the Canadian system is horrid. Fortunately, the Canadians would beg to differ.
I don’t know much about the British system, but Canadians’ subjective assessment of their own health and their level of satisfaction with their system is comparable to Americans (according to the National Center for Health Statistics’ 2004 Joint Survey of Health in Canada and the United States). Canadians achieve these comparable results while covering all their citizens and spending about half per capita what the US does. Canada also outperforms the US in health outcome measurements such as infant mortality and life expectancy.
What Physicians for a National Health Care Plan is proposing is a Medicare for All system. The infrastructure is in place; we would just expand it to cover everyone instead of only those over 65. There would obviously be some difficulties in making the transition, but this plan seems by far the smoothest and most sensible way of covering all Americans.
And I know this is hard for you to accept, but Medicare’s overhead is less than half that of private insurers. The private sector does many things well; providing health insurance for all who need it is not one of them. The profit motive will always drive them to avoid the sickest patients, who need them the most.
You also said:
“By contrast, in socialized systems unaccountable bureaucrats decide whether you should get care for what ails you, and when that care will be delivered.”
In our new US system, the bodies that make decisions about what to cover should be accountable and transparent. This could be done by state or by region with groups of elected or appointed officials. Certainly whatever system we come up with will be an improvement from the current one in which insurance companies (who have just as many bean-counters as government systems have bureaucrats) make decisions in secret and are accountable to no one.
You also said:
“There’s a reason why the Brits and Canucks come here for medical treatment when they face waits of many months for treatment of painful conditions and just can no longer stand the pain.”
Nice try, but very few Canadians some here for medical care. Here’s a fact:
“Only 90 of 18,000 respondents to the 1996 Canadian NPHS (National Population Health Survey) indicated that they had received care in the United States during the previous twelve months, and only twenty had indicated that they had gone to the United States expressly for the purpose of getting that care.”
Not exactly a tidal wave across our border.
I don’t have any hard figures, but the number of American patients buying medicines from Canada (often at less than half the price) is likely in the thousands or tens of thousands.
You also said:
“No matter how much we might like to be able to afford all the best medical care in the world, unfortunately we can’t because our resources are limited. There has to be some way of prioritizing medical care. In our admittedly imperfect system that is accomplished by a price mechanism.”
This is well spoken. We can’t have it all. You accept rationing by income and leaving 15% of our population uncovered. But I think there’s a better way. In a single payer system, we cover everyone and then decide as a nation or a region or a state what we can afford to provide. This would involve difficult and controversial choices. But it certainly seems preferable to the current system.
And, to my mind, there should be nothing to prevent a private insurance company from offering coverage for a service not provided by national health insurance. Or a patient could always pay out of pocket, like many do today for cosmetic surgery.
In a completely private system, there is no mechanism for cost control. The private companies simple compete for those who can afford insurance. There is no incentive to insure the poor or the sick, for whom insurance provides the greatest benefit.
“Privatiz(ing) the whole shebang,” as you suggest would only increase the number of uninsured, drive up costs, and further complicate our already labyrinthine system (more bean-counters-but that seems acceptable to you as long as they work in the private sector).
Doug,
You said:
“There are a myriad of problems… I’m skeptical that a single payer will make any difference. I’d like to see limits on malpractice awards except in cases of extreme negligence; cut drug patent lengths; go back to the good old days where drug companies did not advertise prescription medications on TV; reward people for healthy lifestyles and making rational decisions about healthcare;”
Medical malpractice and the rest that you mention are important issues but really just a drop in the bucket compared to what we would save with single payer. It’s the only system that will cover everyone and has a mechanism to control costs. Eliminating the unnecessary paperwork and administrative burden inherent in the current system would save $200-300 billion a year by many estimates.
We need a system that will cover everyone and control costs. Single payer is the only system I know of that has both those abilities.
Mike C,
You said:
“Next, medical personnel would be salaried (in some way) and a cap put on the number of practitioners.”
In a US single-payer system, physicians would continue to be paid as they are now. There would be no mandatory salary or caps on the number of physicians. You’re thinking of a system more like the British National Health Service, but that is not what we are proposing.
In addition, nothing between you and your doctor would change. In a single payer system you would actually have more choice. You could see any doctor that would accept you-no more limits based on your private insurance plan. Health care delivery would remain just as it is (a mix of private and public providers, some for-profit, some non-profit, some government agencies). Only the financing would change.
Hospitals would be financed by global budgeting, receiving a fixed amount each year to operate (undoubtedly, this would be a challenge but still preferable to the cost-shifting they currently do, using profits from insured patients to cover the uninsured). Imagine the relief of being discharged from the hospital without a bill. No mysterious charges for $20 aspirin or $300 inhalers or $3000 from a doctor you don’t remember seeing, and no six-week tussle with your insurance company about those fees.
As for tying lifestyle to care, that’s a difficult area. I am a strong believer in personal responsibility. But it’s not always easy to decipher what problems are from genetic predisposition and which are from behavior. Perhaps we could give a tax deduction to nonsmokers or those close to ideal weight. I wouldn’t advocate denying care or increasing the price of a service based on lifestyle, however.
Gary,
You said:
“We have a single-payer system now for the elderly. It’s called Medicare. It is constantly beset by cost woes and it overpays for many services. Physicians are constantly begging Congress to put more money into it. “
Medicare is an agency that shows what well designed government can do. Arguments about what gets covered and reimbursement levels are a healthy part of the political process. Despite the haggling, Medicare continues to hum along, and covers over 40 million mostly satisfied seniors. One major concern is how Medicare can afford to cover the baby boomers, as enrollment is expected to top 77 million by 2031. Single–payer is the only system with the cost-containment ability that can make such a large increase in the Medicare rolls feasible.
Mike Roof,
You said:
“However, medical care has always been the purview of the private, for-profit practitioners who moved to those same communities and established medical practices only when demand insured business.”
I don’t know the history of private practitioners, but many hospitals were created by religious orders or charitable individuals. We see remnants of that in the Sisters of Charity who still run the Providence Hospital in Columbia.
I am not asserting the doctors are blameless for the mess we find ourselves in. Too many times we as individuals and as a profession have put ourselves before our patients.
But the issue is not how we got here, but how we fix it.
You also said:
“Dr. DeMarco and his MD peers continue to seek their profits with their Physicians for a National Health Program, only now they hope to guarantee a universal pool of potential customers.”
Mike, if you think PNHP is about guaranteeing profits, you are sadly mistaken. First of all, if advocating for universal health care was such a promising way to ensure cash flow, don’t you think we’d have a few more members? Of the roughly 800,000 MDs in America, PHNPs membership is only 14,000 (not all of whom are physicians).
Secondly, if doctors want to guarantee a steady income, they have plenty of options. They can choose high paying specialties, practice in wealthy metropolitan areas, join boutique practices in which they see only insured patients, dabble in trendy therapies like Botox, etc.
My interest in single payer comes out of my experience caring for my neighbors in rural Marion County and seeing how poorly our system serves some of them. Does the system work for folks like you and me and LexWolf? Yes, it does, but at too high a price. We ignore and stonewall and frustrate and ultimately hurt too many folks who don’t have enough money or enough education or the right job to access the care they need. I believe there is a better way for us all.
Paul, I may have ceded too much to Lex, but I was only going by what I have known of a few Canadian friends. I’ve had much more personal experience with Britain, and the bottom line is that if it isn’t an emergency, you can wait an awful long time for treatment or an operation, especially, sometimes more than a year. Part of Britain’s problem, in my view, is that they basically opened up the whole system too much–whoever lived there was entitled to care. However I think they’ve started to make some adjustments. Germany always did have some controls in place. Germany doesn’t have the “national health” system that Britain has, but rather a series of providers that are regulated by the government.
Having said all that, I have yet to run into a European who wants to come under the U.S. system. Conservatives here make it sound like everyone there is dying, and hoping for salvation under the American system, but that isn’t true. Everyone I know thinks we’re barbaric.
All,
My take is that Brad Warthen was referring to himself when he wrote, “Unlike some people I could mention, Dr. DeMarco doesn’t just talk; he acts.” Brad’s being cheeky and self-effacing, in my opinion, but he’s thrown down the gauntlet (and pointed to excellent leadership from Dr. Paul DeMarco) all the same.
I want to form the All for South Carolina organization or whatever we want to call it (SCAAASCP?), and I guess I better just go ahead and do it. I’ll follow the leadership of Dr. Paul DeMarco.
I’ll plan the first meeting and write a draft of our charter. Basically, we want to improve the economic progress of SC by empowering citizens, fostering business interests, encouraging the arts, and promoting strength in diversity. Our core values are respect for people, respect for history, respect for the arts, respect for progress, and respect for hospitality. We encourage inspiration from history, pride in action, strength in achievement, happiness in unity, and power in diversity. Everyone has a story to tell, and we are ready to celebrate your story from your history so we can inspire each other to make progressve achievements in business, the arts, and social welfare.
One of our first actions will be to hold public meetings to hear and encourage people’s opinions about being politically responsible about the flying of the Confederate flag from a flagpole on the Statehouse grounds. I really want to promote the State Museum by moving the Confederate flag there.
Any suggestions about any of this are welcome. When and where do you want to meet? And what do you want to accomplish? Post here (if it’s OK with Brad — heck, I don’t even know if this post is especially welcome) or send me an email. OK, stay tuned.
Regards,
Michael Rodgers
Columbia, SC
Paul,
How would you plan to compensate the for-profit insurance companies and their stockholders when you destroy their business?
For example, Aetna has a market capitalization of about $27 billion. Will the government buy the company out or simply watch it disappear along with the jobs of its 30,000 employees? What happens to all the valuable information Aetna holds in its database? Are they forced to turn it over to the government?
The top five healthcare plan corporations (UHC, Aetna, Wellpoint, Coventry, and Humana) in the U.S. have a combined market cap of $160 billion and employ well over 100,000 people. Think of the downstream impact on other companies as well – these companies spend huge amounts of money on technology. You think a CEO is going to invest in the future once he learns his company will be extinct?
I appreciate your vision but don’t believe it is workable. I fear it would create an even wider gap between those who have the funds to pay for services above the single payer rates and those who don’t. Would a single payer system FORBID people from purchasing additional insurance? Will doctors be able to charge above the negotiated rates for those patients who will pay cash for preferrable treatment?
If not, then we will end up with a huge government program and a bunch of niche insurers all over again… but with all of us in the middle class getting hosed once again.
My man Paul sez: “I’m glad you and Herb have decided that the Canadian system is horrid. Fortunately, the Canadians would beg to differ.”
I kinda doubt that, given that even the Canadian Supreme Court thought it was horrid.
Here are the most recent waiting times for medical treatment:
“The Fraser Institute’s sixteenth annual waiting list survey found that Canada-wide waiting times for surgical and other therapeutic treatments increased slightly in 2006. Total waiting time between referral from a general practitioner and treatment, averaged across all 12 specialties and 10 provinces surveyed, increased from 17.7 weeks in 2005 to 17.8 weeks in 2006. This small nationwide deterioration in access reflects waiting-time increases in 7 provinces, while concealing decreases in waiting time in Alberta, Ontario, and Newfoundland.
Among the provinces, Ontario achieved the shortest total wait in 2006, 14.9 weeks, with Alberta (16.3 weeks), and Manitoba (18.0 weeks) next shortest. New Brunswick exhibited the longest total wait, 31.9 weeks; the next longest waits were found in Saskatchewan (28.5 Weeks) and Prince Edward Island (25.8 weeks).”
Somehow I highly doubt that Americans would want this sort of substandard service even if it is “free” (and with 49% of Canadians’ income going to taxes they have every right to expect “free” treatment!).
Further Canadians are clearly voting with their pocket books as they would rather pay out of pocket than wait half a year: Canada’s Private Clinics Surge as Public System Falters. Note this telling comment from the president of the Canadian Medical Association on just how horrid the Canadian system is: “This is a country in which dogs can get a hip replacement in under a week and in which humans can wait two to three years.” Hardly a ringing endorsement of their system, wouldn’t you agree?
Isn’t it ironic that you would want to lead us to your socialist nirvana at precisely the time when countries already there are turning away from it?
Paul –
Your succinctly describe one goal for a single-payer plan as follows:
Let’s look at that from two perspectives: that of the citizen and that of the taxpayer. There will be a tension between the two that policymakers will have to resolve by rationing — establishing caps throughout the system.
The citizens essentially gets whatever they want. While one would hope for responsible usage of the free system, we know that when something is free, folks can’t get enough of it. Many (most?) folks tend to rely on medical practitioners to solve maladies brought on in part by making poor lifestyle choices like an unhealthy diet, overeating, sedentary lifestyle, heavy alcohol use, drug use, unsafe sex, fireworks, sweet tea, and the like. There’s no incentive for personal responsibility, just a limitless healthcare charge care to cure what ails one.
Taxpayers (same folks, different day) want to pay as little as possible and will demand caps, coverage limits, and whatever other limits are necessary to controls the costs that their taxes pay for. Single-payers system administrators would have to set up an annual budget that would in effect cap payments to practitioners for the fiscal year; they’d also have to limit the number of specific procedures allowed, type and cost of drugs permitted, range of therapies available, and so forth. It would make Medicare look simple.
As for Medicare and the growing shortage of specialists like endocrinologists, a single-payer plan will only aggravate the mess we’re in today. As Dr. Robert A. Swerlick (associate professor of dermatology at Emory University School of Medicine) wrote in Monday’s Wall Street Journal:
I do not argue that today’s system is perfect. It’s a mess, but I do argue that a single-payer system is not a viable alternative because it does not take into effect two basic flaws of the human animal: The desire to get something for nothing and the certainty that one knows precisely what’s good for everyone else.
There’s no incentive for personal responsibility, just a limitless healthcare charge care to cure what ails one.
-Mike
This statement makes absolutely no sense at all. Of course people have an incentive for personal responsibility. They don’t want to get sick. That is a much more important incentive than cost. After all, folks like Bill Gates would smoke, drink and use drugs like crazy if there was not a non-price incentive.
I do argue that a single-payer system is not a viable alternative because it does not take into effect two basic flaws of the human animal: The desire to get something for nothing and the certainty that one knows precisely what’s good for everyone else.
-Mike
Again, this argument would apply to many types of goods and services but it makes no sense when it comes to health care. If we get sick we go to the doctor or hospital. We don’t decide to choose a cariologist, endocronoligits or other specialist because the price is right. We use these specialists because we’re sick and need a professional diagnosis.
On the other hand, basic preventive medicine, which might greatly reduce the need for the expensive specialists, is often avoided precisely because of the cost factor. This results in a greater use of the more expensive health care services (ERs, medical specialists). If the basic services were provided at an affordable cost (not for free necessarily) then more people would obtain early intervention. The whole system would be far more efficient.
Libertarian arguments about supply and demand fall apart when it comes to medical care. The elasticity of demand for health care services is such that price has little effect on the quantity of extreme health care measures but is more of a factor in the more routine services. Fear of doctors alone is probably incentive enough to insure the system is not overused. Certainly in certain cosmetic areas price incentives are useful. For general health care the competive pricing model with normal elasticity of demand simply do not apply.
As for the supply of certain medical services, this is something that will require market incentives to match the supply with the demand. Your supply side arguments have merit but as you point out the current system is already failing. Since we will never have a pure market system the single payer model should do a better job addressing this issue.
I know Mike and the rest of my libertarian friends will continue to believe the private sector is more efficient and trustworthy than the public, but you really can’t get around one thing — a lot of the cost we’re paying now is pure profit for the insurance companies. It would take much greater inefficiency than I believe we would ever tolerate in a public system to make up that amount of cost.
For instance — and I think anecdotal stuff like this is inadequate, but it does dramatize the point — I think Ed Sellers is a good guy, and he does a lot of community service. But do we really need for folks who need to see a doctor to first hand him this much money? This is from the Post and Courier, Aug. 16, 2003:
Paul, I think you’re making a valiant effort, but it’s going to be interesting to see if you can make any headway at all in South Carolina. There’s a considerable groundswell for universal healthcare, and probably the best mechanism is single payer, but the movement in that direction is probably doing to have to come from elsewhere. The best you can do, I think, is to spread education as much as you can and temper the opposition as much as you can, but that’s still worth doing.
But you are going to continue to get opposition from people like Lexwolf, who base their oppostion not on any understanding of factual reality, or on observation, but on a simple adherence to a set of “principles” that they adhere to as if it were a religious faith. Lexwolf’s “principles” tell him that “government-run healthcare is bad,” therefore, to him, the Canadian and British systems are worse than the U.S. system, and despised by the Canadian and British publics, even though the reality is that the Candians and the British are pretty happy with their systems and certainly wouldn’t trade them for the U.S. system, and both systems provide better health care at less cost than does the U.S. system.
One thing I don’t understand is the fetishization of malpractice awards as a culprit in the high cost of health care, and the labeling of them as “exorbitant.” The reason people are awarded large sums for personal injuries they suffer is that the injuries they suffer are grave.
First, malpractice awards are not the cause of high healthcare costs; there is plenty of evidence demonstrating that.
Second, and more importantly, even if malpractice awards were responsible for high healthcare costs, that is a PUBLIC concern, affecting the PUBLIC, with the costs and disadvantages of resolving it properly borne by the PUBLIC. It is not appropriate to solve a PUBLIC problem (paying or or otherwise bearing the costs of injuries caused by incompetent or negligent physicians) by creating a class of untermenschen (in this case, people who have been gravely injured by incompetent or negligent physicians) and forcing them to bear all the costs of the problem.
Mike Cakora, you are of course correct to observe that I was only talking around a part of the problem, however, as Dr. DeMarco states, it is a complex one. My intention was only to address what seemed to be Dr. DeMarco’s main contention that the problem is the fault of “Big Insurance” profit motives. There are plenty of motives to go around, to include those profit motives of the medical industry and its key profit takers, the doctors.
As to the “insulating effect” that the insurance industry has on high costs, I would again look to who is actually establishing those costs and who is receiving payment for the services provided. The insurance industry certainly has some motive, but so do Dr. DeMarco and his cohorts. The reimbursement costs are negotiated by both the medical providers and the insurance industry and are based on, and will always be as high as, what the market will bare. The insurance industry essentially “pays off” the health care providers, ensuring that both profit handsomely.
Dr. DeMarco says in his reply (above) that the issue is not how we got here, but how we fix the mess we’re in. I agree that “playing the blame game” is essentially counterproductive, however, in his original guest editorial he is the one who made the comparison between public education and a public (universal) health care system. While the history of the current situation is indeed only somewhat academic, the principles on which the current system operates are founded on that same history. To subsume the historical principles of the public education system for a potential universal public health care system without acknowledging and addressing the that such a new system would require a major change in the operating principles of the current system is, I submit, a bit intellectually dishonest.
As to Dr. DeMarco’s contention that PNHP is not about guaranteeing medical industry profits, well, perhaps that’s not his personal motivation. I’ll accept his personal stance at its face value. However, the end result would certainly be doctors and hospitals making profit from otherwise indigent patients at the expense of the taxpayers paying for the system. (Of course, this is the case as we stand now. I can only assume that the proposed system would just ensure that services provided to indigent patients would just be reimbursed at higher, more market-like rates.)
After having said all of the above, however, I do agree with Dr. DeMarco that there must be a better way. Unfortunately, universal government provided single payer is probably not it. It carries too much “social engineering” baggage in the current manifestations offered. Whenever the government assumes the responsibility to care for its citizens it ultimately assumes the authority to think for them as well. In the heat of the moment, a sick person probably finds that argument pointless. However, we only have to look at many laws and taxes presently on the books and under debate to see the efforts by those who presume to do our thinking for us under the excuse that because the government is paying for the effects of some activity, it has the right to regulate that same activity.
Brad might call this “hyper-libertarianism” (BTW, isn’t that same as anarchy?), but I for one cherish my illusions of civil liberties and the personal principle of living my life as I see fit.
Hal says:
“One thing I don’t understand is the fetishization of malpractice awards as a culprit in the high cost of health care, and the labeling of them as “exorbitant.” The reason people are awarded large sums for personal injuries they suffer is that the injuries they suffer are grave.
Which law firm do you work for? I’ve sat as an alternate juror in a malpractice case several years ago and also have a very good friend who was a defendant in the high profile malpractice case last summer in Lexington that Geoffrey Feiger (Kevorkian’s lawyer) led against Lexington hospital and the doctors. Feiger sued the hospital and included the ortho surgeon and the anesthesiologist. Why? Because the hospital had a $500K cap on damages while the surgeon had a multi-million $ cap and the anesthesiologist had no limit. I sat in on the trial for two days and watched Feiger basically make stuff up to try and convince a jury of what is supposed to be one’s peers (but in this case have no understanding of medicine, chemistry, surgery, etc.)
Feiger won only a judgement against the hospital and that judgement was set aside by the judge later on. It was a complete and unnecessary debacle driven by greed.
In the case I sat on as a juror, the doctor was obviously at fault, but the plaintiff’s lawyers tried to include all sorts of pain and suffering “fees” for everything but the kitchen sink. They wanted several hundred thousand dollars just for the woman (whose injury involved a leaky bladder) for her “loss of ability to do housework”.
The large awards for malpractice drive higher insurance costs for doctors which then result in higher fees AND “defensive” tactics.
Brad,
I asked a similar question of Dr. DeMarco – what would you expect to happen to Blue Cross Blue Shield of Columbia (perhaps the Midlands largest employer) if a single payer system were adopted? Aside from the CEO losing his beach house, do you think there would be an impact on the thousands of employees, vendors (you know, like The State), etc. that are part of the Blue Cross environment. What happens to them?
What about all the local community work done by Blue Cross and its employees? You think a government agency is going to do the same thing? Tell us what impact a single payer system would have on the existing companies… think it through before hopping on the fantasy bandwagon.
Rather than create a whole new bureacracy, fix the system by fixing the laws that both protect profits and inhibit competition.
Bud –
You may think that the statement “there’s no incentive for personal responsibility” makes absolutely no sense at all, but consider chronic conditions and some diseases where lifestyle changes would reduce the cost of medical therapies. Obesity is a good example where “sufferers” could eliminate blood pressure and other medications were they to slim down.
Cindi Scoppe made a good point about behavior in her 4/20/2007 column:
The point being that were medical care free, he’d jaywalk and go snowboarding.
To the rest –
Unlike food, beer, and most consumer goods, we’ve managed to develop a system where the real price of healthcare has been hidden for years. In the 1/31/2007 edition of the WaPo economist Robert J. Samuelson explained it this way::
You ought to take a gander at the whole article, because he goes on to describe several myths and some proposals regarding healthcare. He ends with this:
I’m no fan of excessive executive compensation, but the BC chief may have earned his compensation by growing his firm’s business in a quite Byzantine industry.
I happen to be a booster of something like HSAs — Cindi mentioned them in the column I liked to above — where consumers put aside money-tax free for regular maintenance and use insurance only to provide catastrophic coverage. The Bush proposal would support this approach, as well as others: employers and employees could choose.
The insurance model has never worked for healthcare because it’s not insurance, it’s insulation, as I noted above. Back to Kling:
Were we to move to a system where a real insurance model, one that pays for catastrophic claims, and found a different way to pay for the regular stuff, we’d have a more rational system.
Brad –
I should add that libertarian economists are developing innovative ways to make healthcare more efficient and affordable. Like the Klingster.
As for malpractice awards, this paper from June 2003 (the height of the most recent malpractice insurance crisis) states that in Pennsylvania, 18.6 percent of obstetricians/gynecologists (ob/gyns) have dropped obstetrics, while in West Virginia nearly one in five has stopped; from 1990 to 2000, medical malpractice tort costs rose by 140 percent, more than double the 60 percent increase in medical costs generally over the same period. So there’s clearly a sizable direct effect on medical care costs.
The indirect costs are believed to be substantial. Medical practitioners test more and use more expensive diagnostic methods. What’s most shocking is that even the malpractice insurers are have trouble making a buck!
It’s not that we have so many lousy physicians, but that slip-and-fall attorneys, especially those with really nice hair, are adept at convincing jurors that a perfect outcome is the standard; any patient that does not get such is owed big-time. Again, look at ob/gyns, the folks that deliver the babies. They can do their part perfectly yet will invariably bear the blame for any birth defect, even one they could not possibly have caused.
“you are going to continue to get opposition from people like Lexwolf, who base their oppostion not on any understanding of factual reality, or on observation, but on a simple adherence to a set of “principles” that they adhere to as if it were a religious faith.”
Hal, methinks it is you who is not facing “factual reality” or engaging in “observation”. I have provided several links above showing that Canucks aren’t exactly happy with their system. Now here are some for the Brits as well.
Filth and shame in an NHS hospital
Twenty-four hours to save the NHS! I wonder how often that promise comes back to haunt Tony Blair 10 years later. Week after week reliable reports and the government’s own figures tell a disgraceful story of incompetence, debt, misery and filth in the National Health Service. That story is supported, week after week, by heart-rending personal accounts of horrors on the wards……
In a reversal of a decade-long trend, British doctors are now fleeing the system as Indian hospitals beckon unemployed British doctors and British patients follow them as they can’t get treatment at home.
Training of surgeons is being drastically reduced: they previously “underwent approximately 30 000 hours of training before becoming consultants, this will now decrease to 6000.”
I’m sure that’ll increase the confidence of British patients in the qualifications of their doctors.
Even former members of parliament can’t get treatment that would be commonplace here in the US:
“A former MP who is going blind is set to sue the NHS after it refused to give her a new drug that could help save her sight, it emerged yesterday.
Veteran left-winger Alice Mahon has lost most of the sight in one eye while waiting for treatment.
The former Labour MP – and thorn in Tony Blair’s side – is now preparing to go to the High Court to make the Health Service pay for a drug that can help her.”
Yes sirree! Those horrid realities of socialized medicine are a true sight to behold – now if we could just get Hal Jordan to open his eyes and ears!
Here is an interesting tidbit concerning the Marion County Medical Center. The Whistleblower got $600,000 for turning in the fraud.
http://www.usdoj.gov/opa/pr/2006/July/06_civ_447.html
Lex, what those articles indicate is that neither the British nor the Canadian system is perfect. There are failings in and complaints about both.
So?
The question is, does each system produce a better outcome, at less cost, than does the American system.
The answer is yes.
Doug, I don’t see how your examples are in any way relevant. What I understand is that some friend of yours was sued by stranger that you don’t care about. The thing is, to the friends of the stranger, the situation is reversed. To his friends, what happens to him is important, and what happens to your friends (strangers to them) is unimportant, just as what happens to your friends is important to you and what happens to strangers is unimportant to you.
I don’t understand how the solution to any perceived imperfections in the justice system is to force people who are injured by incompetent or negligent physicians to subsidize those physicians by receiving less than full compensation for their injuries.
The issues you speak of are general social issues. Why should the costs of their solution be borne by a class of untermenschen forced to accept a compensation schedule set by lobbyists for and representatives of incompetent and negligent physicians?
Hal –
You raise good points regarding malpractice, but the US tort system has allowed virtually limitless awards for pain and suffering on top of actual damages.
If you’re under the knife and a surgeon cuts off the wrong leg, you’ve suffered damages that can be roughly computed in an economic sense: prosthesis, physical therapy, rehabilitation, reduced earning power over your expected lifetime, special vehicle requirements, modifications to your home, etc. I think we can all agree that simple justice demands compensation over your lifetime for all that.
Moreover, you’ve certainly experienced pain and suffering, but that’s tougher to quantify and, as a result, has grown over the years into a lucrative field for the plaintiff’s bar where enterprising attorneys try to make a case for million$, and have often succeeded. Loads of states (see the links from my Jun 7, 2007 3:10:00 PM comment above) have passed caps on pain and suffering awards of $250K – $500K; this reduction has led to reduced rates for malpractice insurance. Note that folks still get the funds for economic loss, but the punitive awards allow insurers and medical practitioners an escape from what has been a form of legal extortion.
An intended consequence of the caps has been to reduce overall litigation because a third or even a half of $250K is not enough for a trial lawyer to bring a difficult case. Insurers readily agree to settlements for economic loss; when they don’t, complaints to state boards are often enough to get them to cough up the funds. Sometimes a lawyer may be needed to spur action, but the motivation of a $10M settlement no longer exists. That seems fair and just to me.
As for your points on costs, yes there are inefficiencies and outrageous costs in the US healthcare system, but don’t forget that qualitatively, we’re pretty good. Look at cancer survival rates: thanks to our practitioners and drug companies we do pretty durn well in comparison to Europe. That’s the quality aspect.
As for costs, take a long look at this poor person and what modern medical techniques have wrought, several times over. Cosmetic surgery, Lasik, teeth whitening, etc. all count against US medical costs in the aggregate. Have you noticed the ads in The State and other local publications for, er, vacuuming out those bulges that displease one and adding, er, material to enhance bulges in other places? Those are medical costs.
I lived in Yurrip — the old country — for eight years altogether and have to say that teeth tell a lot. Even today, 2007, overall dental care here in Vespucciland has few equals worldwide, and I’m not even talking about braces.
I appreciate your points and again assert that the US healthcare system needs a major rewiring. But malpractice reform is essential, and we have to look at cost and quality when considering solutions.
“The question is, does each system produce a better outcome, at less cost, than does the American system.
The answer is yes.”
So sez Hal Jordan, despite all evidence to the contrary and without producing any evidence of his own to support this breathtaking assertion. Of course, like all of us, he’s entitled to his opinion (and we all know how little that’s worth) but so far that’s all he’s posted – opinion. No facts in sight anywhere. Nothing substantial whatsoever.
By the way, the Swiss had a referendum on a single-payer scheme last year, and overwhelmingly rejected it by a 71-29 margin. There are quite a few very smart people in Switzerland and for them to reject this scheme by such a huge margin there must be something very rotten with it.
Doug –
Your remarks on the contributions that Blue Cross makes to the community are spot on; they also point to the politics involved in any massive change that affects local enterprises.
Over the years, the various Blue Cross / Blue Shield companies nationwide have provided superior service to individuals, companies, and state organizations in financing and delivering excellent healthcare. They compete with other insurers (and in some cases with each other) for term contracts (typically five years) under Byzantine federal and state rules. What results is a cost plus fee arrangement to the buyer.
Say your company has had XYZ health insurance and the annual increases are driving your costs out of sight. The contract is nearing its end, so you invite Blue Cross, your current insurer, and others in for a bit of competition. You’ll have to provide your past claim data, info on the demographics of your workforce, etc. to all the bidders for them to analyze so they can make a viable offer. They know the tax rules, they know the competition, they know your state’s mandated coverage requirements, etc. Each will likely offer one or more options for you to choose from.
Blue Cross can usually offer a great price because of its negotiating power with medical providers. That’s important and part of the reason it’s a successful supplier.
But we’re at a point where something bold has to happen — them there paradigms are a shifting –and we need to have a whole range of analyses to figure out how we’re going to cross the chasm in one leap, because two leaps is generally inadvisable.
From a policy perspective we need to figure out the best — the most efficient, effective, responsible — way to finance healthcare in the US. Let’s be blunt: there are two clearly opposite ideologies: one views healthcare as a right, the other views healthcare as a matter of personal responsibility. At the upper level of analysis, we should ignore the impact on local enterprise like our Blue Cross so that we can focus on the global benefits. Later, in the political process, we can introduce the impacts you cite, and I’m pretty sure that Blue Cross will have at least one of the seats at that table.
SC’s education standards are among the highest in the nation. A study indicates that the disparity among standards between states makes state comparisons iffy.
For example, North Carolina and South Carolina students score about the same on the national tests, but South Carolina has higher state performance standards than its neighbor.
The education hate-mongers blow smoke about how we compare to the other states based on faulty comparisons.
Hal,
The Feiger case was a travesty regardless of the fact that one of the parties was a friend. It was such a debacle that the judge threw out the award that the untrained jury awarded mainly because they feel better by giving a grieving widow money no matter what the facts are. The lawyers go after the deepest pockets (those with the most insurance) and the result is higher insurance rates that must be passed on to consumers. There was no incompetence in this case, no negligence. People die sometimes when they are in the hospital. My father died in January following complications that occured during aneurysm surgery. We didn’t sit down afterward to try and figure out who we should blame and how much money his life was worth.
How about we pass a law requiring the plaintiff to state before the deliberatiobs exactly what percentage of any award would go to the lawyers in malpractice cases? Shouldn’t that factor into the jury’s decision? Because the money is for the “victim”, right?
What about the other case I had no interest in? Do you think $200,000 is a fair amount to expect for loss of ability to do housework due to bladder reflux? The injured party got a fair settlement for her pain and suffering, but the system allows the lawyers to attach whatever costs they feel like making up to “pain and suffering”. You think they do that for their client’s benefit?
Mike C,
You said:
“Let’s look at that from two perspectives: that of the citizen and that of the taxpayer. There will be a tension between the two that policymakers will have to resolve by rationing — establishing caps throughout the system.”
The tension you describe is real. The tendency to overuse a free service has been termed the “moral hazard.” Malcolm Gladwell (author of “The Tipping Point”) wrote an interesting essay called the “Moral Hazard Myth” in which he argues that the fear of such overuse is exaggerated. It is true that moral hazard and the opposing desire to control cost is a central tension in a single-payer system.
But there are tensions in every system. Currently a main tension in our system is how to make insurance more affordable while still supporting a profit-driven insurance industry that avoids those who need coverage the most. I believe that is an insoluble problem.
Any system we choose will have problems. I’d rather have the overuse issue and the problems it generates than the problems in our current system, which primarily involve lack of access.
I think bud’s rebuttal to you is well argued. The tendency to overuse free health care is blunted by the fact that health care is time-consuming and often onerous. If we were talking about something people really enjoyed (beer, vacations, subscription to The State, etc.) then, I agree, demand would be limitless.
You also said (to Hal):
“I appreciate your points and again assert that the US healthcare system needs a major rewiring. But malpractice reform is essential, and we have to look at cost and quality when considering solutions.”
With a single-payer system, awards for future medical expenses would be eliminated since those costs would already be covered.
Randy,
Not sure what your post has to do with the insurance/healthcare debate. Guess you felt the need to sidetrack a fairly civil discussion with some name calling for old times sake. Maybe you’re just mad about Schilling losing his no hitter?
Brad,
You said:
“I think Ed Sellers is a good guy, and he does a lot of community service.”
I agree that Ed Sellers is a fine man. But remember, the grants BC/BS provides to so many worthwhile charities around the state are funded by high priced policies that are out of reach of too many. We applaud when BC/BS funds a free clinic, forgetting that in a single payer system, there would be no need for free clinics.
Hal,
You said:
“But you are going to continue to get opposition from people like Lexwolf, who base their opposition not on any understanding of factual reality, or on observation, but on a simple adherence to a set of “principles” that they adhere to as if it were a religious faith.”
You’ve got Lex’s number. Thanks.
Mike Roof,
You said:
“As to the “insulating effect” that the insurance industry has on high costs, I would again look to who is actually establishing those costs and who is receiving payment for the services provided.”
I appreciate your thoughtful comments. You and Mike C. are right to point out the insulating effect of our current system. I think single payer helps clear away the fog surrounding the cost of medical care. We will now be forced to confront as a nation difficult choices and do needed research so we can make evidence-based decisions. Whether a woman should have a mammogram every year or every two years (or whether and when PSA levels should be done to screen for prostate cancer) become front burner questions when we as a country are footing the bill for one another.
You also said:
“I can only assume that the proposed (single-payer) system would just ensure that services provided to indigent patients would just be reimbursed at higher, more market-like rates.”
Mike, no one reimburses doctors for care of the indigent-it simply becomes bad debt. Hospitals do receive some federal subsidy for indigent care through the Disproportionate Share Program but this only covers a fraction of the actual cost.
When an indigent patient ends up in the hospital, you and I pay for that care by virtue of the insurance premiums we pay. I have seen an estimate that every person with health insurance pays an extra $922 a year to cover the cost of those without insurance. What’s the difference between that and a 1 or 2% income tax that would fund a national health insurance plan that could be much more efficient and better designed than the incoherent system we have now?.
You also said:
“…but I for one cherish my illusions of civil liberties and the personal principle of living my life as I see fit.”
Like you, I cherish my civil liberties, but freedom is hard to enjoy if you are ill and can’t get the care you need. Single payer would advance civil liberties rather than restrain them.
Doug,
You said:
“(W)hat would you expect to happen to Blue Cross Blue Shield of Columbia (perhaps the Midlands largest employer) if a single payer system were adopted? Aside from the CEO losing his beach house, do you think there would be an impact on the thousands of employees, vendors (you know, like The State), etc. that are part of the Blue Cross environment. What happens to them?”
You’re right to consider the jobs of the thousands of good people who work for insurance companies. I know some folks who work for BC/BS and realize that with single-payer they would lose their jobs. However, I don’t think it is just to perpetuate our flawed system to preserve jobs.
When America finds a better way, those doing things the old way lose out. With every major technological advance there has been economic upheaval and job loss. Livery stables, carriage makers and farriers were all done in by the automobile. Typewriter companies and ribbon makers were decimated by the desktop computer. Eight-track tape makers…well, you get the idea. Some of those who work for private insurance companies will be needed to staff a single-payer system. Many in that industry have health care expertise, such as nurses. Some of those could return to the bedside. If the impact was unbearable, a single-payer bill might include some one-time money for retraining to help with the transition.
Whistleblower,
I’m puzzled by your post. The hospital where I work, Marion County Medical Center, paid a 3.75 million dollar fine for violating Stark Laws and submitting improper bills to Medicare, Medicaid and TRICARE in 2006. McLeod Regional Medical Center in Florence paid a much larger fine ($15 million) in 2002 for similar violations. Many other hospitals have paid fines for Medicare violations. What has that got to do with this discussion?
Lex,
You said:
“Isn’t it ironic that you would want to lead us to your socialist nirvana at precisely the time when countries already there are turning away from it?”
I’m a red-blooded American capitalist just like you. I drive a gas-guzzling pick-up truck, own plenty of major appliances, and think the United States is a great country because we work forty-hours plus a week at good private sector jobs (and sneer at the French and their pitiful 35-hour work week). A single-payer system would help keep our workers healthy so that they could be even more productive making barbecues for me to cook my steak and cowboy boots for me to wear (I own an ostrich leather pair) and new cars for me to buy (so I can get better gas mileage). The socialist label just doesn’t stick.
You reference a Times article which states: “The late Eileen Fahey, for instance, dying of cancer, was put onto a mixed geriatric ward where confused people wandered about without supervision.”
If the best you can do is cite an article that describes the humiliation of being in a mixed-gender ward as evidence for the failure of national health care, you’re really reaching.
First, remember, an American single payer system will be more like Canada’s than the British system.
Second, very few American hospitals have open wards. My hospital has only private rooms and I believe most newer hospitals are similar.
Third, I’m not discounting the unpleasantness describes in the article, but in our system 18,000 people a year are dying because they lack medical insurance. I’m sure most of them would be happy to accept good medical care, even if it were offered in a mixed-gender ward.
You also offer this quote: “A former MP who is going blind is set to sue the NHS after it refused to give her a new drug that could help save her sight, it emerged yesterday”.
This former MP at least has a basis on which to claim she’s being mistreated (i.e. the NHS’ mission to provide decent care for all citizens). An uninsured patient in the US has no such claim. Millions of uninsured patients go without needed medicine or care every day; most suffer in silence.
You also said:
“The Fraser Institute’s sixteenth annual waiting list survey found that Canada-wide waiting times for surgical and other therapeutic treatments increased slightly in 2006.”
You raise an important point in about waiting times. Although I have reason to doubt the accuracy of the figures from the Fraser Institute (yet another conservative think-tank you’ve managed to dredge up), there is no doubt that waiting times will increase for some services in a single-payer system. That is, they will increase for the insured. Many uninsured wait years for certain elective procedures (usually the years between 60 and 65, as they wait for Medicare benefits). At 65, they are finally able to have that cataract removed or stop limping by having their arthritic knee replaced.
You and I and the rest of the insured in this country must decide whether we’re willing to be somewhat inconvenienced, to wait an extra month for a cataract surgery or joint replacement or colonoscopy, so that millions of our fellow Americans can have access to coverage. I think that’s a fair trade.
Boy those anti-robot codes we’re required to enter before posting now are hard to read. Is anyone else having trouble making them out?
Paul –
Regarding the robot codes, I agree wholeheartedly! I’m astigmatic and a lousy typist, so I get to go through turnstile more often than most.
It almost makes me wish that I were more agreeable. Almost.
I think Brad should consider secret decoder rings.
Paul –
Just to clarify my viewpoint, as an economics’ buff, I’m quite familiar with “moral hazard” and have even used the phrase on on Brad’s blog in the past. I try to limit jargon so as to reach more folks. It takes more words, but verbosity is my strength. And my weakness.
That said, from your remarks I wonder if we’ve been talking past each other to some extent. Do you recognize the position that a single payer system puts healthcare professionals in? With one entity — presumably the government — in control of all aspects of healthcare, there will be pressure to lower costs overall, to include prices charged by all providers.
Canada handles this by setting a budget for all providers per province for the fiscal year. With the variable demand for specific specialties, they find that towards the end of the year, money dries up and docs go on vacation, probably to South Carolina and Florida, although we should never discount the threat posed by our neighbor to the north and must always regard Raleigh with suspicion. Canada thus limits expenses by rationing access to providers; what can’t be paid for this fiscal year gets provided in the next, assuming that the patient has survived.
Other national systems handle this by making docs and other providers civil servants, paying them a salary — in the UK it’s rather low in the national system. This method provides neither high quality nor high productivity, but at least the doc is in the office even towards the end of the fiscal year.
One of the more interesting provisions of HillaryCare last decade was the introduction of quotas –limits on admissions — for medical schools. This measure was coherent in the sense that the overall goal of the proposed system was to manage costs quite carefully, and one key component of overall cost is labor. Each physician was viewed as a cost under the system, so carefully controlling their number was imperative.
As a matter of economics, I assert that such systems are inefficient. As a matter of ideology, I assert that they are immoral and unfair to all.
To support my assertions I’ll cite the Soviet system in which healthcare providers were relatively low paid and the population’s general health was abysmal, a trend that continues even today. Single-payer implies a controlling authority that has enough information to budget resources efficiently. We know that in theory and in practice that that is not possible.
What I long for, and I think that you should to, is a state approaching chaos. By that I mean each individual collects and assesses information to make decisions. That’s already happening with physicians as evidenced by the link I cited in my Jun 7, 2007 5:52:45 AM comment: fewer physicians are willing to spend the time, energy, and money to move into specialties like endocrinology because they believe that they’ll not be rewarded for such effort. The challenge is to make everyday folks start shopping for medical care the way they shop for other consumer goods.
As for your remark that “with a single-payer system, jury awards for future medical expenses would be eliminated since those costs would already be covered,” you imply that a change in law and practice would eliminate any action for malpractice. I was not arguing that malpractice should not be pursued, only that incentives for seeking frivolous and highly remunerative awards be removed. Malpractice needs to be acknowledged and its practitioners penalized.
Finally, when you cite the “Moral Hazard Myth” and argue that the “tendency to overuse free health care is blunted by the fact that health care is time-consuming and often onerous,” you seem to acknowledge that some sort of rationing is in place that makes even required use, well, time-consuming and often onerous. Don’t get me wrong, I agree that’s an effective deterent. Just look at the Veterans Administration, an agency dedicated to meeting the needs of all those vets, but uses rationing and other methods to minimize costs in serving a population with infinite needs.
So if stopping by the doc’s office is free, folks will do so more often unless faced with long lines. And that’s exactly the way that Canada and the UK handle the matter. Are you therefore saying indirectly that single-payer will work because we’ll find ways to ration treatment, one of which will be to limit the number of physicians so that folks will have to stand in line?
Gotta love ya, Paul. If Stalin drove a pickup truck and Mao wore cowboy boots that still wouldn’t make them capitalists. Surely you know that what you wear and drive by no means makes you a capitalist – it’s what’s between your ears that makes you a socialist. Face it: a single-payer medical care system is by definition socialist. You can hem and haw until you’re blue in the face but the truth is undeniable.
Now I’ll tell you what I think we should aspire to have:
1. Let’s take care of the poorest members of our society out of general tax revenues. Say up to twice the poverty level (that would mean $40,888 for a family of four). IMO, they should still pay something but the amount should be minimal. Heck, for several years of my life, I would have qualified under that cutoff but the real point is that we should limit government programs to those who really need them. For the rest, if they can take care of themselves, they SHOULD take care of themselves (and I don’t want to hear that they can’t “afford” it because their cable bill is too high). We don’t need some medical system that would cover Bill Gates – yet that’s what you’re advocating.
2. Everybody else should start taking care of themselves (yes, you and I and lots of other people can indeed take care of themselves, with the help of real insurance – so why should we start this latest big-government boondoogle you propose?). Get rid of employer-paid insurance and instead have employers increase wages and salaries by whatever amount they would have paid for medical insurance otherwise. Give people a $15,000 tax deduction for medical expenses, as Bush and Guiliani have proposed.
3. Reserve medical insurance for only very large (catastrophic) expenses, just as we do for car insurance, fire insurance, etc. The premiums for that coverage would be fairly low and affordable.
Now make your case. Why do we need a big-government socialist boondoggle instead of letting people take care of themselves, with all the direct control of their treatment entailed? (please leave out all the poor-people crapola – point 1 takes care of all that)
Mike, you say:
“Moreover, you’ve certainly experienced pain and suffering, but that’s tougher to quantify and, as a result, has grown over the years into a lucrative field for the plaintiff’s bar where enterprising attorneys try to make a case for million$, and have often succeeded.”
So?
“Loads of states (see the links from my Jun 7, 2007 3:10:00 PM comment above)”
Thank you. No. What you fail to realize is that stating a proposition is not the same as proving it, and I have learned to ignore the innumerable links to wingnut publications that tend to adorn your posts.
“have passed caps on pain and suffering awards of $250K – $500K; this reduction has led to reduced rates for malpractice insurance. Note that folks still get the funds for economic loss, but the punitive awards allow insurers and medical practitioners an escape from what has been a form of legal extortion.”
Well, obviously, arbitrary limits on awards tend to reduce premiums. That is so obvious a proposition as not to be worth stating. Any time someone shifts a cost to someone else, they save money. Incompetent and negligent physicians, and their lobbyists, have managed to shift a substantial portion of the costs of their incompetence and negligence from themselves to the people they injure. That results in a savings to themselves, naturally. But I don’t see how that is a desirable outcome, and I don’t see how it reduces the TOTAL cost, which is what’s important.
Again, what you and all other advocates of malpractice “reform” and tort “reform” propose is having the costs of injuries borne by the people who suffer the injuries, rather than those who cause them.
Why is that desirable? Why should the costs of injuries fall on those who suffer them, rather than those who cause them?
And the costs of malpractice premiums are not important to the larger society. What’s important to the larger society are the overall costs of health care. And even if malpractice “reform” reduced the overall costs of health care (which it does not) that cost reduction would be achieved by imposing the costs of a problem affecting the society as a whole on a class of untermenschen.
You state that the monetary value of noneconomic injuries is hard to quantify, and leap from that proposition to the conclusion you want to achieve, which is that because the value is hard to quanitfy, it should be set at an arbitrary minimal level chosen by representatives of those who cause the injuries. You fail, however, to show how the first proposition leads to the second.
Obviously the proper way to value a thing whose value is hard to quantify is to just do the best you can. It is not to say, well, who can place a value on human life? It’s hard to figure out, so Mrs. Jones, we’ll let the value of your husband’s life be determined by how much the person who shot him feels like paying.
Well, Lex is right about one thing: a single payer system is by definition socialist. Of course, it’s wrong to associate Marxism with true socialism because a supposed dictatorship of a proletariat is at odds with democratic control of the economic system as required by socialism. Socialism antedated Marxism by two thousand years as evidenced by the teachings of Jesus Christ. In the Gospels, Jesus makes statement after statement, and point after point that is consistent with what we now call socialism. On the other hand, Jesus makes few if any statements that advocate the usury that capitalism is based upon.
Healthcare in the US is already controlled by big government (i.e., undemocratic corporate government). Corporations have done a lousy job of running our healthcare system. Something like 30% of our health care dollars go to the most inefficient corporate bureaucracy imaginable. We deserve better. Democratic government can do a better job.
Good point Mark. It can’t be stressed enough that we already have socialized medicine in the U.S. It’s just a convoluted version that pays lip service to the free market system. Brad’s example of the BC CEO shows how much money is siphoned away from actual health care. The U.S. system is much worse than what exists in Europe. The next time you need health care you’ll understand how true that is.
Paul writes, ” One major concern is how Medicare can afford to cover the baby boomers, as enrollment is expected to top 77 million by 2031. Single–payer is the only system with the cost-containment ability that can make such a large increase in the Medicare rolls feasible.”
Well it’s nice to see the advocate of complete government-run health care acknowledge he’d also impose cost-containment. I just don’t believe in our plural political system it’s really possible. It would make Medicare’s flaws — and they are HUGE — even worse. Paul cites beneficiary satisfaction. But the physicians aren’t satisified, because more and more of them want to drop out of Medicare. They don’t get enough money, they say. How’s a LARGER Medicare system going to fix that, and save money at the same time.
The only way it can do it is to do the same thing other government-run health care systems have had to do it: restrict the rights of people to have certain procedures. Paul argues, rightly, that in some cases we have that now. But his proposal won’t reduce it.
Better get AARP onboard with any plan before getting started… even the hint of messing with old people’s Medicare causes panic.
As an example of how NOT to do a government healthcare program, see the recent prescription drug plan that went into effect last year. What a mess! Far too confusing than necessary — but that’s what happens when you have government bureacrats involved.
Hal –
I got the feeling that we’re not gonna see eye-to-eye. Heck, you blast me for failing to realize is that stating a proposition is not the same as proving it, then admit that you “have learned to ignore the innumerable links to wingnut publications that tend to adorn your posts.” Sheesh, you refuse to look at any supporting links, then lambaste me for not providing proof.
That hurts, especially when the link that supported my proposition was to a “wingnut publication” of the Insurance Information Institute. That’s pretty motherhood, apple pie, and American cheese, no?
So when the report states:
I get the distinct impression that such costs have some sort of effect on healthcare prices because insurers will increase rates to recover losses. Perhaps you don’t. Nor did you look at the text and tables showing docs quitting or limiting their ob/gyn practices in droves.
If not, you may not care that the overall US tort system cost $205 billion — $721 dollars per person — in 2001, up slightly from $12 per person in 1950. Admittedly, inflation accounts for about $70 of the increase, but where did the extra $650 come from? That’s a significant cost to society, no? Especially considering that some folks aren’t kicking in their $721, meaning I gotta pay theirs along with my family’s share.
I recommend that you read the report to get a good feel for the massive impact medical malpractice insurances costs are having on docs, hospitals, etc.
BTW, those numbers in the report come from those wingnuts over at Tillinghast-Towers Perrin, a pretty prestigious risk management and actuarial consulting firm to some.
Hal, it still hurts. I find all these links to support my drivel, and you won’t even look. I guess Dorothy Parker was right.
Mike,
You can lead a lawyer to the facts, but you can’t make him think.
Mike,
First, I really appreciate your willingness to debate this with me. I not was insinuating that you didn’t know what moral hazard was, I just wanted to make the connection for other readers to the Gladwell article. You can be sure that your knowledge of economics is superior to mine.
You said:
“Are you therefore saying indirectly that single-payer will work because we’ll find ways to ration treatment, one of which will be to limit the number of physicians so that folks will have to stand in line? “
Every nation rations health care. Health care is now so expensive that I’m not sure if it would be possible for a government to fully fund what once was called “executive” health care. In the US, we ration by income/access to insurance. In the other developed nations they ration based on government policy.
Both systems are problematic, but I’m partial to the problems posed by the latter system because they produce the tangible benefit of access to decent care for almost everyone (as Lex has demonstrated, no system is perfect).
The problem with end of the year shortfalls in the Canadian system is real (although I couldn’t find any stats on this). But again, the overwhelming benefit of everyone having access to physicians of their choice for routine medical care for hypertension, diabetes, high cholesterol, etc. dwarfs that issue. Many more people will get preventive care, many more will be spared devastating consequences (heart attack, stroke, amputation) and many more will sleep better, knowing that if they are involved in a serious car accident tomorrow, they won’t be forced into bankruptcy.
Will the insured face lines as we accommodate an influx of uninsured into a new single-payer system. Initially, I suspect so. But it will be up to us to craft coherent policy and incentives to insure an adequate supply of physicians to care for them (including the endocrinologists you are so worried about).
Lex,
“If Stalin drove a pickup truck and Mao wore cowboy boots that still wouldn’t make them capitalists.”
Stalin and Mao! Now I’m about ready to lay some ostrich leather across your backside. I’m not sure why the term “socialist medicine” strikes fear into so many hearts. This country has socialized education, socialized police and fire protection, socialized transportation and socialized defense.
The United States will never have a socialist government. But we have discovered that certain services are better provided if we pool our resources. I would rather pay a small tax for fire protection provided by the government than deal with the hassle of creating and maintaining a local volunteer fire squad.
I believe health care also falls in the category of services that we should provide as one nation for everyone rather than leaving the individual to fend for himself.
Here’s why:
1) Someone will eventually have to pay for the care delivered. Unless we mandate that everyone must buy adequate health insurance and are willing to fine and prosecute those who don’t, many people can’t or won’t purchase insurance. But when they get sick (unless we’re willing to deny them emergency care) they will be cared for.
2) It is very hard to predict health care expense. You don’t plan on having a heart attack or a kidney stone or appendicitis like you plan on buying a new microwave. Many fewer people die from microwave popcorn deficiency than heart attacks.
3) Hoping that middle income folks with limited discretionary income will sock money away in health savings accounts is a nice idea, but I’m trying to imagine telling my wife, “Yes, honey, I know we have $2000 in our HSA, but, no, we can’t take the kids to Disney world, because you never know when Daddy might slip a disc.” Or to use less trivial examples-paying for an urgent car repair, funding a child’s education, or just making the mortgage payment.
4) Realistic health care financing works better if it’s prepaid and automatic. That’s one of the reasons why employer-based health insurance is so popular. I never see the money; it goes right to my health insurance and it’s there if I need it. And, if I don’t need it, someone else can use it (since my premium then is available to pay for the care of another person in my risk pool).
So your 3-step system amounts to essentially what we already have.
1) Coverage for the poor-Medicaid
2) An enlarging group of uninsured and underinsured working poor and middle class folks to whom you tax deduction would mean very little
3) Catastrophic care, which the taxpayer and insured are already paying for, since we subsidize the uninsured.
Lex, you’re off your game. We’re past sixty posts and you haven’t mentioned a legitimate problem with single-payer-illegal immigrants.
As a second–generation Italian American (my grandfather came through Ellis Island after WWI), I don’t use the word immigrant as a pejorative. However, unless we refuse to care for illegal immigrants in a new single-payer system (which would be unconscionable), they threaten to put a significant strain on the system. So I believe those who advance single payer must also advance immigration reform. Unless we get a hold on our borders, national health care will be another incentive to draw illegal immigrants into the US.
Gary,
Medicare works well. The majority of my patients have Medicare and it is a good, fair, decent system. It provides comprehensive care for people who otherwise would go without and allows me to make a good living. It’s not perfect, but I’d much rather deal with Medicare than a private insurer.
Doug,
The prescription drug bill was flawed because it was written for the drug companies, not for Medicare beneficiaries. A simple solution would be to nationalize the VA formulary. It’s the most coherent, complete and cost-effective formulary I use and would significantly drive down the cost of Medicare prescription drugs if used exclusively.
Mike, you say this:
“That hurts, especially when the link that supported my proposition was to a “wingnut publication” of the Insurance Information Institute. That’s pretty motherhood, apple pie, and American cheese, no?”
Ummm, no.
“So when the report states:
AM Best indicate that medical malpractice underwriting losses skyrocketed from $289.3 million in 1996 to $3.0 billion 2001, an increase of $2.7 billion, or 938 percent in just 5 years.
I get the distinct impression that such costs have some sort of effect on healthcare prices because insurers will increase rates to recover losses.”
First of all, that excerpt doesn’t tell us the cause of the increase in underwriting losses. Insurance companies collect revenue in two ways, by collecting premiums, and by making investments. The fact that underwriting losses increased doesn’t tell us anything about whether insufficiency of premiums was the cause of the increase in losses.
Second, your impressions aren’t important, what’s important is whether such occurrences do in fact have an effect on healthcare costs.
And again, none of that is in any way relevant. I admit that if I am allowed to burn your house down without having to pay you any compensation, I will experience less of a financial burden than I would if forced to compensate you for the loss of your house. The question is, does my gain properly compensate for your loss, and the answer, of course, is no it doesn’t.
“If not, you may not care that the overall US tort system cost $205 billion — $721 dollars per person — in 2001, up slightly from $12 per person in 1950. Admittedly, inflation accounts for about $70 of the increase, but where did the extra $650 come from? That’s a significant cost to society, no? Especially considering that some folks aren’t kicking in their $721, meaning I gotta pay theirs along with my family’s share.”
No, the increase in the costs of the “tort system” as compared to the 1950’s bothers me not at all. You ask where the extra $650 per person comes from; I’ll tell you. There is not “extra $650 per person”. The $650 per person you speak of has always been paid; back in the 1950’s, it was paid by people who were killed and maimed by defective products, by medical malpractice, by drunken and otherwise negligent driving, by being dragged out of their houses at 2 in the morning, beaten, shot, tied to a cotton gin fan and thrown in a river, and by falling victim to a whole host of other horrors without ever receiving anything approaching reasonable compensation.
You may be upset that the costs of injuries are distributed more widely, rather than being concentrated on those who suffer the injuries, but I certainly am not.
“The tort system is also highly inefficient, returning only 46 cents on the dollar to claimants. In its breakdown of costs, Tillinghast found that just 22 cents of the tort dollar goes to litigants for their actual economic losses and 24 cents to compensate for pain and suffering. Of the remaining 54 cents, 19 cents pay for claimants’ attorney fees, 14 cents for defense costs and 21 cents for administrative costs.”
And your solution for this is to set arbitrary limits, dictated by insurance companies, on the compensation that can be received by people injured by incompetent and negligent physicians?
Why should injured people bear all the social costs imposed by the tort system? To the extent that a problem exists at all outside of insurance company propaganda, it is a social problem, the costs of whose solution should be borne by society as a whole, rather than by a class of untermenschen.
Hal/Mary:
Are you now or have you ever been a member of the bar association?
Hal –
I apologize if I wasn’t clear about this. Certainly folks should be reimbursed for economic losses, a point I think I made. Where we disagree is over the issue of non-economic losses, what’s generally referred to as “pain and suffering.” That’s where the caps — the “arbitrary limits” as you call them — are applied as I’ve indicated above and restate now. The caps are working in reducing insurance premiums as this report from the National Center for Policy Analysis indicates. In 2003 caps on non-economic damages went into effect in Texas:
Where our system has gone awry — and the point I think you are arguing from — is that when folks get hurt (the non-economic pain and suffering), they’re entitled to compensation for that hurt. I might agree, except that:
We all should know a lot more about this thanks to a nurse who became a judge and caught the connivers in the act.
I am of course referring to Janis Graham Jack, the U.S. District Judge who took on the trial lawyers who brought suits alleging silicosis contamination thereby exposing how they manufactured evidence without regard to the truth. Her medical background enabled her to analyze the claims and determine that something stank. Since Judge Jack’s
courageous ruling, other judges have found similar shenanigans in asbestos and other claims.
You complain that the caps set for non-economic losses, typically $250K to $500K are arbitrary. I think — I haven’t bothered to look it up because it’s late, I’m tired, and I’ve cut into my beer-drinkin’ time too much already — that these limits are meant as a disincentive for plaintiff’s attorneys to bring suit. A third to a half of $500K as a potential award is not enough to motivate them.
In the cold, hard world of economics, determining the “value” of a life is straightforward in one sense: how much life insurance has the “victim” purchased. That tells you a lot. But again, that’s not a non-economic loss: whether an individual made $20K per year or $200K per year, the malpractice insurance system can compute and will cover that economic loss as I noted above.
Finally, I suggest that you read up on the purpose and function of insurance. If you don’t like insurance companies as they exist today, you are quite free to set up your own. With just a little effort and not a lot of cash, you could set up a mutual insurance company to provide the coverage you and your fellow insureds desire.
Mike, that was certainly a long post. It didn’t really address any of the points I made, but it certainly failed to address them at considerable length.
Yes, I understand that you believe that people who are injured by incompetent and negligent physicians should be compensated for their economic losses, and it is only their non-economic losses for which they, rather than the incompetent and negligent physicians who caused those losses, should bear the cost. How big of you.
Your “argument,” such as it is, is that non-economic losses are difficult to quantify, therefore they should be set at zero, and some token payment should be given as a sort of act of noblesse oblige. The only losses that are important are economic losses. Not because the other losses aren’t real, but because they are hard to quanity – hard for you, anyway, especially given your lack of desire to quantify them.
And again, yes, I will admit that naturally insurance premiums can be reduced if incompetent and negligent physicians are allowed to avoid paying the costs of their mistakes, and to force the people whom they injure to bear those costs instead.
I can’t help but notice that allowing incompetent and negligent physicians in Texas to force the people they injure to bear the costs of their negligence and incompetence hasn’t really reduced premiums all that much. Maybe the act should be called the Insurance Company Legislative Campaign Contribution Preservation and Continuation Act?
The other part of your “argument” is that there are aspects of the judicial system that you don’t like, at least when it produces outcomes that disfavor people with whom you identify, and favor people you look down on. This should matter to me why?
Now, your contention – a reasonable one – that the token compensation to be awarded for non-economic losses, such as the incapacity resulting from loss of a leg, total paralysis from the neck down, the grief of seeing one’s baby die and the loss of companionship resulting from that death, was set so as to discourage attorneys from taking cases, is interesting. You are saying, apparently, that the maximum allowable recovery was deliberately set so as to foreclose the possibility of bringing a claim, thus precluding not only the recovery of the actual losses suffered by victims of medical incompetence and negligence, but even the token payment nominally allowed.
In the cold, hard world of economics, there are courses beyond economics 101.
One thing about this, it is mostly blogging at its best! And Paul and Mike especially, thanks for taking the time to respond to each other extensively on the issues.
Medicare works wonderfully for you and your patients, Paul, because there’s little consideration costs. The magical fairy picks up the tab. Except that there is no magical fairy, it’s the taxpayer. And the budgets continue to get strained by several factors, all of which are about to constrain satisfaction on the beneficiary and physician level: there’s little coordination of care (and doctors resist what little there is), everyone gets paid for services no matter what their effectiveness, Part B (not D, but B) drug costs are way out of line (but doctors resist changing them because they like the margins), and there are far too many things Medicare does not do well in (such as preventive services).
I keep the focus on Medicare because I want to make sure readers know Paul is talking about the government running the entire health care system. Also because I know something about it having worked at CMS for a couple of years under Dr. Mark McClellan.
Gary, you point some of the problems with Medicare. I don’t dispute what you say (and Paul has conceeded that no system is perfect). But if you look at the healthcare environment outside medicare/medicade you’ll quickly see how much worse it is. The profit margins and executive salaries for the insurance companies result in very excessive costs that are ultimately born by either the patients. For the uninsured the low-cost preventive treatments are foregone while the very expensive treatments that address a serious illness are provided but in a very inefficient manner. The magic fairy you speak of comes into play in a very big way in the non-government health care portion of our system. The ultimate goal would be to utilize some free-market incentives while recognizing the demand for health care is outside the standard free-market model for consumer goods. It’s a tough balancing act but single-payer of some sort seems to be the best answer.
Bud,
Thanks for the back-up, my friend.
Gary,
You’re right to keep the focus on Medicare because what we propose is essentially Medicare for All.
I disagree with several items in your last post.
1) Medicare does attempt to constrain cost through mechanisms like the DRG (Diagnosis-Related Groups) which pays hospitals a fixed amount for admissions based on the final diagnosis. In addition the Balanced Budget Act of 1997 has targets that limit the rate of Medicare growth. These limits are currently set too low and every year physicians rightly appeal Congress for relief. But that political give-and-take, though frustrating for us as physicians, is done out in the public square. If most people think that Medicare pays physicians too much then they can call their Senators and tell them so. This public, inclusive kind of negotiating about health care seems preferable to opaque deals between providers and private insurers or patients being denied insurance without any hope of appeal.
2) Where did you get the idea that Medicare doesn’t cover preventive services. The opposite is true. It covers cholesterol screening, yearly PSAs and prostate exams, yearly mammograms and breast exams, yearly Pap smears and biennial bone densities, and screening colonoscopes. Medicare is certainly as good as most private insurers in covering preventive care.
3) Mark McClellan, director of CMS, makes roughly $200,000 to administer the entire Medicare program. I couldn’t find Ed Sellers salary at SC BC/BS (Brad, do you have this?), but I suspect it’s a bit more if he can afford a 3 million dollars lot on Sullivan’s Island. That inequality is symbolic of the inequity for patients in SC.
Reading the PNHP proposal leads to more concerns. Hospitals would recieve a monthly “lump sum” payment for operating expenses as determined by the central government organization. Hospital expansion and capital funding would have to be approved by the same central organization. And this is going to lead to MORE efficient delivery of healthcare?
All it will do is consolidate the power to distribute large sums of money which in turn will lead to political influence and unethical behavior.
Who will determine the salaries for doctors and nurses? Would we see a similar structure as in public education where pay is based on years of service and degrees regardless of performance?
Also, the PNHP document states that funding for its plan will come from “income or other progressive taxes” — meaning that those who have more, will pay more. I already pay 1.5% of my income to Medicare for services I do not get (as does my employer). What would the percentage be with single payer? I’m guessing 10-12% minimum… with no guarantee that single payer will match the excellent private plan I have now. Basically, I’ll be working to make sure other people who make less money can get medical care they couldn’t pay for.
And their incentive to try and accept more responsibility for their health is what?
Any talk of funding this system should begin with a national sales tax, not an income tax. There also have to be co-pays and deductibles involved to prevent abuse of the system.
This is an interesting discussion… luckily, there are so many huge holes in the plan that it will never happen. The impact on our economy would be staggering and I am fairly confident the majority of doctors will resist anything that limits their personal incomes.
Doug,
In 2006, the average premium for an employer health plan covering a family of four was $11,500. Add the deductible and co-pays and you’re likely over $12,000 (roughly three-quarters of which is paid by the employer). For a family with an income of $100,000 that’s a tax of 12%-a 9% payroll tax for the employer and 3% for the employee. For a family making the US median income (about $47,000), you can double those numbers to a whopping 19% for the employer and 6% for the employee. Most of the single-payer tax estimates I’ve seen are lower than the first set of numbers (9% and 3%), meaning that the vast majority of individuals (except those who make incomes exceeding $100,000+) would pay less than they do now.
Businesses that already offer insurance would also probably pay less than they do now. What to do with small businesses that can’t afford to insure their employees is a tough question. I would not support a single-payer plan that was harsh on small businesses. Very small businesses would likely pay no tax; a progressive payroll tax beginning with employers with a certain number of employees (perhaps 10) and increasing incrementally until the full tax was due (at perhaps 50 employees)-I’m just making those numbers up as an example-would be one possibility.
And remember, single payer offers our best chance to control costs in the near and long term. Most estimates show if states were to switch to a single-payer system they would save money (for example, a study done by the Lewin Group in 2004 estimated that Georgia would save 716 million dollars by switching to single payer). And the fact that Canada spends roughly 10% of their GNP on health care and we spend 15% shows the ability of single payer to constrain costs over the long term.
Finally, don’t underestimate physicians for the following reasons:
1) I think there is significant support in the medical community and some momentum building. The vast majority of physicians want what is best for their patients.
2) For many physicians, particularly those in primary care, single-payer could increase incomes.
3) Although the AMA has generally opposed government-sponsored health coverage over the past century, both Medicare and Medicaid were passed in spite of organized medicine’s objections. Only a minority of physicians belong to the AMA (I couldn’t find a figure but I believe it is in the thirty percent range). I am a proud member of the AMA but believe on this issue it is out of step with the majority of patients and physicians. A recent survey of over 400 Minnesota physicians revealed that 63% supported single-payer.
And their incentive to try and accept more responsibility for their health is what?
-Doug Ross
This question boggles my mind. It’s been stated by several people in this thread in different ways. The obvious answer: People don’t want to get sick. That’s the incentive. Long-term economic factors simply do not come into play when people make life style choices that affect their health. In the short term economics may factor in. Higher cigarette prices, for example, might deter smoking, but to think that people will make better choices if they believe they’ll spend more on doctor visits years from now is simply preposterous.
All,
The meeting that I advertised in the op/ed occurred yesterday in Conway and was a success. A grand total of 9 people attended, so Lex and Doug, you’re safe for the moment.
I am heartened by a couple of quotations: Victor Hugo’s line “Greater than the tread of mighty armies is an idea whose time has come” and Margaret Mead’s line “Never doubt that a small group of thoughtful committed citizens can change the world. Indeed, it’s the only thing that ever has.” Well, at this point we definitely qualify as small-we’ll see about the rest.
I have received more that twenty emails and personal contacts expressing support, and I’m hoping there’s a silent majority out there waiting to be moved-public opinion polls suggest this.
The working name for our group is South Carolinians for Universal Health Care. We’ll be the state affiliate for Physicians for a National Health Plan.
Our next meeting will be Saturday, July 28th in Columbia. I’ll post the time and place here within the next week.
Our initial goal is to collect 1,000 pledges of support for single-payer health care. If you’re interested, just email me the statement, “I support a single-payer health care system in South Carolina.” Include your name and the town in which you live.
If you are a member of a civic, religious or any other group that is interested in health care, please give out my email and ask those gathered to sign the pledge as well.
We’re also trying to create a persuasive Power Point program and build a web site. If you have computer talents and would like to lend them, let me know.
I heard an interesting statistic (unattributed) on the McGlaughlin Group this morning. In a discussion regarding Jack Kevorkian and end of life decisions, one commentator said that 30% of all medical costs occur during the last three months of a person’s life. Consdering my father’s bill for 12 days in ICU was $120,000 that is not surprising. That was easily more than he had spent on healthcare from birth to age 75.
Single payer?
Just an HMO run with Post Office precision to benefit doctors and lawyers.
In my experience, hospitals and their minions function with the same self-serving tendencies of car dealers, mechanics and vinyl window salesmen.
Taking the insurance company out of the loop would remove the biggest safeguard.
Paul:
If you’ll read my post carefully, I didn’t say Medicare did not cover preventive services. My point was that many believe does a poor job focusing on preventive care. Fact of the matter is that Medicare pays for all kinds of services regardless of the quality and cost. And unfortunately, health care providers — including physicians — resist tying performance to payment. There’s no reason to believe that won’t continue to happen if we have your world of a government-run health care system.
I’m not persuaded by the inequality of Dr. McClellan’s salary (he’s not there any more, for what it’s worth) and Ed Sellers.’ If you gave every health insurance CEO a salary of $200,000 a year, I bet the savings wouldn’t pay for 20 seconds in your waiting room for every senior in Medicare. You are merely making a symbolic argument here.
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