I found this piece from Slate interesting:
At the end of 2011, the remarkable innovator Donald Berwick was forced to resign as the recess-appointed head of Medicare and Medicaid, a casualty of Republican-led opposition to his confirmation. An outspoken fan of the United Kingdom’s single-payer system, Berwick was portrayed by critics as a socialist who once commented that “excellent health care is by definition redistributional.” In 2010, for example, Republican leaders of the Senate Finance Committee grilled him about whether he “still distrusted the free market” and made it his goal to “make health care rationing the new normal.”
The furor over Berwick reflects a broader, fundamental disagreement over the nature of health insurance. Should it be “social” insurance, with which financial risk is leveled between those who are ill and healthy, so the carefree twentysomething and diabetic elderly man pay equally into the system? Or would it be better structured as “actuarial” insurance, where those expected to consume more shell out more, just as those who drive flashy, expensive cars or rack up speeding tickets pay higher auto insurance rates? If your view is the former, you generally support the notion of a single-payer system, as Berwick and many Democrats do. On the other hand, if you see health insurance as actuarial, you favor tiered premiums depending on age and pre-existing conditions, and tend to like health savings accounts, as many Republicans do. This dispute is central to continuing political wrangling over the 2010 health reform legislation, the main provisions of which are scheduled to take effect in a few years.
But Americans made their choice clear long before Barack Obama ever signed the law—and they picked social insurance. The issue today isn’t whether we should redistribute health care dollars. We do, arguably to the same degree that every other country does. Systems with national health insurance systems explicitly redistribute money before patients get in car accidents, discover cancer, or develop heart disease. Here we do it in secret after illness occurs. We create the illusion of actuarial insurance, when the truth is that all major American health care institutions have been socialized for decades…
Any rational health insurance system distributes risk, and cost, so that everyone pays a reasonable amount to cover the needs of the few who are sick or injured at a given moment.
And I’ll never understand why people object to putting the whole country in the same risk pool, thereby spreading cost and risk as thinly as possible.
But that’s ideologues for you. They’d rather call something names than think about how much more sensible it would be.
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95% of British drivers consider themselves above-average. We discount the real risks that we are subject to, unless they have happened to us. Unless you have gotten seriously ill, lost coverage or been unable to get coverage, or otherwise challenged, you tend to believe you have excellent, permanent insurance, or that you will never need it because you are above-average healthwise.
Reuters yesterday published a story on Standard & Poors warning all industrial nations that their debt problems were actually health care problems and that by 2015 they were looking to start down grading credit ratings unless the developed nations took the necessary actions to better manage/control the rising health care expenditures.
Its not just the US facing these decisions. We’re just spending more, covering fewer, getting less and less value for our spending than other developed countries. If we want to deal with our debt we need to be grown-ups about dealing with our health care system.
Because the people who typically want to share the risk are the ones who would pay the most if it wasn’t shared.
Like the article says, would you like your auto insurance to reflect the costs of insuring a 16 year old kid driving a Trans Am?
And will my costs (and the millions of people like me who have insurance they are very happy with) go up or down in your model? If it stays the same or goes down, have at it. That’s the biggest issue – how do you convince people who don’t have a problem with insurance that your way is better. Good luck with that.
As someone with three age 22 and under drivers on my auto policy, I’d love to have my retired neighbors kick in something to help me out. I know I didn’t have to help them with their kids 20 years ago, but it’s all about fairness now.
Kathryn, 95% of British drivers ARE above average — on account of having the National Health…
You can choose to be a Trans Am driver. You do not choose heart disease or cancer.
and the Trans Am driver may end up needing long term care just as expensive as Grandma’s. You never know.
I’m happy to have paid to educate your kids, Doug, and would gladly have paid more if everyone else was.
The sad thing is the number of diseases that go undetected because our system is not set up to pro-actively invest in preventative measures.
In Germany I got a coupon to take to the doctor each year, which included an EKG and one of those do-it-yourself tests for occult blood in the bowel.
Here they don’t want to pay until you get sick, and then they still don’t want to pay. That is if one is fortunate enough to have someone who is supposed to pay, even though they don’t want to.
In the meantime, another serious issue goes unnoticed, i.e., the fact that our per capita cost for health care outstrips all other industrialized nations. This is an area in which we could make some real progress, but it’s unlikely to happen; too many fatted calves would be slaughtered.
There’s no way that seniors and the elderly could afford the cost of actuarial insurance at this point, and a significant percentage of one’s lifetime healthcare costs are accrued at or near the very end. The solution is some sort of permanent health insurance, whether private or governmental. In my mind, it would need to operate like a life insurance policy: start paying when you are a baby and the premiums would be very low… Wait until you are older and the premiums get a lot higher. I don’t even particularly care who offers the policy, but if you have a private provider and you don’t like a decision, you can appeal to the governmental regulator. If the provider is the government, who can you appeal to? Yes, I know they could have an ombudsman or some sort of arbitrator, but generally, I have not liked being on the receiving end of federal or state service delivery.
Brad, even though I agree with you on this issue I’m not sure I understand why we’re bringing this up now. Seems like the Republicans are fighting tooth and nail to abolish what little progress we’ve made in healthcare reform. Let’s fight that battle right now and hopefully at a later date we can revisit the single payer system and get rid of this unworkable monstrosity once and for all.
I only brought it up because Kathryn sent me the link, and I thought it was interesting…
@bud–because there are challenges all over to “Obamacare” and people who are opposed to socializing health care who don’t realize it already is!
@silence–and if people fail to purchase health insurance when young, what do we do about that? You have to deal with the free rider problem–either by letting them rot in the streets or by forcing them to participate. The most legitimate challenge to Health Care Reform is the requirement to purchase insurance from a private vendor. Make public insurance a mandatory back-up instead–but the insurance companies didn’t like that.
@ Kathryn – I have no problem, 0 problem with issuing every single person in the United States a high deductible health insurance policy at birth, say one that would kick in after $3000 annually. If people wanted a policy that paid out if they got a cold or whatnot, they could go buy a supplemental one from Blue Cross or whomever. I do have a problem with the public health insurance as currently constructed, where you have extremely low co-pays and threfore no disincentive to use medical services. I know that there are some benefits to having people get treatment, and that even a low copay might prevent some folks from seeing a doctor, but it is kind of ridiculous that the taxpayer would be out hundreds of dollars each time some child on S-CHIP or Medicaid gets a sniffle. That’s just not really sustainable.
I know the arguement about preventative services as well, but I think that there are also some studies that have concluded that there is no real cost savings arising from preventative services.
@Kathryn
I am already paying several thousand dollars a year for the healthcare of those on Medicare – lifetime so far, my wife and I have paid at least $50,000 for other people’s healthcare outside my own risk pool. And since it comes out as a percentage of my income, I pay more for other people’s healthcare than most do.
That’s the part that so many of you so easily brush aside. As long as someone else is paying for it, you don’t care if some people pay more for the same thing and others pay less (or zero). I’m supposed to feel privileged somehow to do that.
I’m waiting to see someone come up with a tax to pay for bald people like me to get hair transplants. People with nice hair like you should feel honored to donate to the cause. We’ll just trim a little bit off the back and you’ll never notice.
“You can choose to be a Trans Am driver. You do not choose heart disease or cancer.”
So much for that whole chain smoking, binge drinking, fast food eating theory my neighbor keeps harping about to his 400 pound, alcoholic, 2 pack a day patients.
I think we need to move toward a forced medical insurance program where as a citizen you’re required to participate financially and if you don’t you’ll be assessed a fine or jail term.
Okay, so I’m stealing a page out of Barry Obama’s playbook.
Sounds good to me, Steven. Oh, you were kidding…
But hey, I had the same thought — lots of people DO choose to have heart disease, or cancer, or Type II diabetes.
They do not, however, choose to be bald. I’d be interested to hear Doug elaborate on that. He doesn’t like to believe that certain human conditions (such as poverty) can result from the luck of the draw. So I’ve got to ask — what did you do to get bald, and why did you choose to do it?
(See how infuriatingly smug those of us with full heads of hair can be? Next, I think I’ll taunt endomorphs…)
Poverty can be “bad” luck of the draw. Getting comfortable with it and making it a lifestyle is usually a choice.
@ Doug–I have nice hair? I have hair, but not much of it.
Nobody chooses heart disease or cancer or diabetes, and none of those are 100% lifestyle-caused diseases. The public health gurus can’t even tell us how to lose weight or what we should eat, other than vegetables–pretty much everyone agrees on those. There are even benefits to smoking, believe it or not–Parkinson’s prevention, weight control, and so on.
@ Silence–If we had a decent health system that covered everyone, especially a centrally controlled one, we could make much better use of triage nurses and other almost doctors. We could engage in more meaningful health care allocation–for example, if you have a fatal disease that is curable, you go to the head of the line, no antibiotics for viruses, early treatment for hypertension for everyone who needs it, and so on.
If people don’t buy healthcare, we’ll just have to take them abroad. In these moments, you can normally find an Italian who isn’t too picky….
@Brad
Seriously? Genetics play a huge role in the incidence of disease.
The “luck of the draw” only puts you in a situation. It’s how you respond to those situations that determines your outcome in life. You think bad luck can be overcome by more government involvement in our lives from cradle to grave. I’ll take my chances on my own abilities over the government’s.
And can you address the key point of my issue with single payer: how do you guarantee me and the tens of millions of Americans who are happy with their insurance a better system than what we have now at the same or lower price?
You want it because it’s a better deal for you.
I do have a problem with the public health insurance as currently constructed, where you have extremely low co-pays and threfore no disincentive to use medical services.
-Silence
This is the point that is the most offputting and illogical of all the anti-healthcare arguments. If someone suffers and injury or an illness is there really any sort of incentive NOT to use medical services. If conservatives want people who can’t pay for medical services to just be denied then just say so. Otherwise leave these ridiculous arguments alone. It just makes you look stupid.
Doug, just because you base your policy decisions on how they affect YOU doesn’t mean other people do. Single-payer would benefit the entire society, and that has always, ALWAYS been the basis of every policy position I have ever taken.
If you don’t accept that about me, then every word of mine you’ve read has been a waste of time…
The good news is with unemployment dropping to 8.3%, along with a healthy growth in jobs the Obama presidency, along with Obamacare, are likely to be with us for at least 4 more years. Unless the interventionist courts get involved.
“Nobody chooses heart disease or cancer or diabetes”
But there are people who do things that increase the chances of getting all of those diseases. Short of shaving your head, there’s little one person can do to bring on the non-life threatening disease of baldness. Why should I be forced to pay my share of health costs and the share of the bedsheet wearing, 1400 pound, fast food eating, chain smoking, alcoholic down the street who can’t work because he’s “handicapped”?
@Brad
Single payer would benefit YOU at MY expense. Can you prove otherwise? It’s the segment of society that has issues with the insurance industry that complains the loudest. I’ve worked for three different companies in the past year, two of which had more than 100,000 employees and all three had very acceptable insurance coverage: multiple options depending on the amount of risk a person wants to assume and a common rate for EVERYONE (except for smokers who pay a higher rate). That’s the system I want. If you want to implement it across the country, go ahead. Multiple plans, one price per plan, everyone pays for his or her own insurance.
No matter how you try to spin it as me being selfish, my views represent a majority of Americans who are not on Medicare or Medicaid already. We want choices, we want to pay for our insurance… we don’t want the broken Medicare model… and certainly don’t want it under threat of punishment.
And I’ve asked you before – you have access to plenty of politicians. Ask them why they cannot allow any citizen to buy into the same plan they have. That would solve most of the problem without overhauling the entire system.
@bud
Ok, so now 3.1 years into his Presidency, can we now call it the Obama economy from this day forward?
I’d just like to know at what point Obama owns it.
People do the same things with different results, healthwise. For example, I can eat whatever I want and my cholesterol will stay very low. My weight will not. My friend can eat whatever she wants, and stay thin, but battles her cholesterol. There is no known perfect universal template for health behavior (except eat organic vegetables you aren’t allergic to), and until there is, we need to stop judging people based on many factors outside their control.
“Actually, single payer would benefit everyone at OUR expense.”
The same expense for everyone? Sign me up. Or do you mean the “be happy you can pay more for the same thing” model like Medicare?
Anyway, single payer will never happen. Most doctors (particularly those with highly specialized skills) will never accept a pay cut. But, I know, they should not be in it to make money, just to serve people at whatever the government feels is the proper payment.
Actually, single payer would benefit everyone at OUR expense.
And do you really think a president ever owns the economy? They get blamed for it when it’s bad, and credit when it’s good, but much of that is overblown.
Of course, he probably wants to own it today, with the latest unemployment figures.
You mean the Obama economy characterized by this headline?
“Unemployment rate falls to 8.3%; fifth straight monthly decline”
What are the doctors who will never accept a pay cut going to do? There are no other countries that [over-]pay as much as we do, and only so many people who can pay out of pocket?
Burl, where are these jobs? In Hawaii?
Is there even a standardized way to count unemployment or is it reported however the reporter wants the numbers to turn out.
“Anyway, single payer will never happen. Most doctors (particularly those with highly specialized skills) will never accept a pay cut.”
Many of those that I know who still see Medicare and Medicaid patients have already seen reduced pay cuts. One who sees a Medicaid patient says that Medicaid doesn’t even pay enough to cover his overhead for the procedure. He’s stopped taking new Medicare and Medicaid patients, and is doing what he needs to to get the current ones off his list of patients.
@ Burl – Shadowstats puts the real unemployment rate – including the “long term discouraged” at about 23%. Even the BLS’s U6 unemployment measure (which doesn’t include the long term discouraged) is about 15%. Just redefining the measure of unemployment doesn’t put people back to work.
Also, what’s wrong with asking individuals to pony up a little scratch when they go to get their stitches or tetanus shot? I understand that little problems untreated can turn into big problems, but everyone’s gotta have some skin in the game. Free (just about) anything = no incentive to conserve = tragedy of the commons.
@ Doug & Steven – I’d rather keep paying doctors very well and attract the highly talented to the medical profession. The eventual alternative would be to have a bunch of less capable docs around, and the smartest, most capable would then go into either law or high finance. Either way, we’d be screwed.
By far the largest health issues are not catastrophic. They are simple flus and colds and cuts that need a stitch or two and a tetanus shot. But for people without any health coverage, these simple issues can spiral out of control and result in lost work, lost productivity and unnecessary visits to the ER when a cold becomes pneumonia. Having a nation that is generally healthy is a good thing. Sorry, I just don’t get why anyone wishes ill health upon their communities.
@Kathryn
Talk to some doctors about Obamacare. They can’t afford to take Medicare patients now. Do you think they’ll make it up on volume?
It’ll never happen. You can’t put the toothpaste back into the tube.
@ Burl–self-centeredness and greed. After all, these people are sick because they are weak, weak, I tell you! Cull the herd!
Silence, how would requiring dirt-poor folks to “have a little skin in the game” when it comes to basic vaccinations help anything? Are people going to double up on polio vaccines because they’re free? Just think about how completely illogical that reasoning is. I know it’s your basic econ 101 theory that the demand for anything is infinite but in this case it’s not so.
Silence, so you’re in agreement. We need to keep medical insurance system the way it is rather than have it run as a government controlled system where doctors get paid what beaurocrats dictate what they get paid.
Silence, I know one lawyer who told me specifically that she went into law because it paid better than medicine.
@bud – I’m not talking about vaccinations and general (let’s call them required for everyone) health services. What I’m talking about is the system we have today where the copays are so low as to make them virtually nonexistent. Right now people with extremely low income pay nothing under the QMB program, and people with a little more (still very low) income pay only monthly premiums.
If I have an ailment, I decide if it’s bad enough to warrant the time off work to see the MD, and if it’s worth the out of pocket expense to go visit the doc. My copay makes me essentially the first gatekeeper against going to the doctor every time I have a muscle ache or a sneeze.
Right now as I understand it, our ER’s are overwhelmed by people who use them as a primary care doctor. I’m not saying they need to pay much, but everyone should pay a little. Certainly the last thing anyone wants is for people with legitimate ailments or contagious diseases not to receive treatment.
@Steven Davis–she is sorely mistaken. The data show very clearly that MDs make multiples more than JDs.
A handful of very successful lawyers make a lot more than most docs, but most lawyers make less than 6 figures in this state, as compared to most docs.
@ Silence–There are many reasons why ERs are overloaded with people who use then as primary care docs–insufficient primary care docs–we let med students specialize when we need more generalists. People don’t have health coverage (yet), so they have to use an ER. They cannot afford a PCP–so making them pay won’t help. You can’t get blood ou of a turnip.
I think most poor people actually work, and don’t get paid unless they do–no personal time for docs appointments. They have “skin in the game.”
I think some centralized planning (gasp!) to allocate medical school training where we need it most (med students do not pay even most of the cost of their training), fund triage-type care centers where anyone can be screened/treated for serious illnesses vs. viruses, and these centers need to be open when people need them–I know I’m seldom sick when my doctor’s office is open–much less when she might actually be available. Fortunately, I don’t have acute medical needs, but kids can go from a little sick to critical in a short time, or people with chronic illnesses that flare-up, like asthma….
Silence, I don’t think we disagree all that much. If the only issue is a small copay for emergency room situations then there isn’t really an issue. That could even be addressed for those with no income (more folks than you might think) through charitable organizations. But as Kathryn points out few people actually have no “skin in the game”. If nothing else it’s a huge inconvenience to spend 4 hours in the ER.
@Kathryn – She’s a partner at O’Melveny & Meyers, not Palmetto Legal and Pawn.
@ Kathryn – So by restricting the choices of MD students, and forcing them into primary care/generalist positions, that will improve the quality/availability of care? Agreed that med (along with many other graduate students) aren’t paying the full freight on their training, but forcing them to foot more of the bill or limiting their future practice options would probably not have the effect that you desire.
Along the same lines: We seem (based upon recently available employment data) to have a surplus of certain types of attorneys. Perhaps we should regulate the number that go on to practice various types of law…
Continuing in that vein, there are a lot of computer science students who are work with UNIX, but very few who concentrate on Newton OS. Maybe we should tell a few more of them to go study Newton OS.
Why wouldn’t more PCPs equal better and more available care? and why wouldn’t having the same sorts of controls we already have on hospital beds make sense–AND control costs? Limit the number of specialists, and you will get only the best. It will keep spiraling health costs down, for one thing!
Of course, as an attorney, albeit retired, I should love to restrict future competition! In reality, we could use more DSS lawyers and fewer of other types, and if we’d subsidize the education of those willing to do that kind of work–PDs, other poverty/rural law–or just have slots.
I certainly agree that we should restrict the number of any type of advanced degree that isn’t 100% paid for by the student to some reasonable number of graduates. We over-educate a few and they are increasingly condemned to a lifetime of undischargeable debt.
I don’t know anything about Newton OS, but you won’t get any arguments from Professor Fenner that students need to learn many types of systems/languages, rather than just becoming expert in one that may –will— be replaced. There are not many calls for Fortran any more. He just went to the CS/Engineering job fair, and Perl is the language du jour (which he knows well)….don’t know what OS is hot. What students study is somewhat prescribed by the accrediting body.
@ Steven– how few people get a chance to grab the brass ring of partnership at a silk stocking firm? Even those lucky enough to get an associate job are unlikely to make partner. You proved my point.
@Kathryn – It’s called “hard work”. She didn’t have family ties, didn’t have money and was the first person in her family to even go to college. “Luck” had nothing to do with it, unless her instructors just gave her the grades to graduate in the top 5% of her class.
The way I read comments — all together on the dashboard, divorced from the context of the post — can lead to funny coincidences.
I had just read a comment — from Steven — regarding the post about Her Majesty’s Jubilee, and was thinking about that, when I read, “It’s called ‘hard work’. She didn’t have family ties, didn’t have money and was the first person in her family to even go to college. ‘Luck’ had nothing to do with it, unless her instructors just gave her the grades to graduate in the top 5% of her class.”
Which was, unintentionally, pretty funny…
Lots of law students work just as hard with less success. She was blessed with one or more of the following: good looks, the right personality for the firm and practice group she ended up in, the right kind of smarts to suss out law school exams, etc. I saw plenty of very hard workers with excellent grades not make partner.
Lest you think I’m sour grapes, I graduated in my law class’s top 10% and worked for international law firm Winston and Strawn. I walked away when Steve got a job in Maine. I know of what I speak.
Which of you legal beagles has perky, free advice on how to initiate an investigation of dissemination of false information and misrepresentation of college transcripts on either the employer’s end or the academic institution? Potentially 30+ SC employers; 1 academic institution.
Thanks,
xoxo’s
s/read:
academic institution’s [end]?
Brad – Huh? Two people – both rich, one born into it one worked her way into it. Funny??? I missed the punch line.