In response to the wave of misguided proposals across the country calling for "health care reform" , discussions are beginning for an initiative to amend at least one state constitution with the following:
The right of citizens to enter into private contracts with health care providers for health care services shall not be infringed. No law shall be enacted requiring any citizen, or any class of citizens, to participate in any state sponsored health care system or plan.
I can’t name the state for the time being as the details are still being worked out. Thoughts?
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After many years of managing large organizations in the corporate world I started my own small discount office furniture business five years ago. I have struggled to offer a solid health care plan for my employees. We have had steady growth over the years, but not the cost of health care has grown even faster. Do you know of any states that offer a subsidized small business health care plan like Arkansas?
“Sound like a good idea? Didn’t think so. But it’s the same one you had, Stella. Think it through. There’s no way to determine who is or isn’t making a “good” decision, and people in government aren’t any better at it or any less corrupt about it than anyone else.”
Matthew, Matthew, Matthew, I expected at least ONE person on this frickin blog (you frinstance, or Erick) would have the wit to recognize the first post of mine up there for what it is – a send-up of a certain too-common dogmatism toward single-payer. And what’s all the more interesting to me, is that you yourself say “it’s funny”.
“It’s funny how several people in this comment thread seem to subscribe wholeheartedly to the “Very Smart People in Government” fallacy.”
I made what I thought to be an obvious-verging-on-clumsy satire of this very attitude – and got taken SERIOUSLY, Even by YOU. Gads.
Can it be that in a blogful of the blind, even one-eyed bloggers are not kings?
Let me amend that last sentence (I’d take it back if I could). It’s not really about “free market” vs. whatever, because even the government leverages market forces to accomplish what it wants – DRG’s, APC DRG’s, various governmental incentives through the years that drove expansion in the market (e.g. home health years ago), and even the “clinical integration” exceptions from anti-trust where it can be proven that the integration is in the best interest of patients and not the providers. These all have acted like tools through the years to drive change – whether we liked it or not. So it’s more complex than just a choice of free market or not.
Some real examples of (in my opinion) bad healthcare choices made by otherwise intelligent folks: (and all illustrative of how the focus on “access” meaning “insurance” totally misses much of what is wrong with healthcare. Again I’m responding to the notion that Eric seems to forward time and again that if we just tweak things a little and let the market forces work that we’ll all be better off.)
Cancer: choosing your friend who is a general surgeon to “treat” your breast cancer instead of seeking out at a minimum a surgical oncoligist – if not seeking care at a top end cancer center (e.g. MD Anderson) (I have seen versions of this happen several times).
Heart: Going to your local community hospital on the referral of your primary care to have a device implanted by a surgeon you don’t even have a chance to talk to before you are on the table. Instead of a thorough work up by the surgical team which would likely have included in this case some vital pre-surgical advice that the patient was never told, which resulted in complications and could have been life-threatening. Not to mention that this should have been done at a bonafide “heart center”.
Other examples I have seen: No second opinion when primary is having a hard time diagnosing a problem.
Believing a physician who says, “well, I really don’t think the folks at Mayo will be any better at this than I am (by solo physician in anytown, USA).
More subtle examples include folks who never do any of their own research on preferred techniques (say for prostrate cancer treatment) but simply do what their primary tells them.
People who choose not to go to the regional specialist or to the recognized expert because “they are out of network”. Again not an affordability issue per se – it’s about making the choice to spend $ on healthcare instead of that big screen tv etc. because, well “aren’t all doctors pretty much the same”?
My point in all this is that what we should be talking more about what leads to better outcomes – systems and structures and incentives that are really aligned – in the favor of the patient. Don’t be fooled into thinking I’m simply promoting choice, what I want is incentives to create a Mayo in my town instead of having to travel to Rochester. Or systems that give me decent pediatric care where now I have to suffer because the local hospitals are too busy competing to coordinate and share finite specialty resources.
Our system rewards procedures over cognition, technological innovation over prevention. Every effort to “let the free market work” will just get us more of the same.
Eric, I would add to your list of nine:
10: Reinstate the certificate of need
11: Extend CON to physician offices and clinics
12: Reinstate the Stark laws that prevented self referrals (hosptials employing physicians, physicians having ownership in hospitals to which they refer patients, and physicians referring patients to labs in which they have a financial interest).
13: States or the feds must pass “any willing provider” laws
14: Physicians and nurses in the top 10% of their class should receive a 100% rebate on their tuition (perhaps graduating down to 50% rebate at the C level).
15: Eliminate hospital and pharmaceutical advertising
16: Prohibit “deals” between physicians and drug/device manufacturers
17: Establish a national patien database with transparency of hospital and physician best practices info
18: Require drugs to be clearly labeled as remakes (when they are) and require that they be tested against the original rather than a placebo)
19: Prohibit patents on drugs that are (even partially) funded by the NIH
There are more, but my finders gave out on me.
Do your homework. Compared to the next highest country, Canada at 10%, the US health care system is costing 15% of GDP. They have a Medicare-for-all system that has eliminated all of the waste generated by the insurance industry (and others). Not waste huh?
Employers add their costs of health care to their product and YOU reimburse them at the cash register! You reimburse them at the 15% rate rather than Canadians at the 10% rate.
So, keep payin’ maam. They love you for it.
“Stella, quit being an a**hole”
Still playing the buffoon eh? See, bud, I don’t CARE if a person who can say THIS “appreciates” my “views”:
“Medicare has problems, but they will not be fixed with a free market system to further drain public assets.”
Yes, Medicare has “problems”. You seem to have no idea how big. Your curious religion aside, what you suggest will just go on draining the public assets by public expenditures. That won’t fix the problems.
“A Medicare-for-all system with all of the healthy young bucks folded into it will be far cheaper overall than any free market system you could point to.”
Hows your idea make anything “cheaper”? All it does is soak my children and their children and their children to the end of time. The government has already promised more than it looks like it can deliver, and you want MORE of it. Sheer buffoonery.
Stella, quit being an a**hole and perhaps your views will be a bit more appreciated.
This buffoon realizes that Medicare has problems, but they will not be fixed with a free market system to further drain public assets. It is projected that by 2016 health care costs will go from 15% to 20% of GDP. That’s not because of Medicare, which takes on old geezers like us and deals with virtually all of the heroic end-of-life costs, and thus its per-capita costs are higher than all others.
And Medicare will become further in debt as the Bush trillion-dollar giveaway to the pharmaceutical industry plays out.
A Medicare-for-all system with all of the healthy young bucks folded into it will be far cheaper overall than any free market system you could point to.
“I am thankful to be on Medicare.”
Who is this buffoon?
I’m on Medicare too. Medicare is much further in debt than even Social Security. The Medicare system is at risk of collapse because of its debt, unless fundamental change takes place such as big reductions in the benefits (the benefits arent so great right now, if you know about Medicare).
None of that makes ME “thankful”. It scares me.
Who recognizes this problem and has ideas to rescue Medicare? I don’t see them – I sure don’t see them here.
>>> “… better price and quality transparency tools that would help both patients and doctors determine the relative quality of hospitals, …. learn the actual insurance company reimbursement rates paid to hospitals, doctors, imaging centers, labs, etc.”
Barry, I agree with what you say ……. except why in the hell do we have to pay the additional 15-20% for an insurance industry that adds nothing to health care and just adds cost? That’s where you and I part.
You are also a big proponent of HSAs, and according to a recent article in the Business Journal you may get your way. In five years that will be our only “free-market” choice. I am thankful to be on Medicare. Eric, you ought to be looking at ways to mitigate your increasing bad debt costs. Certainly if they work as intended you’ll only see the worst of the worst cases so decide how you are going to use your free time.
>>> “….is healthcare a right or a privilege? If it’s a right you have now started down the slippery slope of “healthcare for all”. If its a privilege, well, let’s just say you’re ok with (even more) people dying in the streets if they can’t make good decisions in life. This is the basic conundrum facing us with all of this healthcare “reform”. ”
In a perfect world healthcare should be a privilege. But we are a compassionate society and we treat people in distress even it it costs the taxpayers in the process. And if we could trust the industry to provide only needed care and to eliminate its waste and ripoffs, the public would be less testy.
But we can’t trust the industry. There are too many people finding ways to unfairly make money off the unfortunate. And its not like other consumer products. You can’t just boycott as you can other free-market products. Unless you want to die early or allow your child to die early.
So we hold our nose and go to the doctor and struggle to find a way to pay the bill. Sometimes mothers do that by not taking their blood pressure medicine, and of course dying early.
Indeed we should penalize smokers through higher taxes on cigarettes, and we need to penalize or motivate the morbidly obese. How to do the latter is more tricky. The former just needs a $5 tax per pack of cigarettes, but the tobacco industry campaign money is blocking that.
I just read an excellent piece on campaign reform that could easily be modified to describe health care reform. You can see it here:
http://www.unity08.com/node/44#comment-14585
I can give you example after example of wealthy, intelligent, informed people who make horrible decisions about seeking healthcare.
RW – Could you give us two or three examples. Are we talking about things like diet / exercise / medication compliance or continuing to smoke, failure to lose weight, not wearing seatbelts, etc.? Since these wealthy, intelligent, informed people presumably have insurance, I assume access to healthcare is not an issue. I’m also not sure whether the insurance system were all taxpayer financed (single payer or voucher) or the current hybrid system would make any difference in reducing the number of “horrible decisions” that people make.
I’m a believer in personal responsibility. I also think that better price and quality transparency tools that would help both patients and doctors determine the relative quality of hospitals, see the risk adjusted outcomes data for individual surgeons, learn the actual insurance company reimbursement rates paid to hospitals, doctors, imaging centers, labs, etc. would go a long way toward improving the efficiency of the system and driving patients toward the most cost-effective providers while the less cost-effective lose market share or fall by the wayside. Objective, unbiased infomediaries (modeled after Consumer Reports) could help consumers with their decision making.
>>> “The easiest way to get doctors to see patients is to allow them to take a tax credit for the value of their care. Even if the value of the credit just equalled medicare rates it would vastly increase access to care without significant overhead…”
After re-reading your #7 I understood what you meant and was going to respond that I agreed both on receiving medical care and food stamps and any other govt help. I’ve seen too many case of people well enough to work and finding loopholes so they don’t have to. There are many chores the indigent can be given in return for their care that would actually help train them for work. Then they wouldn’t be indigent!
But even then, we’re talking about taxpayer care. Why don’t we just have taxpayer care through a Medicare-for-all system and avoid the unnecessary administration costs?
Eric – I misunderstood your reference to tax credits. Tax credits to providers who treat the poor would certainly have a positive impact, although why stop there? Medicaid reimbursement rates for primary care providers are so low it’s a disgrace. Vetinarians get paid more for treating animals. Federally Qualified Health Centers (FQHCs) get paid more under federal law, than physicians and physician groups, but are expected to provide a wider range of services.
Some state Medicaid programs are looking at Pay for Performance and this could be a positive development if it leads to both improved compensation and increased accountability for primary care physicians treating Medicaid patients.
I also agree that programs emphasizing lifestyle and behavior changes can produce long-term health care cost savings, but only if they are targeted at the right population – those in the early stages of chronic disease. For those at a more advanced stage in their disease a different intervention is required – care management to prevent unnecesary ER visits and/or admissions.
It is a common misconception that the health care solutions that work for a healthy commercial population will also produce the same positive results for a much sicker and underserved Medicaid population.
OK, healthcare should be cheaper, but one of the ways we do that is with health courts that actually costs the taxpayers MORE than having the private parties pay for it themselves.
That makes sense.
“something dramatic needs to happen”
Good advice. Oh, yeh. Where did you read this?
There’s the way things should be. Then there’s the way things are.
I believe your position Eric represents a great deal of “the way things should be”: that people would take more responsibilty for their own health, that people would stop smoking, overeating, etc.; that people would take the time to understand their health so that they could partner with their physicians effectively; that people had the ability differentiate a good doctor/hospital/etc from a bad doctor/hospital/etc and that typical market forces actually applied to healthcare … and so on. Sadly none of these is even close to being true or achievable in our current framework, including its focus on insurance as the primary mechanism for payment. I can give you example after example of wealthy, intelligent, informed people who make horrible decisions about seeking healthcare. It’s not elitist to recognize that healthcare is exceedingly complex. We lack even the most basic tools to evaluate healthcare decisions the way we can evaluate other kinds of choices in life.
Those of you stuck in the “personal responsibility” camp are not living in reality. Having said that I believe strongly in personal responsibility myself – but I also realize that healthcare is too complex and only a portion of healthcare demand is driven by issues that can be moderated through personal responsibility. Healthy people still get sick and injured. Healthy people of all socioeconomic levels.
Now is healthcare a right or a privilege? If it’s a right you have now started down the slippery slope of “healthcare for all”. If its a privilege, well, let’s just say you’re ok with (even more) people dying in the streets if they can’t make good decisions in life. This is the basic conundrum facing us with all of this healthcare “reform”. How do we reconcile the way we wish things were with the way they are.
Healthcare is so incredibly broken right now that something dramatic needs to happen to effect real change. Even if every one of your proposals was implemented tomorrow Eric, not a thing would change that would impact quality or accessibility.
Dean/Jack — Barry is right… as I wrote many moons ago in a post ‘how to easily increase access to health care’…
The easiest way to get doctors to see patients is to allow them to take a tax credit for the value of their care. Even if the value of the credit just equalled medicare rates it would vastly increase access to care without significant overhead…
sorry for the confusion…
also, Dean— are you suggesting that patients cannot control every aspect of their health and outcome? Of course you are… the same is equally true for the doctors and outcomes (see my ‘outcomes primer’ post).
what you can do, however, is try to establish process measures. You twist my words to imply that I believe Medicaid beneficiaries have moral and work ethic problems– which is not something I believe– nor have I ever believed. But I do believe in high expectations: blind people are not incapable, many of the chronically ill are enormously successful.
Remember the 10%-65% numbers… if you are interested in spending, getting small changes in behaviors can make a significant difference– but it will take efforts on both the patient and provider sides. Not everyone can make changes on his or her own- but most can.
Just look at public education– students learn and can excel– but it takes more than just the teacher; it takes family involvement, an expectation from parents that homework is more important than hanging out, an instilling of the importance of education and pride in achievement. The system today has no ‘stick’ to use for the parents, but it loves to wield one against the teachers.
If you believe that this is the model for success in health care– you have found a fundamental difference in our point of view.
“I don’t trust the market,”
Jack, that’s because you know in your heart that you are smarter than the market. Just like that lieutenant in “Good Morning Vietnam” knew he was funny. Most people who don’t trust the market believe they are smarter than the market. (And smarter than just about everyone as a matter of fact. Well someone has to be.)
Me? I want people who believe they are smarter than me to make decisions for me. Then when things don’t work out, they are responsible – not me. And then they have to pay for the things I don’t like. This lets the naturally-deserving intelligentsia make the important decisions (which they like), pay most of the taxes (which I like) and lets go-along, get-along people like me just float by with the current (which I also like). It’s a great system. Please don’t muck it up.
7. tax credit for care for the truly indigent.
I think Eric may have meant a tax credit for doctors and other providers for uncompensated care given to truly indigent people. No?
7. tax credit for care for the truly indigent
Or as Stephen Colbert described it:
“It’s so simple. Most people who can’t afford health insurance also are too poor to owe taxes. But if you give them a deduction from the taxes they don’t owe, they can use the money they’re not getting back from what they haven’t given to buy the health care they can’t afford.”
http://www.nytimes.com/2007/02/15/business/15scene.html?_r=1&adxnnl=1&oref=slogin&adxnnlx=1171560141-Cq+PtdAMLDSpRr6QZQiYHA
4. make medicaid recipients demonstrate they are making an effort (like for unemployment insurance)
An effort? To do what?
About a third of the people in Medicaid qualify because they are aged, blind or disabled. They are developmentally disabled, they have schizophrenia or bipolar disease, they have had an amputation, retinopathy or renal function failure as result of advanced Diabetes. They have Altheimer’s disease and live in nursing homes. Or they are at home but on ventilators or have such compromised immune systems that they need to fed through a tube.
Aged, blind and disabled beneficiaries are the high cost beneficiaries responsible for most of the costs in the Medicaid program. The remaining Medicaid beneficiaries are the TANF (Temporary Aid to Needy Families) mothers having babies and children receiving low cost preventative care, or in the case of foster children, case management from social workers.
They are also undocumented immigrants who we apparently want in our country to pick crops, work in meat-packing plants, and provide labor at construction sites. But when they hurt themselves performing any of these dangerous tasks we become offended when they seek medical attention for their injuries.
So tell me again, how is improving the morals and work ethic of Medicaid beneficiaries going to cut costs?
1. health care choice act
If it were a part of a Medicare-for-all system I’d support the patient’s right to opt out.
2. small business health plans
Do you mean having INSURANCE plans for small businesses? I’d support that if we had a Medicare-for-all system, though if we did it would take a complete fool to opt for a private plan.
3. allow doctors to bill more/less than medicare rates
Under they current system you can and you do. But not with Medicare. What you want is to revert to the old “usual and customary” where doctors billed Medicare whatever they wanted. I see.
4. make medicaid recipients demonstrate they are making an effort (like for unemployment insurance)
I agree (surprised?)
5. prevent asset transfers to make the state pay for long term care
I agree
6. health courts
I agree
7. tax credit for care for the truly indigent
First, the truly indigent pay no taxes so tax breaks are moot. But under a Medicare-for-all they’d receive the same care as every one else.
8. encourage people to keep track of their own health problems and treatments.
No, what we need is a national database that would track not just the patients but also the doctors.
9. allow good doctors to make more and bad doctors to make less– by letting the market decide.
I partially agree (with the first part) but I’d rather see it tied into a best practices database. I don’t trust the market, and I don’t see patients going to the lowest bidder.
Jack:
1. health care choice act
2. small business health plans
3. allow doctors to bill more/less than medicare rates
4. make medicaid recipients demonstrate they are making an effort (like for unemployment insurance)
5. prevent asset transfers to make the state pay for long term care
6. health courts
7. tax credit for care for the truly indigent
8. encourage people to keep track of their own health problems and treatments.
9. allow good doctors to make more and bad doctors to make less– by letting the market decide.
and that’s just the start… but, as you know, I have suggested this all before in longer posts, nor have I ever denied we have serious problems– rather it is because we have serious problems that I spend up to 20hrs each week researching and writing about it.
Barry, I was responding to “The attitude that many people are either a) not intelligent enough or b) too lazy to figure out what’s best for them is horribly arrogant…..” and the comments earlier. Picking the right physician is a challenge no matter what the system.
>>> “Even seniors, with some help in many cases, were able to sort through the large number of drug plan choices available to them and select a plan that best met their needs.”
I would argue that point. My mother-in-law can’t even use a computer let alone understand the 45 plans in Wisconsin.
Eric, you are really jumping through hoops trying to deny that we have serious problems and serious waste and that the CEOs are not going to save the system for you. I’d still like to see YOUR plan.
Dean– what you say is true, to the extent that a larger pool can possibly smooth costs— but here, in healthcare, as you say, 1% of the population account for about 24% of spending, and 10% account for 65%. While older people account for more, on average than younger, most people never join the ranks of the sickest 10%, let alone the sickest 1%.
But, if you do not mind me saying, you offer only false choices (as evidenced in this ‘study’ from Minnesota- http://www.mmaonline.net/Publications/MNMed2007/February/Clinical-Albers.cfm).
Jack, jack– food stamps= vouchers to purchase goods in the private sector (something you are against vehemently in health care)
homeless shelter= temporary shelter that no one would equate with owning a private residence or even renting an apartment (and ‘equal’ healthcare for all seems to be the very basis of your comments)
perhaps not the best analogy to advance your argument
Jack,
What the heck does picking a doctor have to do with whether we have only a Medicare for all system or lots of private insurance options? Or a high or low deductible?
Even when interacting with a physician, there are many medical conditions that have more than one treatment option (prostate cancer to take one example). Each option has different risks, benefits and costs. Two similarly situated people may choose different options for perfectly valid reasons even if the doc recommends the same one to both. People can research their condition on the Internet or join a support group. I think it is reasonable to expect a doc to explain the risks and benefits of treatment options, and I think most people can make a judgment about which is best for them rather than blindly follow whatever the doc recommends. Second opinions are also an option.
On insurance, give me choice of plans and deductibles. I’ll decide what’s best for me. I don’t need to or want to be forced into a one size fits all government plan. Give me healthcare price and quality transparency tools, and I’ll make even better decisions.
Even seniors, with some help in many cases, were able to sort through the large number of drug plan choices available to them and select a plan that best met their needs. As I said before, Medicare Part D has a high satisfaction rate, is saving money for seniors, and is costing taxpayers about 30% less than government budget experts initially estimated. Give people some credit for a modicum of intelligence. They’ve demonstrated that they have it and know how to use it.
Having spent 25 years dealing with patients, let me say that you are very lucky that you are (or believe to be) smart enough to out-guess your physician. Most patients are not, and indeed should take their advice where it is reasonable. But even then there are going to be mistakes.
Do we need better tools? Indeed, like a national database to track best practices and make this available to the public. In the meantime I know some pretty suave physicians that should be electricians. Glad you can pick them out without help.
It’s funny how several people in this comment thread seem to subscribe wholeheartedly to the “Very Smart People in Government” fallacy. To think that politicians are better at making decisions for us, or have a moral grounding for doing so, is silly at best. The attitude that many people are either a) not intelligent enough or b) too lazy to figure out what’s best for them is horribly arrogant, offensive and displays a bizarrely elitist attitude that in any other context, the lefties spewing it would have complete disdain for.
Perhaps I’ll declare voting “different” too, like health care, and I’ll set up a government body to make voting choices for people since they’re too dumb to decide for themselves in a rational way. That way, the Very Smart People can make things better for everyone.
Sound like a good idea? Didn’t think so. But it’s the same one you had, Stella. Think it through. There’s no way to determine who is or isn’t making a “good” decision, and people in government aren’t any better at it or any less corrupt about it than anyone else.
Eric – Could you comment on how the implementation of your proposal would further fragment insurance risk pools and promote adverse selection.
Back in 2002 I served on the Parish council for my Church and one of our tasks was to buy health insurance for our Priest. The cost of the Archdiocese health plan had been rising steeply because the average age of Priests in the plan had also grown steadly older. Our Church had a younger Priest and we discovered we could buy him a less expensive individual plan elsewhere. Opting out was in the best interest of our parish, since we could have saved several hundred dollars a month, but not in the best interest of the archdioces as a whole.
If all of the parishes with younger Priests, like ours opted out to save money, the aging of the remaining Priests in the Archdioces plan would have accelerated so that not after too long the cost of the Archdiocene plan would have become unaffordable for the remaining parishes with older Priests.
Economists who study the distribution of health care costs throughout the population have found the distribution is highly skewed, and that a relatively small percentage of older, sicker people are responsible for a much larger percentage of total aggregate costs. According to the Kaiser Foundation
“the one percent of the population with the highest health spending account for almost 24% of all expenditures; the 5% of the population with the highest health spending account for almost one-half of health expenditures; in contrast, the 50% of the population with the lowest spending account for less than 4% of total expenditures. (according to data from U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey (MEPS), 2003).
If even a relatively small portion of these higher spenders is able to anticipate that they are at higher risk and choose more comprehensive plans instead of less comprehensive plan options, the average claims costs of comprehensive plans would increase and the average claims costs of less comprehensive plans would decrease due to selection.”
See “Illustrating the Potential Impacts of Adverse Selection on Health Insurance Costs in Consumer Choice Models”, November 2006
http://www.kff.org/insurance/snapshot/chcm111006oth2.cfm
This means that not only does adverse selection occur an can have a meaningful impact on total claim costs for the risk pool even where there are no extreme changes in enrollment.
We chose to stay in and absorb the additional costs. In several decades our Priest will be older too, and since he is a good at what he does we probably want to keep him around. If all other parishes with younger priests stay in, rather than opting out it will work to our mutual benefit because we will may still be able to afford insurance for our Priests when they are older.
My question is: why doesn’t the lesson learned by our parish council apply to society as a whole?
What’d you say? Do you not realize that the for-profits are willing to spend $100 million per year in lobbying and campaign contributions to keep the system just as it is, broken and inefficient and moving money from your pockets to theirs? I’m retired and on Medicare. I have nothing to gain but to protect my kids (and yours) from the ripoffs that are occuring. Talk about clueless!
“We know we are on the right track when we raise the ire of the for-profit interests, including yourself.”
That is so 1960’s. You think the test of being correct is to piss someone off? People who attack the for-profit interests demonstrate with their every word that they do not understand people, do not care, and are intent on creating a train wreck for their own self-centered reasons.
Looking back on the past half-century, I’d say you and your fellow-travelers are succeeding. Congratulations. What a wonderful world this clueless generation of yours has left for me and my family.
>>> “If health care is such a ‘right’, why not start with things that are even more important, like food and housing.”
Eric, we do. It’s called food stamps and homeless shelters and low income housing. It’s the “compassionate” side of us.
I’m not impressed with your “debunking the 3% myth,” as though we are really being hoodwinked by single-payer proponents. We know we are on the right track when we raise the ire of the for-profit interests, including yourself.
You deny that physicians over-order because of purchased technology, when either Peter or Barry pointed to a McKenzie study which showed that physicians order 8 times as many studies when the own their own lab. At least here your denials are falling on deaf ears.
Is it the major part of the waste? Probably not. It represents (according to the study) only $8 billion. Big deal.
But I am sure you have a concise list of your suggested reforms and I’d love to see it if you’d be so kind as to post it.
Peter, Peter– just becasue it is not your desired reform, does not make it ‘subvert’ing reform.
If health care is such a ‘right’, why not start with things that are even more important, like food and housing. Are those ‘rights’? Should we have fully nationally controlled food and housing markets?
The right to not do something is just as important as a right to do something in a free society.
Jack– given that others (not just me, to say the least) have debunked the 3% myth of medicare overhead, you have moved on to accusing the current system of being ‘free-market’. You and I know this is not the case. The alternatives you offer are like asking a man whether he wants to die by firing squad or hanging. The options I have proposed and rearticulated are genuine (no matter how much you disagree with them) free market reforms.
Private Health Insurance Is Not the Answer
By Phil Mattera, Corporate Research Project.
See http://www.alternet.org/stories/48371/
Also click “comments” in the lower right to add yours
By Eric,
“Preserving the right of individuals to opt-out and preserving the ability to actually pay for a service you believe valuable– even if the state disagrees, is not about ‘rich’ people’s rights, it is about basic freedoms.”
Now Eric reveals the stealth purpose of this constutional ammendment. No universal system can financially support itself if individuals are permitted to “opt-out”. The purpose of this law is to subvert reform, not encourage it.
If the free-market isn’t status quo, Eric, what am I missing here? I can understand not wanting Medicaid, but you prefer PPO/HMO to Medicare? Well, hold on because it’s going to get a lot tighter.
Jack- old fashioned ‘indemnity’ plans do not exist in Arizona– I have never seen one patient in 6 years… It is very heavily managed here– whether you call it HMO or PPO or Medicare or Medicaid.
I am disappointed you interpret my many posts and comments as ‘the status quo’.
I won’t list the array of initiatives that I have supported on THCB over the months, but ‘status quo’ certainly is not one of them.
And ‘what will I do then’, if my life and career become totally at the mercy of the government? Easy– do something else— the public can find others who are willing to do their bidding… but that is (thankfully for now) irrelevant to the discussion (and also the argument that doctors have used and backtracked on for years).
So, say what you wish about my thoughts and ideas and comments– but please do not charactarize them as promoting ‘the status quo’.
Eric, a Medicare-for-all system would cover Medicaid patients, so whatever second opinion rules apply for Medicare patients today would apply for them when they come aboard.
I would encourage you to read the national bill at http://www.healthcare-now.org/resources/hr676.htm
But every time I hear you you support the status quo, I keep wondering if you realize that “the status quo” is temporary. In five years there will be very few luxurious insurance policies of today. There will be Medicare for those over 65 and managed-care-for-all-others. The corporations are already heading in that direction. They will not take it anymore. What are you and DrThom going to do then?
Jack- have you read any of the single payer proposals? I’ll link to the text of the Arizona proposal, introduced by AZ house Minority leader Phil Lopes.
text here: http://www.azleg.gov/legtext/48leg/1r/bills/hb2677p.pdf
Also- do you realize what medicaid beneficiaries give up in terms of rights to seek and even pay for second and third opinions?
Preserving the right of individuals to opt-out and preserving the ability to actually pay for a service you believe valuable– even if the state disagrees, is not about ‘rich’ people’s rights, it is about basic freedoms.
Frankly, I haven’t seen any good reason (yet) as to why citizens should not be able to enter into private contracts with health care providers for health care services, unless in the process of implementing a single-payer system they expect some tax break for forgoing the Medicare-for-all system.
I think it would be stupid to pass on a Medicare-for-all system because it is nonrestrictive and provides most if not all of the same coverage a private policy provides. As a medicare patient they pay 80% and I pay 20%, but in my case I purchase Gap insurance to cover my 20%. I can buy other services Medicare does not cover, so I have the best of all worlds.
But I’d let the Medicare system compete with the private system and let the best man (sorry, plan) win. Let Eric become a botique doc (there can only be so many docs for rich folks). But if that gets us coverage for 100% of the people, so be it.
Matt,
For me, the issue of whether or not health courts are better than the jury system for resolving medical disputes comes down to a judgment as to which approach is more likely to reach a sound judgment most of the time.
I suspect that, if given a choice, most doctors would opt for health courts assuming that the judges are perceived as having an extensive body of medical expertise as well as a solid legal background. Neutral experts, who do not have a stake in the outcome of the case but are just paid for their time and expenses, would help the judge to sort through conflicting scientific claims. Lawyers would represent each side in arguing the case, and the plaintiff lawyer could, presumably, retain the contingency fee payment structure.
The question then becomes, is the plaintiff more or less likely to get a fair shake under this approach than with a jury trial? If I were to project myself into the position of a potential plaintiff, I don’t think I would have a problem with the health court approach. Why? If I, in consultation with my lawyer, strongly believe that I have a sound case, I think a knowledgeable judge with healthcare expertise will see it my way. The probability of an unusually large verdict (sometimes referred to as jackpot justice) will be much less likely than with a jury trial.
The other benefit of a health court system is that, for the judges, knowledge is cumulative. As you hear dozens or even hundreds of similar cases with similar issues over time, you get a pretty good sense for the issues including the appropriate level of damages for cases where malpractice occurred. Jurors are only likely to hear a malpractice case once and, in any case, are not equipped to absorb the scientific counterclaims and reach a well reasoned conclusion a significant percentage of the time.
Perhaps, like so much else in our healthcare system, this is something that should be tried on a pilot basis in one or two or three states and see how it goes. I think it could work pretty well, but nobody would know for sure until we try it.
Separately, regarding the issue of whether people are capable of making good healthcare and health insurance decisions or not, any such decision I make for myself and my family only affects me and my family. Furthermore, healthcare decisions are made in partnership with our doctor(s), and we rely heavily on their judgment and expertise. Believe me, I’ve had a lot of interaction with the healthcare system as a patient over the last dozen years and had to make numerous decisions. With the help of good medical professionals, it wasn’t that hard. As for insurance, most of us get that through our jobs. If there is more than one option with more or less restrictive networks or high or low deductibles, most people can easily make decisions like those based on their budget and risk tolerance.
Harvey- your comments (up until the last line) are perfect. What about the second sentence? Any unintended consequences there?
Barry, maybe you’re just guilty of bad timing, but I just delivered a coworker to the ER after she tripped on the sidewalk and gashed her head. I gather, in the kind of world you’re describing where you say “in all other areas of life, people are perfectly capable of acting rationally and in their own best interests,” it would be fine to say, “here’s a needle, here’s some thread, you know what the right thing is to do.” Nope. There’s a very good reason doctors go to medical school for long periods of time and are required to take continuing education courses, and insurance brokers, though they get by on slightly less college, also must maintain continuing education. Healthcare is the most complex human endeavor, and insuring it ranks right up there, too. If it were easy, everyone would do it.
You unintentionally put on a comic display of irony in the very next sentence when you used the words ” . . . at a recent investors conference, I heard managed care executives commenting . . . ” Let me ask, at this investors conference, how many Wal-Mart clerks were in the audience? Bricklayers? Auto body mechanics? The problem is that the discussion of what’s right for the American healthcare system only takes place among the elites, who know far less than they think they do about “how the other half lives.” Stay away from the grand pronouncements, and stick to the facts.
“The right of citizens to enter into private contracts with health care providers for health care services shall not be infringed.”
What about contracts to provide narcotics, or to commit Kevorkian-style murder? Did the right-wingers who wrote this realize it would also prevent attempts to outlaw any type of abortion?
“No law shall be enacted requiring any citizen, or any class of citizens, to participate in any state sponsored health care system or plan.”
What about taxes to set up community emergency care systems? What about vaccinations for epidemic diseases?
Looks like the Libertarians have taken over the asylum!
Harvey
Gladwell’s otherwise thought-provoking piece on moral hazard takes an unusual trajectory on the mythology.
Contrary to the thrust of Gladwell’s essay, and despite the ‘logic’ of assuming that a
financial hurdle to care that’s imposed on a ‘covered life’ (an insured patient) is truly
intended to aggrieve that individual, in health insurance circles moral hazard is not
generally treated as emanating directly from the consumer of care. It’s the generator
of care – the care-giver – against whom financial hurdles to care provision are erected.
In a sense, insurers aim to destroy the village (burden the individual) in order to
save it (him/her, and his/her fellow insureds, from springing for too-costly,
possibly-unnecessary care ordered up by eager but spendthrift – or worse – care
providers).
In other words, insurers are less concerned about the treatment choices of the ill than
the choices of the would-be treatment providers. See Wennberg’s work work at Dartmouth (Matthew’s
admiring note is a good place to start), and/or Emory’s Thorpe et al on treated disease, for an
inkling of why they’d have such concerns.
As for the constitutional initiative about which Eric has solicited thoughts, I’m struggling to imagine the citizenry capable of grasping the tangle of issues ensnared in its identification of a special class of contractual rights that merits protection – by constitutional decree – of (apparently) special privacy guarantees.
I can’t understand an EOB – what chance do I have of casting my vote appropriately on an initiative such as this?
Truth in posting notice: my personal opinion is that healthcare privacy issues are not well articulated by any party to any discussion of the subject anywhere; that as a result none of us can effectively gauge the “risks” to which our healthcare privacy is exposed; and that more people should read the kind of writing people like Clay Shirky have done years ago on matters of privacy, and health, and the like.
“How can it be that in all other areas of life, people are perfectly capable of acting rationally and in their own best interests, but, when it comes to healthcare and health insurance, we all have IQ’s of about 23? I totally reject this out of hand. ”
Barry, don’t you embrace that same argument when you claim that juries shouldn’t hear medical malpractice cases?
Anyway, to the larger point, it appears the hospitals may be on board with some of these reform proposals:
http://www.nytimes.com/2007/02/22/business/22insure.html?_r=1&ref=business&oref=slogin
“How can it be that in all other areas of life, people are perfectly capable of acting rationally and in their own best interests, but, when it comes to healthcare and health insurance, we all have IQ’s of about 23?”
Because health care is different. Everybody knows that (well, maybe, you didn’t know it).
“I heard managed care executives commenting on how great a job seniors did in sorting through the initial confusion surrounding Medicare Part D”
Well of COURSE THEY would say that. And of course you take it for evidence. Of what, I have no idea.
“There is no reason why, with help from more robust price and quality transparency tools and objective, unbiased infomediaries (similar to Consumer Reports) people can’t make perfectly good decisions about both healthcare and health insurance.”
At best that is bafflegab, and at worst is just rightwingnut propaganda designed to confuse people even more. But you are certainly good at it.
Oh, and Alex: “Wow, Stella, that is about as dumb a collection of statements as I’ve ever seen in 2 paragraphs.
You win the cheese as dumbest of all in only one sentence. My congratulations to you, sir. (It would have to be a guy, wouldn’t it? . . .)
Ah, Eric. Pity that, we’ll have to change it.
As I interpret the phrasing, the draft language for this initiative is aimed at stopping reform attempts the authors disagree with. I.E. stopping health care ‘reform’ — reform that the authors disagree with.
The quotation marks around the word ‘reform’ are the thing. It’s not a subjective title. I’m not taking a stand on it either way.
I’ll do that later.
Malcolm Gladwell writes:
“The issue about what to do with the health-care system is sometimes presented as a technical argument about the merits of one kind of coverage over another or as an ideological argument about socialized versus private medicine. It is, instead, about a few very simple questions. Do you think that this kind of redistribution of risk is a good idea? Do you think that people whose genes predispose them to depression or cancer, or whose poverty complicates asthma or diabetes, or who get hit by a drunk driver, or who have to keep their mouths closed because their teeth are rotting ought to bear a greater share of the costs of their health care than those of us who are lucky enough to escape such misfortunes? In the rest of the industrialized world, it is assumed that the more equally and widely the burdens of illness are shared, the better off the population as a whole is likely to be.
The reason the United States has forty-five million people without coverage is that its health-care policy is in the hands of people who disagree, and who regard health insurance not as the solution but as the problem.”
http://www.newyorker.com/fact/content/articles/050829fa_fact
If you believe health care is a private commodity rather than a public good, and that only rich people should be to have access to health care while the rest of us just slink off somewhere and suffer or die in silence, than I suppose it’s a fine proposal.
Actually, it is a morally reprehensible and economically disasterous proposal. To find out why read Malcolm Gladwell’s excellent essay entitled “The Moral Hazard Myth”, which appeared in the New Yorker magazine on August 29, 2005. Here is the link.
http://www.newyorker.com/fact/content/articles/050829fa_fact
I would take issue with John adding the title of ‘stopping’ health reform. This IS health reform.
It stops the state from taking complete control over individual choices.
Peter- this is absolutely NOT self serving… as I have said over the months, more freedom in healthcare results in lower incomes for many doctors, the same for some, and more for a few.
Also- this would prevent lobbyists from hijacking the system— the power would be in the hands of the people. (generally, a rather liberal idea…)
If “healthcare reform” is misguided, then what – its pretty good right now? It just needs a little “tweaking”? If reform is a misguided term then in my mind its because “massive overhaul” or “complete redesign” don’t quite have the right ring to them…
Not that that was the point of your post, but you are really raising two issues, not one: 1) what type of “reform” is needed? 2) how compulsory should healthcare coverage be in a system where the government and businesses ultimately end up paying if the individual can’t?
Ah, deep pocket special interest bribes and loggying money is alive and well in at least one state. Not only will this help docs it will help insurers. Way to go Eric, as usual your issues are self serving.
Wow, Stella, that is about as dumb a collection of statements as I’ve ever seen in 2 paragraphs.
the regular people do not have the knowledge to shop for health care and for their own good, should not be allowed to shop for health care because they will make poor decisions. In the same way, the regular people do not have the knowledge to shop for health insurance, and should not be allowed to shop for health insurance because they will make poor decisions.
Yikes, the nanny state on steroids!
How can it be that in all other areas of life, people are perfectly capable of acting rationally and in their own best interests, but, when it comes to healthcare and health insurance, we all have IQ’s of about 23? I totally reject this out of hand. Indeed, at a recent investors conference, I heard managed care executives commenting on how great a job seniors did in sorting through the initial confusion surrounding Medicare Part D and selecting a plan that best suited their needs. Satisfaction rates are high, seniors are saving money, and taxpayers are spending about 30% less than the federal budget experts initially estimated.
There is no reason why, with help from more robust price and quality transparency tools and objective, unbiased infomediaries (similar to Consumer Reports) people can’t make perfectly good decisions about both healthcare and health insurance.
I’m no expert on constitutional law, but isn’t the wording on this a little vague? I think this could be construed to mean a lot of things …
Erick, the regular people do not have the knowledge to shop for health care and for their own good, should not be allowed to shop for health care because they will make poor decisions. In the same way, the regular people do not have the knowledge to shop for health insurance, and should not be allowed to shop for health insurance because they will make poor decisions.
Therefore the proposed amendment is exactly precisely 180 degrees wrong.
Besides, since everyone knows that neither health care nor health insurance obey the laws of economics, removing choice from consumers will have no affect on people’s health. On the other hand, providing a single-payer insurance option and removing the burden of choice from people will avoid the mistaken insurance choices that people make today. This will lead to better access to medical treatment, better outcomes, and in that way the U.S. will finally, finally see some improvement to its life expectancy and infant mortality statistics.
Is this kind of what Havinghaust has suggested is the problem?