OP-ED

Single Payer Health: It’s Only Fair

The United States is the only major nation in the industrialized world that does not guarantee health care as a right to its people. Meanwhile, we spend about twice as much per capita on health care and, in a wide number of instances, our outcomes are not as good as others that spend far less.

It is time that we bring about a fundamental transformation of the American health-care system. It is time for us to end private, for-profit participation in delivering basic coverage. It is time for the United States to provide a Medicare-for-all, single payer health coverage program.

Under our dysfunctional system, 45,000 Americans a year die because they delay seeking care they cannot afford. We spent 17.6% of our GDP on health care in 2009, which is projected to go up to 20% by 2020, yet we still rank 26th among major, developed nations on life expectancy, and 31st on infant mortality. We must demand a better model of health coverage that emphasizes preventive and primary care for every single person without regard for their ability to pay.

It is certainly a step forward that the new health reform law is projected to cover 32 million additional Americans, out of the more than 50 million uninsured today. Yet projections suggest that roughly 23 million will still be without insurance in 2019, while health-care costs will continue to skyrocket.

Twenty-three million Americans still without health insurance after health reform is implemented? This is unacceptable. And that is why, this week, Representative Jim McDermott and I are announcing the re-introduction of the American Health Security Act, recognizing health care as a human right and providing every US citizen and permanent resident with health-care coverage and services through a state-administered, single payer program.

Let’s face it: until we put patients over profits, our system will not work for ordinary Americans.

It is incomprehensible that drug companies still get away with charging Americans twice as much, or more, than citizens of Canada or Europe for the exact same drugs manufactured by the exact same companies. It is an outrage that insurers still often hike premiums 20%, 40% and 60% a year on individual policy holders; and some insurers still spend 40 cents of every premium dollar on administration and profits while lavishing multimillion-dollar payouts on their CEOs.

It boggles the mind that approximately 30% of every health-care dollar spent in the United States goes to administrative costs, rather than to delivering care. We must do better. Taiwan, for example, spends only a little over 6% of GDP on health care, while achieving better health outcomes on some key indicators than we do; yet they spend a relative pittance on administrative costs.

I am very proud that my home state of Vermont is now taking big steps to lead the nation in health care by moving forward on a plan to establish a single payer health-care system that puts the interests of patients over chasing profits. The American Health Security Act would make sure every state does the same — taking profits out of the equation by implementing a single-payer system, but letting each state administer its own program, according to strict standards, in a way best suited to its needs.

The goal of real health-care reform must be high-quality, universal coverage in a cost-effective way. We must ensure, to as great a degree as possible, that the money we put into health coverage goes to the delivery of health care, not to paper-pushing, astronomical profits and lining CEOs’ pockets.

Bernie Sanders is the U.S. Senator (I) from Vermont, and the longest serving independent member of Congress in American history. He is a member of the Senate’s Budget, Veterans, Environment, Energy, and H.E.L.P. (Health, Education, Labor, and Pensions) committees.

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134 replies »

  1. I would like to see a system that makes serious health care a true public good. …Ie there would be no way to charge for it. By serious I mean conditions that could result in death or disability, or could result in bankruptcy. “Could” means in the near term or in the far term .This means roughly that society would take care of folks without billing or charging who had in-patient types of problems, not ambulatory conditions. … With plenty of exceptions. It would be a county or hospital district or US Representative-sized operation to avoid the dangers of big government. It would be financed by local taxes and federal grants–without strings–and would be hospital based. Expert triage would have to occur., the question being “could this patient have something that might kill him or disable him or cause him to go broke? Lupus would be a yes. A hemorrhoid would probably be a no. The folks turned away could manage their minor illnesses anyway they desired. They could use indemnity insurance, cash, health savings accounts, whatever. The hospitals would only maintain medical records. There would be no billing activity or records therefrom whatsoever. All provider people and administrators would be on salary. Patients would be kept as long as their condition warranted. The intellectual
    thrust of the personnel would be continuing medical education, not cost saving, and arriving at the correct diagnosis would be god like. Cost saving would be from the tug and war of global district budgets and county/federal taxpayers.

  2. Many other countries use insurance mandates. Switzerland, Japan,
    Austria, Germany uses premiums or tax directed to health funds, France could be better described as private-public rather than single-paye, as most French carry some additional private health insurance to complement the program.

    All these systems are admired by reformers and none of them properly qualifies as a true sngle payer. .I would ratrherr have us form any of the above systems than radical single-payer. I say this as a former resident of a nation that refused to treat or even diagnose me,or help me find a private pay alternative in their over-praised single payer system.

    Sanders has no proof that 23 million will not be covered. Here in CA they would most t likely be undocumented workers who are generally well treated in our very generous safety net health system.

    Best for us: Obama’s Reform Law ; It is similar to the successful and universal but (thank goodness) not fully sngle-payer systems I mention above.

  3. “Let’s stop wasting time squabbling over what ‘liberal’ or ‘conservative’ policy is better or worse and instead abandon those terms in favor of policy that actually works.”

    Get rid of the failed liberal policies and we will be there.

  4. It is disheartening to read comments from educated and thoughtful individuals who constantly use the term ‘liberal’ as a slur toward programs or policies they do not agree with (and with glee if the program proves to be unsucessful.)
    Only when we are willing to set aside our egos and this ridiculous obsession with being ‘right’ rather than setting policy that makes social AND fiscal sense will we as a country become whole again. As much as we want to resist, removing the profit motive from health care is change that is long-overdue.
    Let’s stop wasting time squabbling over what ‘liberal’ or ‘conservative’ policy is better or worse and instead abandon those terms in favor of policy that actually works.

  5. http://www.city-journal.org/html/16_2_welfare_reform.html

    “How should progressives respond to what we know so far about welfare reform and children?” he asked. “By progressives, I mean leftist/liberal and feminist scholars and observers, who, based on past experience, probably constitute 80 to 90 percent of this audience.” His answer suggests some serious soul-searching. “[T]here may be something to the idea that long-term dependency on public assistance is detrimental,” he conceded, though he had always “rejected this idea out of hand prior to 1996.”

    That sums up the problem with liberals.

    They reject logical answers out of hand becuase it doesn’t fit their dogma. Despite Wendells claims otherwise facts mean nothing to them, neither does destroying generations of lives.

  6. Whats amazing is even after these over the top claims not one of these people paid any price for being wrong? TANF was unquestionable success, these people could not have been more wrong yet they suffered no accountability, Liberals never do get held accountable.

    “So it seems a good time to remember the drama—make that melodrama—that the bill unleashed in 1996. Cries from Democrats of “anti-family,” “anti-child,” “mean-spirited,” echoed through the Capitol, as did warnings of impending Third World–style poverty: “children begging for money, children begging for food, eight- and nine-year-old prostitutes,” as New Jersey senator Frank Lautenberg put it. “They are coming for the children,” Congressman John Lewis of Georgia wailed—“coming for the poor, coming for the sick, the elderly and disabled.” Congressman William Clay of Missouri demanded, “What’s next? Castration?” Senator Ted Kennedy called it “legislative child abuse,” Senator Chris Dodd, “unconscionable,” Senator Daniel Patrick Moynihan—in what may well be the lowest point of an otherwise miraculous career—“something approaching an Apocalypse.”

    Other Washington bigwigs took up the cry. Marion Wright Edelman of the Children’s Defense Fund called the bill “national child abandonment” and likened it to the burning of Vietnamese villages. Immediately after President Clinton signed the bill, some of his top appointees quit in protest, including Edelman’s husband, Peter, who let loose with an article in The Atlantic Monthly titled, “The Worst Thing Bill Clinton Has Done.” No less appalled, the Chicago Tribune seconded Congresswoman Carol Moseley Braun’s branding the bill an “abomination.” And while in 2004 the New York Times lauded the legislation as “one of the acclaimed successes of the past decade,” the editors seem to have forgotten that they were irately against it before they were for it, pronouncing it “draconian” and a “sad day for poor children.”

  7. To top it off you can find thousands of stories in the media how welfare reform was going to lead to dead bodies in the street then when it turned out not to be true a fraction of the stories with the true outcome.

    The media has no problem carrying water for liberal dogma and doing everything they can to burry the truth. Some point the america public will wake up to what they are doing and tear them both down once and for all. The wizard can’t hide behind the curtain forever.

  8. “Failure has never detered progressivism”

    Nate –

    This has always bugged me as well. I’ve never heard of a government program that failed when liberals / progressives said something like this: We believed in this program, we fought for it; we got it passed into law and implemented. We thought it would work but it didn’t. Let’s kill it and try something else. Instead, they are likely to say if we just put some more money into it, maybe then it will work. That’s their basic approach to primary and secondary education in the inner cities where failure has long been pervasive.

    Conversely, when President Clinton signed welfare reform in 1995 after vetoing it twice, liberals claimed it would be a disaster and people would starve. Some senior officials even resigned in protest. Instead, states used their new block grants to innovate and design programs appropriate for their population. The welfare rolls are two-thirds lower now than they were then, spending in real terms is down 31% and people didn’t starve. Several states want to now try the same block grant approach with Medicaid but they need CMS waivers. Those won’t be easy to get from this Administration.

  9. If the ERISA exemption is for residents of VT would someone not living in VT but covered by VT still have ERISA protection? What about residents that live in VT but work over the border outside VT? We have clients that avoid hiring people that live in NY because of their terrible legislation, VT might find its self in the same boat.

    Not that it all can’t be accomplished it will just be a blast watching politicians that don’t know anything about insurance try to do it.

    If they try to fund it all with payroll taxes that would create a huge incentive for service or professional companies with high labor cost and younger work forces to look at moving somewhere else. It removes all incentive for employers to manage healthcare cost.

    If you were Dartmouth why settle for Medicare rates? They would have the plan over the barrell, the plan either starts already restricting access to providers people are use to seeing or they reimburse more.

    Like you said, better to experiment with 650,000 lives then 300 million. The problem I see is when it fails like all other Liberal reform has they wiull blame it on the small size. Like the already claim with Medicare, if it covered everyone magically it would work. Failure has never detered progressivism

  10. Nate –

    People who work in VT but live in a neighboring state will likely be covered under VT’s insurance if it’s financed by a payroll tax which is probably the most likely approach. By the way, if VT chooses the payroll tax option, it will likely take a tax rate of at least 15% of wages or about the same as current FICA taxes. This is Germany’s rate though it only applies to wages up to €43,000 or about $62K at current exchange rates. Depending on the reimbursement rates, I wonder if providers in other states, like Dartmouth-Hitchcock Medical Center in NH, will accept the insurance. If VT pays Medicare rates, it probably won’t be a problem, but then that will significantly raise the cost of covering people currently on Medicaid as they transition to the single payer insurance. Ah, life is complicated, isn’t it?

  11. “Opposition is largely based on false assumptions in any case.”

    Wow does this sound like your typical liberal. Any opposition to their idelogy means your ilinformed, they are never wrong the public just doesn’t know what is right.

  12. This will have some interesting ramifications. Going to make VT very unattractive for some employers. VT will need an ERISA exemption like HI has. This will allow them to have single payor for their residents. What about someone that lives in another state on the border and works for someone in VT? If a company has only 1-2 employees that live out of state how do they get insurance now? Or will the VT plan be open to residents of other states that work for VT companies? What happens when they have some multi million dollar claims from non VT residents?

  13. I disagree regarding the premise that employees at companies such as IBM oppose single-payer. It may be true. It may not be. Opposition is largely based on false assumptions in any case.

    Single-payer is a superior system to the current system in the USA for all people. Nothing is lost, much is gained to all.

    Otherwise I agree on the other points. I also agree that Vermont, given its size and the willingness of the population to experiment with alternative means of achieving social benefits, is a good place to institute some version of single payer, although as I note elsewhere, a single payer system works within the largest national entity by far the best rather than within a given state.

  14. Wendell –

    I mentioned IBM as an example of a large FOR PROFIT employer. Employees of such companies are probably more likely than others to oppose a single payer healthcare system. By contrast, hospital systems, colleges and universities, state and local government entities, and the like may be more inclined to favor the approach. The small business sector and individuals who cannot afford to buy insurance under the current system are also more likely to support single payer if the requisite taxes don’t put them out of business first.

    With Vermont’s economy based mainly on agriculture, tourism, state and local government and the education and medical sectors, it’s probably fertile territory to give single payer a try as compared to other states with a more robust for profit sector. So, good luck with the effort. I look forward to seeing the financing mechanism, how the state determines provider reimbursement rates, the extent to which medically needy people move into the state and how well VT controls both fraud and legitimate utilization of healthcare services without rationing.

  15. There needs to be a way to report people like Wendell and have their right to vote taken away. If your this detatched from reality and facts you shouldn’t be allowed to elect leaders. This is almost as bad as the women that said voting for Obama he will pay her mortgage and gas bill. Why are these people allowed to participate in democracy?

    Good ole Peggy Joseph

  16. ” You clearly have shown through this weblog no ability to do the most basic research on any relevant topic. The lack of facts and research”

    so all the facts about how many employers self fund and how many people have insurance through these plans and the factual fraud rate of Medicare and how that relates to the cost of private insurance are not facts because?

    I have posted numerous facts, all you have posted is opinion supported by nothing.

    Let me make it really simple for you. How will your single payor proposal resolve the 10%+ fraud rate inherant in plans ran by the US government?

  17. Wendell,

    1. You can’t find a successful single payer system anywhere
    2. For single payer to survive, rationing access is a requirement
    3. Vermont lack the funds to keep a single payer system going without a strict diet of healthcare rationing and tax increases
    4. If Vermont wants to do what has succeeded nowhere else, it’s fine with me. I don’t live there anymore. You can just continue with the great lie.
    5. Regarding commentators on this blog, please understand that you are the one who started issuing the insults. While I don’t know anyone writing here, it is clear from reading what has been written by various writers that you are least informed. You are hardened to your ideaology; reality is not your concern.
    6. Your writings on your web do not align with what you say on this blog. You are clearly partisan.
    7. Get a medical consult. Do yourself a favor.

  18. “To be anywhere near effective, a single payer system must be universal for the largest relative national entity, i.e. the entire USA.”

    So NHS is no where effective? Can you name any effective single payor system in the world?

  19. As the saying goes, Mr. Valliere, I have forgotten more about the USA healthcare system than you will even learn. I have zero desire to communicate with you privately.

    If you need a fellow traveler in your knowledgeless commentary, please ask Nate or Mr. Turpin for their e-mail addresses.

  20. ” which is why it went nowhere during the healthcare reform debate.”

    Its why it has gone no where the past 100+ years democrats have been proposing it. I think 1904 was the first time they tried.

  21. Nate: Please keep your idiotic comments to yourself. And stop insulting me. You clearly have shown through this weblog no ability to do the most basic research on any relevant topic. The lack of facts and research is matched by the profusion of commentary that is both insulting and nonsensical.

    I have extensive done research. None of what I have learned reflects any political viewpoint whatsoever. Only political extreme rightists such as yourself or Mr. Turpin constantly make factless assertions, then claim that anyone who points out the lack of facts must be some sort of “leftist”, whatever that term is supposed to mean.

  22. Whether the 25% figure you cite represents any reality or not, such as figure is meaningless in regard to anything.

    The average USA resident or citizen has so fully been propagandized against the idea of single payer that any reference to aggregate public opinion only reflects the pervasive propaganda. It reflects next to zero understanding of the choices that individuals might make intelligently of how the USA healthcare system should be structured.

    I do not know how large an employer IBM currently is, but it is not even listed among the top 50 employers in the State, so why mention IBM? The hospital system in the Burlington area is the largest employer with about 5,000 employees.

    Single payer, if implemented well and not undermined by the influence of private insurers or their representatives in the USA Congress, will work in whatever form it is instituted in Vermont. No question about that. There are limitations concerning the efficacy of any state-only system. To be anywhere near effective, a single payer system must be universal for the largest relative national entity, i.e. the entire USA.

  23. ” A single payer system would accomplish the same at a far lower cost in a aggregate.”

    Then why is Medicare, a single payor system, the most expensive and inefficent in the country?

    Medicare loses more per member in fraud then the entire administrative cost of private insurance per member.

    “The fact that some companies, particularly large companies, self-fund”

    Some meaning the majority of people with private insurance are in fact covered by a self funded plan that does not have the claim dening driven by competition you claim.

    How can you claim insurance company competition is the root of all evil and means private insurance will never work when the majority of private insurance doesn’t have an insurance company then say its meaningless? You got caught making a stupid statement and are now trying to spin it. Your like Maggie Maher, you spend a couple hours reading propoganda on the internet then claim your an expert. Actually work in it every day for 20 years then tell me you know something.

    ” the Canadian system of insurance is an excellent starting point for revamping the USA system.”

    The same Canadian system that is being reformed and made more like the US? Oh so your one of those time traveling liberals that want to implement some other health system of 10 years ago and pretend their current austerity measures, budget shortfalls, and crisis won’t happen becuase you have your magic liberal wand that makes everything turn out just like the title of your bills. How did your Medicare Budget from 1965 turn out clown? Wendell your nothing but a ranting liberal hoping if you repeat your dogma enough someone might believe you.

    “Extreme rightists politically seem to forget that they too can do some basic research and learn some facts rather than depending upon extreme rightist ideology as a basis for thinking, abut alas no expectation that that will ever happen.”

    So non partisan their buddy

  24. You have not presented one verifiable fact other than Vermont continuing to repeat the same mistake every six years. Worse, you are out of touch with your own reality, and fail to grasp the fact that the information on website is leftist dogma. You appear to choose to have relaity hidden from you so you can cling to your stronly held beliefs. My offer to get you mental health assistance still holds. Just let me know how to reply to you privately.

  25. Wendell Murray –

    You can advocate for single payer health insurance all you want. The fact is, though, that there is not more than 20%-25% support for single payer in the U.S. which is why it went nowhere during the healthcare reform debate. We already have Medicare which many single payer advocates want to extend to the entire population, yet it hasn’t been able to control costs either despite supposedly low administrative costs and dictated prices. It also has significant fraud which some estimate at as much as $60 billion per year or more than 10% of total program costs.

    I actually think Vermont is probably the perfect place to give the single payer approach a try. The population is only around 625,000 and, aside from IBM, it doesn’t have many large, for profit private sector employers. Vermont’s legislature and governor think they can make it work. Go for it. Be the laboratory. Let’s get some real world experience with insuring the under 65 population and learn from it. In the meantime, a little civility and respect toward others who don’t share your viewpoint would improve the tone of the discussion.

  26. Mr. Valliere might make an attempt to learn the most basic facts about the USA healthcare system, about Vermont, about single payer, etc. rather than make the usual offensive comment to me personally.

    He has a brain. He should attempt to use it once in a while. Extreme rightists politically seem to forget that they too can do some basic research and learn some facts rather than depending upon extreme rightist ideology as a basis for thinking, abut alas no expectation that that will ever happen.

  27. Thank you for your interesting and uninformed comments. My I recommend one of my psychiatrist colleagues in Vermont to assist you with some reality therapy?

  28. It would be helpful if Mr. Valliere made a modest attempt to gather some of the most basic information regarding the USA’s and other countries’ healthcare systems. Further Mr. Valliere knows nothing about Vermont nor about Vermonters. Vermont voters as a whole would normally be considered quite conservative in the traditional sense of the world. They are not extreme rightwingers ideologically, as I assume Mr. Valliere and his cohort of fellow idiots are.

    Bernard Sanders has repeatedly been elected to state-wide office in Vermont because he pays attention to the true needs of Vermonters of any political opinion. He knows whereof he speaks when talks about the interests of Vermonters. Mr. Valliere has no clue given that he presumably is utterly blinded by extreme rightist ideology.

    Regarding items that I have made available, Mr. Valliere might read among many the excellent research by the McKinsey Institute which is completely non-partisan.

  29. Wendell,

    I don’t understand how you can claim that you’re not partisan. I clicked on your name and read some of the stuff on your site. It reads like a page from the Democrat party playbook. And really, private insurers don’t need government subsidies and sadly, Medicare and Medicaid are contributing significantly to national and state insolvency. Let Vermont go single payer and go broke. They can lead the way. Oh, and watch state residents leave the Green Mountains. Ethan Allen would be disgusted.

  30. Nate: I am neither partisan nor a hack. I know more about the USA healthcare system than you do. I am also sick of the nonsense that you keep spewing.

    The fact that some companies, particularly large companies, self-fund and use outside companies to handle claims and similar is meaningless. A single payer system would accomplish the same at a far lower cost in a aggregate.

    To repeat the obvious and oft-repeated in most venues, the Canadian system of insurance is an excellent starting point for revamping the USA system.

    The per capita cost of healthcare – all considered – is half that in the USA, outcomes are better, administrative hassle and costs are significantly lower, coverage is universal.

    No reason why any defects in the Canadian system need to be carried over into a revamp USA system. Any errors made by Canada would be obviated if politicians made the slightest attempt to use their brains to objectively evaluate alternatives rather than make proposals based on complete nonsense funded by private interests.

    You can assert continually all the irrelevant nonsense you want, but that and similar facts are unassailable and are the most relevant in regard to reform of the USA system.

  31. “private health insurers ultimately can only survive through government subsidy and through the exclusion of the infirm or potentially inform from coverage.”

    This is not true at all. Private insurance is more capable of survival without government then government is without private insurance.

    Wendell appears to be ignorant of his facts and history no matter how many times he claims otherwise.

    Wendell why does PPACA require private insurance to cover dependents till age 26 and why do numerous states require private insurance to cover dependent to age 28 or 30? Apparently you don’t know what you write about.

    Medicaid is killing state and federal budgets, to push cost off to private insurance they passed these laws so sick young adults would be eligible for their parents plans and thus get off public assistance.

    Medicare Secondary payor was passed to push seniors off Medicare and back onto private insurance.

    Private insurance is almost always primary over Medicare, Medicaid, and VA why is that Wendell if Government doesn’t need them?

    ” the exclusion of the infirm or potentially inform from coverage. ”

    You mean like how Medicare only covers so many hospital days? How Medicaid usually doesn’t cover dental and vision? Government plans in american ration care far more then private insurance and are still unsustainable unlike private insurance.

    ” That is the history of all private insurance because that is how the overall market forces individual companies to “compete”.”

    LOL wow are you trying to come off as stupid? What sort of idiot doesn’t know most employer private insurance, more then 50% of all private insurance is not sponsored by insurance companies but self funded plans, thus there is no competing and thus more proof you have no idea what your talking about you partisan hack.

  32. “I normally avoid the dog pile but you are too big a target”

    This is apparently all the Mr. Turpin is able to muster in support of his nonsense. Does this mean that I personally am too big a target of dogshit?

    I am afraid to write that no one with the slightest grasp of facts or with a non-ideology-based perspective will agree with me not Mr. Turpin.

    Unfortunately I happen to know what I write about. I have no ax to grind one way or another regarding any aspect of the USA healthcare system. I am neutral in regard to any actual or potential feature of any healthcare system. I am indifferent to which politician or political group advocates which policy to any aspect of the healthcare system. I advocate what the facts indicate, nothing more or less. I have written many times before that a single payer financing scheme is in fact consistent with core Republican policy positions. However xtreme rightist political ideology holds complete sway in any Republican proposal, practicality and representation of traditional, mainstream Republican thinking play no role whatsoever.

    The essay by Senator Sanders is about the efficacy of single-payer/single-insurer financing of medical expenses. Senator Sanders’ arguments are impeachable and accurate. No amount of justification from any perspective regarding the USA system of financing has any factual basis to warrant its recommendation as an alternatively efficacious means of financing.

    Private healthcare insurance is and always has been a poor system due its very nature: private health insurers ultimately can only survive through government subsidy and through the exclusion of the infirm or potentially inform from coverage. That is the inevitable result of private insurance: exclusion of the infirm and avoidance of even paying legitimate claims. That is the history of all private insurance because that is how the overall market forces individual companies to “compete”.

  33. we have this discussion with employers all the time, the problem is a defined contribution plan isn’t as valuable of a benefit as insurance. Employers offer insurance by choice, because of that they are very cosanent of value. This is usually to a fault, they worry more about the 2% of employees that have large claims and thus ignore the 98% of the group that has minor claims. This is how the dreaded death spirals start. If an employer is seeing such high cost that they look at DC then they would usually be leaving a handful of employees unable to get insurance. Not to say its not done, cost have got to the point that some employers just don’t have a choice any more but it is usually a benefit of last resort.

    Its very realistic becuase it would kill the exchanges. Very quickly people are going to figure out they are further ahead paying the penalty then waiting till they are sick to buy a policy from the guarantee issue exchange. Pocket the cash when healthy and stick it to the system when your not.

    Very quickly government is going to be confronted with the decision to scrap guarantee issue or go all in with mandatory insurance no exceptions, system is not sustainable in the middle.

  34. I don’t know whether exchanges are the right thing and am not an advocate for or against.

    And I agree that employers haven’t tried to exit before, but there are a couple of reasons for that … competing for quality employees has required they offer health insurance (in fact some like Microsoft and Starbucks have used their HC benefits as a differentiator when recruiting).

    But if I am an employer and I have been able to hold overall wage increases to 1-3% per year and my health insurance costs have been increasing at 7%+ per year, I would find it interesting to be able to deliver a defined contribution $ amount that I increase at 1-3% per year and let the employee take on the increased risk associated higher medical costs. The employee doesn’t feel the issue for a year or two and by then I (the employer) have already transferred the risk.

    All I am saying is if they head that direction, there may be implications that we haven’t thought of and reliance on the exchanges could grow.

    Time will tell if it is a realistic concern.

  35. Wonder why this survey is so far off all the others?

    I did notice the 9 million people underreported in Government plans.

    I see they also included 10 million illegal imigrants, should they be included in discussions on uninsured Americans? If we include all of South America then our uninsured population is closer to 200 million.

    “The $4-5K per year is from the Kaiser Foundation and it is the average cost of employer insurance — which is what COBRA is”

    Why would a healty person who can buy a $1500 policy take COBRA? COBRA was designed for people that couldn’t buy cheaper individual insurance. The discussion was about healthy people, roughly 70-80% of the population.

    “albeit with a $3500 deductible … which means that he’s paying $5K per year out of his own pocket …”

    Again you were talking about healthy people who don’t meet their deductible. In fact 80%+ of all insured people don’t meet their deductible, I don’t see how the $5K should even be discussed.

    “family of four living on a HH income of $75,000 paying $4500 a year for health insurance and then a $17,000 deductible”

    Why would they have a $17,000 deductible instead of a $3500 deductible each? Are you assuming every family member is going to hit their deductible every year? Statistically that just doesn’t happen. Your worry about the exception, the very very rare exception.

    “And with the average US income at ~$55,000 per year,”

    Average which includes those 10s of millions of people on Medicaid, what is the average income of people who are not given government insurance at little or no cost? And your also not taking into account that insurance is most expensive in the metro areas like MA, NJU, NY etc where the average income is also much higher.

  36. “, is that at some point they will figure a way to exit offering insurance.”

    They have had 50 years to exit insurance and have not. Inspite of never ending government efforts to force them out of it they have continued to offer it. Contrary to finding a way to exit they keep finding ways to continue offering it.

    Examples of Anti Employer legisltion and regualtion would be COBRA, HIPAA, MSP. Its not even what the bills tried to accomplish that is a problem its the punative way the bills were written that destroy businesses for no benefit.

    I don’t see exchages being successful or long term, they build on everything that is wrong instead of the things that are actually working

  37. Wendell, have you lived abroad? Have you accessed a different healthcare delivery system ? Have you worked in any capacity in the healthcare system – payer, provider, medical devise manufacturer, male nurse, perhaps a ward of the criminal justice system for the self aggrandizing, criminally insane?

    I normally avoid the dog pile but you are too big a target. Checked your BMI lately?

    No need to reply. Best go back on the Nickolodeon chat room with the kids.

  38. Not much here to disagree with … my principal concern with the employer market, however, is that at some point they will figure a way to exit offering insurance. They may still be willing to pay for it … but it will be a defined contribution plan where the user goes out on to the free market to buy with the $ their company gives them. The exchanges will be an enabler for this … the unknown is what the consequences will be from it.

  39. Can you provide a link to this?
    http://www.census.gov/hhes/www/cpstables/032010/health/h01_001.htm
    Second column … not covered at any time during the year.

    Back to facts, the premium for a healthy 18-34 year old is $1800 a year not 4-5K, again I sell this all day so I know that for a fact,

    The $4-5K per year is from the Kaiser Foundation and it is the average cost of employer insurance — which is what COBRA is … the continuation of employer insurance … age has nothing to do with it when you purchase COBRA. You are right with respect to individual insurance, if there is no pre-existing condition, according to eHealth a male aged 33 in my state could purchase a policy for $1,512 per year … albeit with a $3500 deductible … which means that he’s paying $5K per year out of his own pocket …

    I wouldn’t consider a family of four living on a HH income of $75,000 paying $4500 a year for health insurance and then a $17,000 deductible on top of that as being high income … The premium alone is 6% of their gross income … if they really needed to use that policy in a given year, they would be forking out 29% of their income before the real policy kicked in — and that’s a family with a good health insurance policy. And with the average US income at ~$55,000 per year, that challenge becomes even greater. Household income between $50-$75K per year is NOT high income unless you live outside of the major population centers.

    Finally, with a close to 10% unemployment rate … choosing employers based on your individual health risks (e.g healthier people choosing to work for larger employers) is becoming more and more difficult. Many people are working multiple PT jobs to make ends meet and don’t have the option of employer provided insurance.

  40. “According to the US Census bureau, in 2009 50.1 million citizens did not have health insurance “at any time during the year”. ”

    Can you provide a link to this? I have never seen a number any where close to that. Further never once have I heard the census bureau claim they asked who was uninsured all year. Further their have been numerous studies to measure the number of people that were uninsured all year and that number is always substantially lower then the USCB number. For example;

    “For instance, while last year’s Census report found 46.3 million uninsured in 2008, a separate study by the Centers for Disease Control found that 31.1 million Americans were uninsured for one year or longer in 2008, and a survey of health spending conducted by the Department of Health and Human Services found 40.7 million Americans lacked coverage for all of 2008.”

    “These aren’t abused numbers Nate, they are real and they are reported by the US Census bureau.”

    I can’t find any study anywhere that supports 50 million went a full year without insurance.

    http://www.american.com/archive/2008/july-august-magazine-contents/what-do-we-know-about-the-uninsured

    “The widely cited CPS statistic is considered closer to an estimate of those who were uninsured at the point in time surveyed, rather than of the total number of people uninsured for the entire year. The Survey of Income and Program Participation (SIPP), also handled by the Census Bureau, suggests that roughly half of those counted as “uninsured” remain without health insurance for the entire year.”

    “however, they cannot afford the cost of COBRA.”

    By who’s measure? Does someone with three cars, and a 3000 SqFt house and debt to income of 80% qualify as not being able to afford COBRA? COBRA is not a priority so people choose not to afford it. THey have the ability not the desire.

    Further as someone that actually administers COBRA and benefit plan eligibility I know for a fact a large chunk of uninsured times is during job change. Someone leaves a job to take another job so their is no break in income. Instead of paying for COBRA during the waiting period for their new job they go bare for 60-90 days. These people are working and clearly able to afford it, they choose not to.

    ” they are healthy and gambling that they will remain that way instead of paying $4-$5K per year in health premiums”

    Back to facts, the premium for a healthy 18-34 year old is $1800 a year not 4-5K, again I sell this all day so I know that for a fact, please don’t jump on my case John Ballard.

    “For the vast majority of them the choice is one of economic necessity, not personal choice.”

    You can’t produce anything to support this.

    Some more interesting data on your supposed 50 million that can’t afford insurance;

    “The so-called “Medicaid undercount” is derived from findings that Medicaid coverage levels based on survey data are consistently lower than the count of Medicaid enrollees obtained from the program’s administrative records. On the high side, a recent study concluded that the CPS overestimates the uninsured population by as much as 9 million people for this reason alone!”

    “Surveys suggest that one of the more significant sources for recent annual increases in the number of uninsured Americans involves persons in relatively higher income households. According to the CPS, more than 17.6 million uninsured live in households earning more than $50,000 a year, and household income is above $75,000 for more than 9 million uninsured.”

    “But a more narrow and consistent measure of the higher income uninsured is closer to 2 million, involving people with regular incomes over $50,000 who lack insurance for spells of more than a year.”

    “Adults with weak or uncertain preferences for health insurance are less likely than others to obtain job offers with insurance, to enroll in offered coverage, and to be insured. On the other hand, individuals with higher health risks are more likely to seek and obtain health insurance coverage, particularly in the large employer group market. Higher premiums for higher risks are not a significant contributor to the large uninsured population.”

    “Adding a “residual” question to the Census survey in 2000-to confirm that those without employer, individual, or government coverage were in fact uninsured-reduced the number of uninsured Americans by 8 percent. One survey conducted for the Department of Health and Human Services in 2005 adjusted for the number of individuals which the Centers for Medicare and Medicaid Services (CMS) reported were enrolled in Medicaid, but who did not report insurance coverage for the Census survey. As discussed above, such adjustments for the Medicaid undercount reduced the number of uninsured by about 9 million-or one-fifth of the total uninsured-and the number of uninsured children by half. For these reasons, the Census Bureau report itself admits that “health insurance coverage is underreported [in the Census data] for a variety of reasons.”

    Let me highlight this for you Lara,

    “For these reasons, the Census Bureau report itself admits that “health insurance coverage is underreported [in the Census data] for a variety of reasons.”

  41. Nate, we don’t have a system for 295 million people. We have a variety of systems — Medicare, Medicaid, Tricare, employer funded insurance, individual insurance, employer paid health care expenses …

    Now … back to using facts.

    “Without reading your reference the numebr cited usually reflects those uninsured at some point during the year. At any one time far fewer then 50 million are uninsured.”

    According to the US Census bureau, in 2009 50.1 million citizens did not have health insurance “at any time during the year”. Yes it’s a bit number, yes it’s a scary umber and it is not misleading … these people did not have health insurance from Jan 1 2009 to Dec 31 2009. Using that basis of fact, it stands to reason that transitional uninsured would bring the total number of uninsured to a greater number than 50 million at “some point during the year”. These aren’t abused numbers Nate, they are real and they are reported by the US Census bureau.

    I would agree with you that some people have access to COBRA and choose not to take it … some of them because they don’t “need it”. However, as I am sure you would agree, the true value of health insurance for the healthy is the pooling of risks and coverage if they become unhealthy (we would both agree that insurance plays a different role for people with chronic or major health conditions). While many people recognize the need for that (e.g. making sure they are covered for a major car accident for example), however, they cannot afford the cost of COBRA. Which currently sits at ~10% of the average wage earners income in the US, and if they are on COBRA, their HH income is likely even less during that timeframe.

    I can’t speak to the validity of the 30-40% of the 50 million who may be eligible for Medicaid and choose not to take it. I can say that close to 50% of those who are uninsured are aged 18 – 34 which leads me to believe that they are more likely uninsured because they are choosing to “self insure” e.g. they are healthy and gambling that they will remain that way instead of paying $4-$5K per year in health premiums when they are only dealing with an occasional low cost illness and/or prescription.

    The challenge with that is if only the sick buy insurance … it is no longer insurance … it is prepaid medical. And the folks that need the “insurance”, the healthy don’t have it when they need it.

    We will have to agree to disagree on whether the 295 million people are covered in a system that works … but we cannot dismiss the 50 million uninsured as if it is their choice. For the vast majority of them the choice is one of economic necessity, not personal choice.

  42. This is just more fun then work.

    ” And quick the juvenile attacks on me”

    Like this one;

    ” reader should ignore the usual nonsense on this topic from Nate and from Mr. Turpin. No brains, no relevant knowledge, guided by a stupidity and ignorance-based ideology,”

    Which was odd, sorta out of no where wasn’t it? You hadn’t been part of the discussion at all for the past 10 days, then you pop up and say I have no brains. Fine no water off my back, been accussed of worse. But then you want me to quit the juvenile attacks on you? What attacks no one was talking to you or about you. I think they call that projecting, very common illness amoungst liberals.

    Which facts is it you know? Why don’t you share them with the rest of us so we can all know “The Facts”

  43. Nate: All you apparently do for your work is write nonsense here. Ever consider actually spending some time learning some facts about something? Unbelievable nonsense that you appear to spew without the least concern for any relevant fact. And quick the juvenile attacks on me and others who happen to have some brains and know the facts.

  44. keep telling yourself that as you hide in the dark corner rocking back and forth intellectually scared to death.

  45. Nate: You have no intellectual capacity whatsoever nor any relevant knowledge. You have no hope of success in discussing any relevant topic with me, so please drop the pretense.

  46. Not only that but any reader should ignore the usual nonsense on this topic from Nate and from Mr. Turpin. No brains, no relevant knowledge, guided by a stupidity and ignorance-based ideology, I am sorry to write.

  47. Senator Sanders has been correct on this issue since (and before) he entered politics many years ago. He is almost the sole member of the Senate who is willing to address the facts on any issue, including notably on healthcare policy.

  48. “Your condescending tone in your constant trolling of this blog is starting to irritate me.”

    Trolling really? Correcting your bias uninfomred opinion and factually stating how things are is trolling? Then I am a troll and proudly wear the title.

    “how would I get insurance if I was no longer able to work because of disability?”

    Our Medicare and Medicaid programs are designed specifically for that sitution. If you don’t have income then your qualify for Medicaid, if you are diabled then you can qualify for Medicare.

    “It happened to an American friend of mine.”

    Seeing as how you provide no facts or information to support this not much can be said about it. Pretty weak way to make an argument.

    Why would you not qualify for Medicare or Medicaid, what if your provencial plan decided not to cover your illness, that is just as valid of an argument.

    “What if I couldn’t afford the deductible or co-pay?”

    What if you couldn’t “afford” to pay your taxes in Canada. The difference between the two systems in in Canada the government takes the money from you then delivers some volume of care to the public. In the US they let you keep more of your money and your responsible for the first small part of your expenses. Saying you can’t afford your insurance or out of pocket then is really no different then saying you can’t afford to pay your taxes. If we took the money from you before you cashed your paycheck suddenly you could “afford” to pay them, majority of the time the problem is people choose not to priortise those expenses not that they can’t be afforded.

    ” I may not be able to afford or qualify for individual insurance.”

    Why, did you wait till you were sick to try and buy insurance? If you play by the rules it is almost impossible to not have access to insurance.

    “That should tell you there are hospitals that don’t.”

    Can you walk into any hospital or doctor anywhere in Canada and get free care. Of course not. A lot of the time you can’t get in at all until you come up in line and you can’t just go anyplace you like for treatment. Why do you then hold up this false expectation of being able to walk into St. Jude? Not every hospital provides free care and some limit the free care they provide. That doesn’t mean for those requiring free care there are not other options.

    Further I much rather have a hospital tell me they won’t treat me until I find a way to pay then tell me they won’t treat me no matter what even if I could pay.

    I’m sick of uninformed Canadian liberals calling our system disgusting and passing judgement on us. If you don’t like being called out for your ignorance don’t run your mouth on subjects your ignorant about. At least don’t do it in the insulting manner in which you did.

  49. We have to begin to really sit down and see whey the US is falling behind so many other countries in the cost of healthcare per capita. It is out of control and the cost of healthcare continues to increase when it should decrease with all the new technology available.

  50. My main concern would be: how would I get insurance if I was no longer able to work because of disability? When/if that happened, I may not even qualify for medicare or medicaid. It happened to an American friend of mine.

    And what if I didn’t have group coverage at work? What if I couldn’t afford the deductible or co-pay? I may not be able to afford or qualify for individual insurance.

    As for children, St. Jude Hospital in the US says they accepts patients who cannot pay for care. That should tell you there are hospitals that don’t.

    Your condescending tone in your constant trolling of this blog is starting to irritate me.

  51. ” I lauded the fact that I don’t have to worry about being denied health insurance/coverage because of my pre-existing conditions. If I was in the US, I would.”

    Ashley it still sounds like you have no idea how the US system works. If your working why would you need to worry about pre-existing in the US?

  52. Med School,

    I didn’t laud the system in general as you seem to have inferred; I lauded the Community Health Centres specifically, saying that they help to fill “huge” gaps in my province. I lauded the fact that I don’t have to worry about being denied health insurance/coverage because of my pre-existing conditions. If I was in the US, I would.

    Like I said, I have a bunch of health problems, so of course I know there are huge wait times in Canada. I know both personally and through my work with the Association of Ontario Health Centres that my “system” is far from perfect.

    -Ashley

  53. Having lived in the Uk ( http://usturpin.wordpress.com/waiting-for-dr-godot/) and having been a patient along with my three kids and spouse of the NHS for over three years, I saw its advantages and disadvantages. I have to admit as a spoiled “give me access, or give me death” American healthcare consumer, I was not happy. However, it does not mean it was inferior care if we measure value as outcomes/cost.

    Generally, under a single payer, access to care will improve for the some 50mm uninsured and underinsured ( including Medicaid and Medicare patients who may increasingly find near term access issues as Fed and State reimbursement cuts are passed to deal with budget deficits ). Access will decline to some degree for those who had been covered under private insurance – especially those accustomed to generous open access PPOs that do not distinguish between cost or efficiency. I want my MRI and I want it NOW!

    One generally accesses primary care easily in the UK, waits ( sometimes uncomfortably ) for elective care and goes right to the head of the line when facing a life threatening situation. My son was treated very successfully diagnosed and treated for a disease called Legg Perthes Syndrome. He is fine today. The physical therpay nurse came to our house and gave him therapy – yes, to our house for free.

    Gray areas do abound where patients needing tests and access to certain services simply have to wait – and there are many stories of waiting times leading to complications – as there are for those who are uninsured and underinsured in the US. Let’s face it, there are finite resources and often infinite demand.

    Whoever pays for care, also instantly wears the black hat and is vilified when they make a decision that a treatment is not appropriate, warranted or not likely to achieve the ROI that public funds could achieve if they were better invested in a higher probability for success patient. The National Institute for Clinical Effectiveness in the UK makes many of the tough calls and uses evidence based care guidelines to determine whether care will be reimbursed and how therapies should be delivered. They are always under siege – just as today’s private payers are. CMS and Medicaid generally are not under siege for questioning clinical efficacy as historically they have focused on rationing reimbursement, not intervening to determine efficacy of care or coordination of care. Part of our problem is the enormous waste and overtreatment in our state and Federal programs as a result of no national oversight on clinical effectiveness. It is only just now starting.

    Point is, a nationalized system is not the end of the world but caveat emptor – it is very different and don’t expect your favorite specialist to be doing back flips of joy. Access will become an issue and quality will retreat into rationed pockets based on one’s ability to pay. Fewer will be able to afford private access and even when private care policies and alternatives are available, access to private care can be an issue simply die to the fact that there is often limited bed space.

    No easy answers. I still believe that employers could act as the market forces necessary to restructure the delivery system, but I am not certain they possess the skill at the bottom ( generalist HR professionals ) or the will at the top ( professional benefit managers ) to act as a market force for inverting the pyramid. Most seem more focused on limiting disruption to employees by shifting rising costs versus forcing lifestyle change.

    In the end, I believe the fiscal crisis will escalate to a point that we will have to ration something — access, quality, coverage. You choose. It’s a zero sum game and until the average American stops equating access with quality, the consumer will not change. Until we restructure incentives around health and well being and restore the PCP to their rightful role as quarterback and coordinator of care, the provider system will not change. I also think many Human Resource Managers and low attention span CFOs need a remedial lesson on healthcare economics. Many are provincial buyers with focused more on low imagination risk transfer, cost shifting and benefit cutting than actively attacking unit costs and seeking solutions that reduce units of care consumed. Just converting employers to self insurance, reduces insurer profits by 40%, improves access to actionable data on population health and reorients the employer to consider ideas to control loss costs.

  54. Having lived in the Uk ( http://usturpin.wordpress.com/waiting-for-dr-godot/) and having been a patient along with my three kids and spouse of the NHS for over three years, I saw its advantages and disadvantages. I have to admit as a spoiled “give me access, or give me death” American healthcare consumer, I was not happy. However, it does not mean it was inferior care if we measure value as outcomes/cost.

    Generally, under a single payer, access to care will improve for the some 50mm uninsured and underinsured ( including Medicaid and Medicare patients who may increasingly find near term access issues as Fed and State reimbursement cuts are passed to deal with budget deficits ). Access will decline to some degree for those who had been covered under private insurance – especially those accustomed to generous open access PPOs that do not distinguish between cost or efficiency. I want my MRI and I want it NOW!

    One generally accesses primary care easily in the UK, waits ( sometimes uncomfortably ) for elective care and goes right to the head of the line when facing a life threatening situation. My son was treated very successfully diagnosed and treated for a disease called Legg Perthes Syndrome. He is fine today. The physical therpay nurse came to our house and gave him therapy – yes, to our house for free.

    Gray areas do abound where patients needing tests and access to certain services simply have to wait – and there are many stories of waiting times leading to complications – as there are for those who are uninsured and underinsured in the US. Let’s face it, there are finite resources and often infinite demand.

    Whoever pays for care, also instantly wears the black hat and is vilified when they make a decision that a treatment is not appropriate, warranted or not likely to achieve the ROI that public funds could achieve if they were better invested in a higher probability for success patient. The National Institute for Clinical Effectiveness in the UK makes many of the tough calls and uses evidence based care guidelines to determine whether care will be reimbursed and how therapies should be delivered. They are always under siege – just as today’s private payers are. CMS and Medicaid generally are not under siege for questioning clinical efficacy as historically they have focused on rationing reimbursement, not intervening to determine efficacy of care or coordination of care. Part of our problem is the enormous waste and overtreatment in our state and Federal programs as a result of no national oversight on clinical effectiveness. It is only just now starting.

    Point is, a nationalized system is not the end of the world but caveat emptor – it is very different and don’t expect your favorite specialist to be doing back flips of joy. Access will become an issue and quality will retreat into rationed pockets based on one’s ability to pay. Fewer will be able to afford private access and even when private care policies and alternatives are available, access to private care can be an issue simply die to the fact that there is often limited bed space.

    No easy answers. I still believe that employers could act as the market forces necessary to restructure the delivery system, but I am not certain they possess the skill at the bottom ( generalist HR professionals ) or the will at the top ( professional benefit managers ) to act as a market force for inverting the pyramid. Most seem more focused on limiting disruption to employees by shifting rising costs versus forcing lifestyle change.

    In the end, I believe the fiscal crisis will escalate to a point that we will have to ration something — access, quality, coverage. You choose. It’s a zero sum game and until the average American stops equating access with quality, the consumer will not change. Until we restructure incentives around health and well being and restore the PCP to their rightful role as quarterback and coordinator of care, the provider system will not change. I also think many Human Resource Managers and low attention span CFOs need a remedial lesson on healthcare economics. Many are provincial buyers with focused more on low imagination risk transfer, cost shifting and benefit cutting than actively attacking unit costs and seeking solutions that reduce units of care consumed. Just converting employers to self insurance, reduces insurer profits by 40%, improves access to actionable data on population health and reorients the employer to consider ideas to control loss costs.

  55. Having lived in the Uk ( http://usturpin.wordpress.com/waiting-for-dr-godot/) and having been a patient along with my three kids and spouse of the NHS for over three years, I saw its advantages and disadvantages. I have to admit as a spoiled “give me access, or give me death” American healthcare consumer, I was not happy. However, it does not mean it was inferior care if we measure value as outcomes/cost.

    Generally, under a single payer, access to care will improve for the some 50mm uninsured and underinsured ( including Medicaid and Medicare patients who may increasingly find near term access issues as Fed and State reimbursement cuts are passed to deal with budget deficits ). Access will decline to some degree for those who had been covered under private insurance – especially those accustomed to generous open access PPOs that do not distinguish between cost or efficiency. I want my MRI and I want it NOW!

    One generally accesses primary care easily in the UK, waits ( sometimes uncomfortably ) for elective care and goes right to the head of the line when facing a life threatening situation. My son was treated very successfully diagnosed and treated for a disease called Legg Perthes Syndrome. He is fine today. The physical therpay nurse came to our house and gave him therapy – yes, to our house for free.

    Gray areas do abound where patients needing tests and access to certain services simply have to wait – and there are many stories of waiting times leading to complications – as there are for those who are uninsured and underinsured in the US. Let’s face it, there are finite resources and often infinite demand.

    Whoever pays for care, also instantly wears the black hat and is vilified when they make a decision that a treatment is not appropriate, warranted or not likely to achieve the ROI that public funds could achieve if they were better invested in a higher probability for success patient. The National Institute for Clinical Effectiveness in the UK makes many of the tough calls and uses evidence based care guidelines to determine whether care will be reimbursed and how therapies should be delivered. They are always under siege – just as today’s private payers are. CMS and Medicaid generally are not under siege for questioning clinical efficacy as historically they have focused on rationing reimbursement, not intervening to determine efficacy of care or coordination of care. Part of our problem is the enormous waste and overtreatment in our state and Federal programs as a result of no national oversight on clinical effectiveness. It is only just now starting.

    Point is, a nationalized system is not the end of the world but caveat emptor – it is very different and don’t expect your favorite specialist to be doing back flips of joy. Access will become an issue and quality will retreat into rationed pockets based on one’s ability to pay. Fewer will be able to afford private access and even when private care policies and alternatives are available, access to private care can be an issue simply die to the fact that there is often limited bed space.

    No easy answers. I still believe that employers could act as the market forces necessary to restructure the delivery system, but I am not certain they possess the skill at the bottom ( generalist HR professionals ) or the will at the top ( professional benefit managers ) to act as a market force for inverting the pyramid. Most seem more focused on limiting disruption to employees by shifting rising costs versus forcing lifestyle change.

    In the end, I believe the fiscal crisis will escalate to a point that we will have to ration something — access, quality, coverage. You choose. It’s a zero sum game and until the average American stops equating access with quality, the consumer will not change. Until we restructure incentives around health and well being and restore the PCP to their rightful role as quarterback and coordinator of care, the provider system will not change. I also think many Human Resource Managers and low attention span CFOs need a remedial lesson on healthcare economics. Many are provincial buyers with focused more on low imagination risk transfer, cost shifting and benefit cutting than actively attacking unit costs and seeking solutions that reduce units of care consumed. Just converting employers to self insurance, reduces insurer profits by 40%, improves access to actionable data on population health and reorients the employer to consider ideas to control loss costs.

  56. Senator,

    Your remarks are emblematic of the reason for the debacle that is healthcare. It is a political program.

    If it were only about healthcare, then utilization would only be driven by healthcare decisions. But NOOOOO!!

    We have politicized it. So if we get everyone on the program ,then costs can really go nuts.

    The government has NEVER controlled costs in anything.

    If you want to cut costs, just give the money to the patient and let them chose where to spend it. Oh, that sounds like a tax cut, doesn’t it. Get rid of employer based insurance so patients can get paid and buy policies with real value that meet their needs. Give “the poor” the money for their own policies.

    Don’t tell my you and the other 534 can make the choice for all of us.

  57. Hi Nate

    While I do agree that nothing in the Constitution supports Medicaid or Medicare for that matter, the reality is that both programs exist. Both are, at present, unsustainable from a financial perspective. Changes are required but they are not easy to do as all changes require actions on the part of elected officials and regulators and no one seems to invested in giving up goodies. Since the inception of the government-administered plan, elected officials have used it for political advantage. They expanded the program scope several times without having any idea how to pay for the additional capabilities, very irresponsible actions. Changes to the government-administered plan will be incremental in design with the absence of money being the primary driver. Many things will be tried, including the HSA and CAP concept. I do not know if it will work; however. the exisitng path leads to diminished access to medical services, lower quality standards, and ultimately fiscal insolvency and currency devaluation. We must be willing to be open to different ideas and act on some of them. As my mentor, Dr. Edouard Drouhet used to say, “Il est difficile de remplir un verre, déjà pleine.” (It is difficult to fill a glass, already full.)

  58. you did see the US at the top for the first one then the paragraphs at the end saying race played a huge factor. Compare white americans to white europeans then tell me if you still have anything to say

  59. ” the survival rate for many diseases (requiring highly specialized treatment) is higher in other countries as well.”
    Can you show any study backing this up, make sure its similiar populations, I don’t want some study showing well off asians live longer then poor south americans … from http://www.emaxhealth.com/51/23285.html. And that’s just what I could find in 30 seconds … and perhaps you should heed your own advice … and get out of the way …

  60. To quote James Joyce again, “The force of idealism is lost when it fails to recognize the reality of things.” Barry, that quote sums up the situation nicely. I agree with your assessment. This a prime example of socialism’s ” fatal conceit”. A governor appointed board of five is going to devise the system! Of course they will be “real smart people”. I wonder how will they prevent the over-taxed employers, high wage earners and health care providers from leaving the state, and the medically needy from immigrating into the state for what is perceived as low cost or “free” health care. This half-baked plan resulted from the hubris of socialist ideologues. How Vermont is going to fund their new health care system is such a “minor” issue, that they passed the law with no funding mechanism. Very reckless legislators in Vermont, there are indeed.

  61. “It is unfortunate that you choose to make your point by be-littling other people”

    And her disgusting comment? That your ok with because….you agree with it?

    ” the survival rate for many diseases (requiring highly specialized treatment) is higher in other countries as well.”

    Can you show any study backing this up, make sure its similiar populations, I don’t want some study showing well off asians live longer then poor south americans.

    Lara your posting junk. Longevity has more to do with race and lifestyle then our healthcare system. Anyone arguing the quality of a system based on the two data points you mention doesn’t have any clue whay they are talking about.

    The problem will be solved by people that know what they are talking about solving it while people that have no idea what they are talking about get out of the way and stop screwing it up.

  62. Mr Ogden —

    It is unfortunate that you choose to make your point by be-littling other people with valid perspectives that may differ from yours (or mine for that matter).

    Yes, others come to the US to access excellent care in specific situations. However, the survival rate for many diseases (requiring highly specialized treatment) is higher in other countries as well. Further, we are paying nearly double for healthcare in a market that delivers health care that lands us in 39th (according to the WHO) place with respect to overall health as measured by infant mortality and longevity beyond age 60.

    We do have a serious problem with access here in the US. In fact, multiple health insurers are reporting that healthcare utilization is on the decline in the US, e.g. people are opting out of procedures and treatments as the cost of deductibles, copays and insurance continues to increase coupled with a troubled economy. Further, those without coverage may get emergency care, but there is NO requirement that they receive care for anything outside of emergencies, and there are very few providers that offer medical care for free.

    According to the Kaiser foundation, the average family out-of-pocket for health insurance is just over $4,000 per year (or over 7% of the average wage earners gross income versus representing just over 3% of their gross income just a decade ago). Aside from rent or mortgage payments, health insurance premiums/deductibles are moving into 2nd place in the household budget.

    Serious illnesses have bankrupted many US families and created economic disadvantages for many others as they have fought their way out of debt, stagnated careers because of health insurance needs and borrowed heavily. And when those who cannot afford it ask the provider for assistance, the healthcare costs for everyone continue to increase.

    Finally, in 2009 the US Census reported that 50.7 million people did not have health insurance in the US — which represent 17% of the total population. When you look at those who are under age 65, that percentage climbs to 19%. And for children under age 18 those numbers are still in the double digits.

    I have not come across a healthcare system that solves for all problems. I can say that many exist that cost significantly less and deliver longer and better lives for their citizens.

    Our system is broken in many ways … there are no easy answers or solutions. More importantly, our problems will not be solved by the ‘government’ or the ‘free market’. They will be solved by collectively pulling together the best and brightest minds we have and thinking about new ways to reinvent our biggest challenge.

    I encourage you to read another article that is on the Healthcare Blog today: https://thehealthcareblog.com/blog/2011/05/21/how-to-blow-the-big-one/

  63. “The corollary is that if central gov’t is too large it can in fact broker much more power.”

    I don’t think it even needs to be two large. Why do we have cable, phone, power, gas monoplies? They are granted by government, usually at the county level.

    Why is health insurance competition lower then in should be in many states, government blocking entry and allowing mergers.

    MG you argue the markets create monoplies then manipulate government to continue to exist, I would counter that government in fact creates the momnoply in the first place and never has any desire, with rare exception, to hinder them.

  64. I am not entirely sure I understand your post, but if you are suggesting that the current lobby power of large companies is somehow immutable and therefore guarantees monopolistic behavior, I disagree. I think you will see in my posts that I believe outsized favoritism to any entity is harmful and contributes to the current crisis. This is an area which deserves reform, and I think such can be addressed. The corollary is that if central gov’t is too large it can in fact broker much more power. I find however most liberals do not however agree to downsizing the federal government.

  65. I also wonder how a single payer health insurance system in Vermont would deal with sick people moving to the state specifically to access care beyond what Medicaid offers in their home state at little or no cost if they have no job and limited income. If Vermont tried to establish a residency requirement, would the courts let them get away with it? You can’t make new residents wait to send their children to public schools. Would it be different for access to healthcare? Probably not.

    Vermont is a state with a bit over 600,000 people. Aside from IBM, there aren’t many large private sector employers. The main industries are tourism and agriculture. It’s doubtful that the state’s economy and its current population could support many newcomers who need expensive care. To quote James Joyce again, “The force of idealism is lost when it fails to recognize the reality of things.”

  66. Not sure what is useful about Kim’s report, its liberal propoganda designed to advocate for liberal reform solutions which are causing the problem in the first place. The article is mostly opinion;

    “Our health care system has been failing the American public for too long. Unfortunately, given the economic downturn and anemic job market, even more Americans could face the desperate plight of losing their insurance down the road. The record number of uninsured Americans underscores the need to fully implement every single lifesaving provision included in the new health reform law.”

    That pretty much sums up the whole article.

    I have a big concern about HSA for Medicaid, while I love the concept of HSAs for engaged consumers, I think to many Medicaid members would cash in their HSA and spend the money after the penalty on non medical expenses.

    In regards to Medicaid distrubutions to the states I don’t think there should be any. Zero federal funds for Medicaid. Nothing in the constution allows for Medicaid. If a State wishes to create a Medicaid program they are free to and can fund it as they see fit. It never makes sense to send money to Washington then beg for it back.

  67. Nate,

    Please read the article before criticing its contents. I sent it to you because it contains useful and referenceable data you can use to bolster your position in various discussions in which you engage. Evidence always trumps opinion.

    Also, Medicaid is growing at alarming rates throughout the US. Many states are looking at addressing Medicaid issues by designing benefit packages that promote individual responsibility. Let’s look at a proposal on which I served as an advisor in Texas, Medicaid recipients would receive sufficient funds to purchase high-deductible insurance policies from private insurers. The state also would fund related health savings accounts for recipients. These accounts could be used for out-of-pocket healthcare expenses and other qualifying purchases. This plan would essentailly cap costs and prevent the payment of Medicaid oblilgations from a state’s General Fund.

    In addition to the above, we want the federal government to revise its formula for allocating Medicaid funds among the 50 states to make it more equitable. Right now, those shares are based on the Federal Medical Assistance Percentage (FMAP), which is derived from each state’s per capita personal income in relation to the national average. This is a poor metric for determining a state’s need for federal assistance. In Texas, the FMAP formula shortchanges the state, giving it less than 7% of federal Medicaid dollars even though the state has 10% of the nation’s population living below the poverty line, and 13% of the nation’s uninsured.

    If you’re interested in reading the report, I will be happy to forward it to you.

  68. Hey Walt,

    We are talking 2 different numbers which is a great example of how stats are abused. People attacking the US system and those advocating reform love to use the 50 million number. While its a big number and sounds scary it really tells us nothing and means less then nothing becuase it is so misleading.

    Without reading your reference the numebr cited usually reflects those uninsured at some point during the year. At any one time far fewer then 50 million are uninsured. The first point to make here is many of those have access to COBRA and choose not to take it becuase they don’t need it.

    Next up a large portion of the 50 million, I think its around 30-40% are already eligible for Medicaid or other programs but shoose not to enroll, again mainly becuase they don’t need it. If its not important enough to them to complete the paperwork should we be that concerned?

    Next up we have double digit % of the uninsured making over 75K, these are people that could afford to buy insurance they just again choose not to.

    Finally we have the illegal immigrants.

    The number of people that truly want insurance and can’t get it are around 5 million. Every time government tries to fix healthcare they increase cost and increase this number. Should we trash a system that works for 295 million people so we can try and fail to help 5 million or should we stop screwing up what works and come up with a seperate program for just the 5 million that need help?

  69. Hi Nate,

    Here is a reference based on the Census Bureau data: Krisberg, K: Jump in Uninsured Signals Need to Implement Health Reform: Economy takes a Toll on Health Coverage. Nations Health. 2010; 40(9) American Public Health Association.

    I don’t know where you get a 1% to 2% percent “of our population needs insurance and can’t get it.” The uninsured rate in the USA is significantly higher than 2%. The article states, “In 2009, U.S. uninsured numbers rose to 50.7 million, up from 46.3 million in 2008 and translating to an uninsured rate of 16.7 percent, up from 15.4 percent in 2008, according to “Income, Poverty and Health Insurance Coverage in the United States: 2009,” which the U.S. Census Bureau released Sept. 16.” I hope you find this article useful.

  70. We’ve noted before that prices per service, test, procedure or drug are significantly higher in the U.S. than elsewhere, especially for hospital based care and for drugs. However, I’ll leave that issue aside for now and address several issues that impact utilization. Those issues are: (1) avoidable harm, especially in hospitals, (2) uncoordinated care including duplicate testing and inadequate hospital discharge planning, (3) the litigation environment, (4) end of life care and (5) patient expectations generally.

    I think avoidable harm needs to be dealt with at the leadership and cultural level within hospitals and, to some degree, changes in payment policy toward non-payment for care related to avoidable harm. The coordination issue could be helped by widespread adoption and use of interoperable electronic records whether the ACO model gains traction or not.

    The last three don’t lend themselves as readily to change because patient expectations are what they are. People want to have the right to sue and have their case heard by a jury. Doctors want to avoid being sued so they practice defensive medicine. Patients often want medically unnecessary tests, especially imaging, or brand name drugs at least if insurance is paying all or most of the cost. If doctors don’t give patients what they want, they are perceived as not thorough. While more people seem to be moving toward hospice or palliative care at the end of life, too many either want everything done no matter how futile or have not expressed their wishes to either their doctors or to family members.

    Perhaps rbaer could tell us how utilization and medical standards of care might be different in the U.S. if patients had expectations similar to the people of France, Germany, Switzerland, Scandinavia, etc. and our litigation system and the associated risk of malpractice suits were also similar to theirs. I suspect that practice patterns might be significantly more conservative in the U.S. than they are today. If high costs are the problem, perhaps the enemy is us patients and not the doctors and hospitals. That said, it would be enormously helpful if both patients and doctors knew the cost of services before they are rendered and doctors started to see it as part of their job to know and to care about costs. A single payer payment system, though, will do nothing to change standards of care, patient expectations or the litigation environment.

  71. ” I can’t imagine the access issues your citizens face. It’s disgusting.’

    Ashley, if you don’t know anything about healthcare in America why are you talking about it? How do you know it’s disgusting, you don’t have any knowledge of it. That would be like me saying your poorly educated and unattractive based on your post. Poorly educated might be a safe assumption based upon your comments.

    While in Canada you truly have access issues, you can’t get a doctor or service no matter what, unless you come to the US, anyone in the US can get care. The question is do you want rationing based on markets or government? A poor person can always borrow money or ask the provider for assistance. When the government rations and the capacity doesn’t exist at all, that sounds far worse to me.

    You don’t see Americans going to Canada or India for life saving care they must have right away. You see stories every couple month about a Canadain rushed to the US for care not available in Canada or becuase the wait is so long. That sounds far more disgusting to me.

    ” I was born with serious health problems and I have no idea how my parents would have paid for my care if we’d lived in the States.”

    Come on, this is a pretty ignorant statement, you think no one in the US is born with serious illness? Who do you think all these world class hospitals we have treat? Only 1-2% of our population needs insurance and can’t get it. We don’t have a serious problem with access like Canada does.

  72. Mr. Graham,

    I did see that ad.

    I am very aware of the primary and other healthcare access issues faced by many in my country. Actually, I’m a Communications Intern for the Association of Ontario Health Centres and a part of my work is to raise awareness about the healthcare access our Centres bring to underserved communities. My Association advocates for more of these Centres, more access. There aren’t enough Centres or healthcare access here.

    There are huge gaps in Canadian healthcare that shouldn’t exist, I know very well. But I DO think we have it better than Americans do. I was born with serious health problems and I have no idea how my parents would have paid for my care if we’d lived in the States. Also, I don’t even know if I would even qualify for insurance there.

    I wasn’t suggesting Canadian healthcare is perfect; I was merely expressing disgust for the American system and explaining that Community Health Centres help to bridge the gaps here (and I know Centers in America help them too).

    -Ashley

  73. So in fantasy land we don’t have any form of centralized gov’t that can be monopolized by firms that gain extensive economic clout and we stay in some utopia market-based society with small-to-medium sized firms competing against one another through constant innovation and improvement? Haha.

    Libertarians are just as delusional as the liberals they mock.

  74. “What happens in reality is that there is extreme consolidation in markets if there is no gov’t action and these firms use their economic clout to gather political clout.”

    LOL its bad when you contradict yourself but to do it in the same sentenace. What do they do with that political clout MG? They get government intervention to protect their power which is the exact oppoist of them existing unless government interfers.

    Monopolies can only exist with government protection. Insurance is a perfect example of how government stifles competition and creates monopolies.

  75. “In a true functioning free market, “obscene” profits don’t last long because someone else will compete for it.”

    Libertarian BS nonsense as anyone who has read anything about economics the last 5 centuries especially economics in the later part of the 19th century in the US after the Civil War. What happens in reality is that there is extreme consolidation in markets if there is no gov’t action and these firms use their economic clout to gather political clout.

  76. Ms. Ashbee,

    Did you not see the campaign TV advertisements in Canada during the recent federal election bemoaning the fact that 5 million Canadians have no access to a primary-care physician? And these ads were run by the Liberal Party, which imposed the government monopoly in the 1960s! (BTW, most health care in the U.S. is non-profit.)

  77. wrong. Medicaid is 100% sustainable becuase it only spends what it has that year.

    Medicare is not sustainable at all becuase it made promises 30 years ago then spent all the money elsewhere.

    Employer insurance is sustainable as it also spends what it has, the only thing that could collapse private employer insurance is government mandates and cost shifting.

    See my point above about we have a system when it helps your argument then we have disparte systems when you want to talk about great hospitals or other aspects.

  78. Nobody has figured out the perfect solution. There are “more” sustainable and “less” sustainable. Ours is on the “less” side. Could be a wild coincidence, but those on the “more” sustainable side seem to also be on the “more” equitable side. I wonder why…..

  79. I agree, thats why the government needs to assign me a womb, if I need to work to support them then I should get use of their baby making oven, I could single handily convince every women to find a job and get off assistance:)

  80. “more sustainable, to name a few.”

    Really Steve, you haven’t heard about the austerity measures being discussed and passed aparently.

  81. “Yes, based on two cases in one particular system in Canada,”

    Really Margalit, you don’t think I could post a thousand more? After how many real people suffering is it a problem and not just an ancedote?

    “we should completely discard the possibility of having an equitable solution in this country.”

    Were those systems equitable to the people I mentioned that suffered? Whats more equitable, discriminating by political connections or giving everyone an equal chance and access and let their efforts determine who gets the limited resources? Your proposed systems is no more equitable you just want the power to pick and chose the winners instead.

    It would also require that 40% of the country not get a free ride, how can you talk of eqiuality while pushing a system that 50% of the country won’t contribute anything to but take from freely? Thats right progressive discrimination is not discrimination its equalization. I double dog dare your self-serving assumption.

  82. “So what? No other system you can name is consistently equitable and also sustainable.”

    France, Switzerland, Germany, Singapore, Japan, all are more equitable and more sustainable, to name a few.

    Steve

  83. “, I do agree that the US has stellar institutions renowned throughout the world, but this does not make the entire system better from the perspective of the average American.”

    Great point Margalit but this just proves all your dogma is wrong. We don’t have a system, we have thousands of systems. When you want to propogandize change you want to lump it all together. Then when its beneficial for your argument magically you admit its not one homegenous “system”

    Compare UT group sponsored insurance to any other system in the world, cost are inline and quality is far superior with much better access. Instead of copying a failing Canadian or NHS system why not copy UT? We have 2 systems and a couple states that are complete failures. Its those failures that drag down the average for the whole nation and make it look bad compared to other nations. Oddly your and other liberals solutions is to build on the worst we have instead of the success we have.

  84. “As to your example above, do you really want to use this cartel driven industry as an example of a free market?”

    Not in the least. We are in agreement it is the worst possible construct.
    I am asserting we got to this point by misguided policy blunders. I simply feel the best solution is to restore free market principles. It seems you favor more involvement by big government. I am not impressed by their track record. Robber barons succeed also when government fails. There most critical and primary job is to referee commerce. Assure equality of chance. That is a tall enough order to fulfill and again I am not impressed with the ability to do that. Equity of opportunity is paramount

  85. I would argue that obscene profits last as long as governments, in the role of regulators, allow them to last. Remember the Barons?
    Your free market perfection is as theoretical as the 100% equitable systems envisioned by the left, and it has never be proven to exist and self regulate to the extent where exploitation was not inherent.
    Inequity does exist and complete equity will never be achieved. Does this mean that we should not strive for as much equity as possible?
    Pursuing profit is just fine. Unbridled pursuit of profit, undeserved profit, may also be fine if it does not blatantly injure everybody else. I think the greed of health care affiliated corporations is definitely injuring many citizens and it must be curtailed.
    As to your example above, do you really want to use this cartel driven industry as an example of a free market?

  86. “However, any equitable solution will require that corporations and others involved, will not be able to make obscene profits from death, misery and disease. Somewhere along the line, someone decided that efficiency and quality must be naturally based on greed, exploitation and inequity. I challenge this self-serving assumption”

    More hyperbole.

    In a true functioning free market, “obscene” profits don’t last long because someone else will compete for it. Industry constantly looks for true efficiency to eek out profit. It is not greed (defined as desire for undeserved gain) to pursue profit, nor is exploitation intrinsic to a free enterprise system. Inequity exists. So what? No other system you can name is consistently equitable and also sustainable. Instead of demonizing wealth creation, it should be emulated. Desire for redistribution is its own form of base greed.
    The tongue-in-cheek example in my previous post is designed to illustrate consequence of all of the deviations from a functional market. I blame the elitist social engineers who think they are smarter than the market

  87. Yes, based on two cases in one particular system in Canada, and just to preempt Nate’s NHS horror stories, other cases in another particular system, we should completely discard the possibility of having an equitable solution in this country. Never mind that other countries, like say, France, Germany, Switzerland, Denmark, Sweden, etc. seems to have found ways to accommodate better solutions, and never mind that the US, if it chooses to do so, could probably come up with an even better idea, as it always did.
    However, any equitable solution will require that corporations and others involved, will not be able to make obscene profits from death, misery and disease. Somewhere along the line, someone decided that efficiency and quality must be naturally based on greed, exploitation and inequity. I challenge this self-serving assumption.

  88. What I find peculiar is that we are talking about developed countries and not the vast majority of this planet which does not fall in this category, unfortunately. I don’t think anybody will argue that Somalia has a better “system”.
    To add to this, as I stated initially, I do agree that the US has stellar institutions renowned throughout the world, but this does not make the entire system better from the perspective of the average American.
    This is very similar to instances when we discuss poverty and you come up with pimps and drug dealers as being representative.
    Since I mentioned Somalia and since this is a weekend, here is some comic relief for you
    http://gregmankiw.blogspot.com/2011/05/libertarian-paradise.html

  89. Oh and as comment to the anecdotes Nate is linking too:
    The arrangement that the article is referring to is apparently more related to geography than other reasons – read Dr. Akshay Khandelwal comment to this story, the physician in charge of the MI program at Henry Ford.

  90. Nate, it’s just silly. The US has, in most areas of medicine, incl. angioplasty, huge overcapacities, and Canada has some shortages, so that’s the arrangement that Canada chose to set up, for whatever reason. What does that prove? Let’s just postulate for a moment that in fact, many Canadians get insufficient care in Canada.
    1) That reflects only on the comparison of USA-Canada
    2) You don’t take into account how many US residents, for various reasons, get system related substandard care (incl. under- and overtreatment).
    You sometimes have worthwhile thoughts and expertise, but can you please stop reasoning like a 4th grader?

  91. If we have a right to healthcare and forcing others to provide it to us with no or undervalued compensation then I surly have the right to reproduce, what government agency is going to provide me a womb and the poor women to carry it for 9 months free?

  92. Thanks for those examples. I grow tired of progressive liberals casting about with hyperbolic language in an attempt to end debate. Anyone who tacitly agrees in unlimited healthcare for all as an innate “right” cannot then reject any argument against a total government solution.
    I too can run amok claiming rights. Gasoline costs too much. Perhaps it is my “right” to cheap gas. I am suspicious that big oil uses nefarious plots to overcharge me. So here is what we should do:

    1. Declare that all citizens must have fuel as a right of citizenship
    2.Start by guaranteeing low cost fuel to target groups (elderly, poor, disabled) and price fix to keep price low for that group.
    3. Allow surreptitious cost shifting to everyone else (unless politically favored in a union)
    4. Encourage oil companies to consolidate market share in the name of “efficiency” (as long as they play by political rules). Relieve them of meddlesome anti-trust laws
    5. Blame oil companies publicly for price spiral and shortages. Publish the salaries of their reprehensible officers
    6. Allow employers to provide discounted fuel to employees with pre-tax money using their pricing power. Call it efficiency.
    7. Blame anyone not employed by a large employer or in a special interest group for being unable to buy gas at $100/gallon. (Irresponsible!) Make sure they use post-tax income to buy gas.
    8. Write prolific regulations along the way to remedy all of the aberrancies created by the last set of laws. Rationalize the system as too complex for the unwashed masses to really understand and navigate on their own.
    9. Blame free enterprise and evil profits in general. Tax the “rich”
    10. Insulate gov’t employees from cost by providing free fuel for life
    11. Repeat above steps until system is socialized and utopia is achieved.
    12. Move on to next segment of the economy

  93. Senator, you work from the false assumption that life is fair. Your model will create new problems that won’t be fair. Risk, death and failure are natural parts of human life. Let market system determine the care products available. Artificial rationing and distribution systems will only lead to future catastrophic failure because of man’s inability to know how to ration over a long period of time. Man’s humanity will destroy our country. We will become a health care country, retirement country and produce nothing of value to the markets of the world. Our life style will decline and the system you propose will break.

    Prehistoric man had a a health care crisis– we have a crisis of entitlement…

  94. “Should Canada’s Health System Become More Like America’s?”

    http://economix.blogs.nytimes.com/2009/07/20/should-canadas-health-system-become-more-like-americas/

    “The controversial ruling applies only to Quebec. And to date, its impact has been relatively limited. Private insurance can be purchased in that province for a small number of procedures including knee and hip replacements. Such policies have so far found few buyers.”

    http://www.cbc.ca/news/canada/montreal/story/2009/03/30/mtl-health-insurance-interest-0330.html

  95. It is amusing to me how when people talk about a single payer health system what they have in mind is a system that maintains the same level of care we currently have, but which is available to every citizen while costing half of what the current system costs. Oh they talk about “getting rid of all that fraud and waste” and “eliminating administrative overhead” but in the end they are still living in la la land. Maintaining what is currently possible to receive from the current health care system while offering that possibility to all will be extraorinarily expensive. Prohibitively expensive. Providing health care to all even while spending the same as we do now will be extraordinarily restrictive – severe rationing (yes I know the current system has rationing, just in a different way, bla bla bla).
    There is however, an answer to this dilemma, but it is unpalatable to most of the posters on this site because they believe in universal equality. Providing basic healthcare to every citizen will only be possible when we accept the unavoidable reality of unequal care. Short of officially adopting socialism the only way to expand health care to all in a way that will be politically acceptable to the country as a whole is if there remains access to what is accessible now including the possibility of nearly instant (compared to other western nations) access to advanced diagnostic testing and treatment.

  96. “no one on earth wants the US health care “system”,

    Just so I am clear Margalit China, India, and Mexico are still on earth correct? Maybe rbaer got some news I hadn’t heard yet and the end of earth hit early and all of those citizens were gone to another planet. When someone claims no one on earth wants our system I think my 2 billion person example was a good rebuttal. What about that do you find peculiar?

  97. its a start, now will you conceed that every day average Canadians come here on their own and come funded by the Canadian system?

    I’m just correcting your miss statements or hyperbole, whichever you wish to call it.

  98. Nate, you are constantly mixing issues and weaving them together in most peculiar ways.

    This particular conversation was about the quality of the US system compared to those “other” developed countries. Your argument was that people from those developed countries are flocking to the US because frankly their Socialist systems suck (or something like that).
    A few comments above you asked about China and India and now we’re back to Mexico. So yes Nate, compared with China, India, Mexico and probably most nations on earth, we have a great system. Is that good enough for you?

  99. “Sanders makes the statement that healthcare is a “right”. What about the right of people to choose? He does not have the high ground here. The inevitable rationing tramples rights we are already guaranteed. ”

    Speaking of rights here are a couple interesting facts you will never get rbaer, matt or margalit to discuss;

    “In the Chaoulli decision the Supreme Court of Canada struck down the Quebec prohibition against patients seeking alternatives to government wait lists. The court found: “democracies that do not impose a monopoly on the delivery of health care have successfully delivered…services that are superior to and more affordable than the services that are presently available in Canada. This demonstrates that a monopoly is not necessary or even related to the provision of quality public health care.”

    “A lawsuit, filed in Ontario Superior Court on September 5th by two brain-tumour patients alleges Ontario’s injunction against private health care alternatives violates their right to life, liberty and security of the person, as guaranteed under Section 7 of the Charter of Rights and Freedoms.

    Lindsay McCreith suffered a seizure in January of 2006 and was diagnosed with a tumour. He was told he would have to wait ten weeks to get an MRI to determine if the tumour was cancerous. Unwilling to risk waiting, he sought an MRI in Buffalo which confirmed the cancer. Ontario told him he would have to wait 8 months for surgery, so he paid $27,000 for life-saving treatment in the United States.

    Shona Holmes began losing her vision in 2005 and got an MRI in Ontario that showed a brain tumour. Forced onto a wait list (up to six months to see an endocrinologist) as her eyesight deteriorated, she went to the Mayo Clinic in Arizona where she eventually got surgery to remove the tumour.

    These two Ontarians were forced to choose between government-mandated wait lists with the risk of deterioration and even death: or immediate and life-saving attention outside the country. Without private insurance options most Ontarians would not be able to afford to make this choice. They would be forced to wait and wait and wait in the hope that government bureaucrats call their number before it’s too late.”

    While Sanders wants to take away our rights to Healthcare the very systems he wants to copy are saying their citizens have the right to care outside those failing systems.

  100. http://www.upi.com/Top_News/2009/08/20/Canadians-go-to-US-hospitals-for-care/UPI-34251250802229/

    “Canadian patients go to U.S. hospitals for urgent or critical care through agreements between Canadian health agencies and U.S. hospitals, officials said”

    Detroit’s Henry Ford Hospital, also excellent reputation attracting people worldwide?

    “Canada, for example, has waiting times for bariatric procedures to combat obesity that can stretch to more than five years, according to a June report in the Canadian Journal of Surgery.

    As a result, the Ontario Ministry of Health and Long-Term Care in April designated 13 U.S. hospitals, including five in Michigan and one more with a tentative designation, to perform bariatric surgery for Canadians.”

    Do you want to take your foot out of your mouth rbaer and admit your full of it and have no idea what your talking about or should I post a few hundred more stories about Average Canadians using all sorts of different American Hospitals and its not just rich Canadians.

  101. “Mayo has a singular worldwide reputation.”

    In Liberal speak what does the word singular mean? I think the Cleveland Clinic with locations in Canada, Middle East, Las Vegas, and Florida might take exception to your use of the word. John Hopkins? MD Anderson for Cancer?

    “People from Canada or other countries don’t come seeking care from the US system.”

    Margalit do you have access to a map? There is a part of this country referred to as the South and Southwest. There are roughly 11 million illegal immigrants many of whom would say your full of it. Your posting a lot of BS lately, are you really going to claim our ERs aren’t abused by illegal immigrants and women dont come here to have babies?

  102. Sanders makes the statement that healthcare is a “right”. What about the right of people to choose? He does not have the high ground here. The inevitable rationing tramples rights we are already guaranteed. Many doctors see firsthand that it is failed government policy which is directly responsible for inability of many to acquire insurance or reasonably priced care. It is gov’t which has created market dislocations by price fixing, allowed market concentration of insurance companies, created volumes of arcane regulations, and sponsored employer-based benefits which weakens the individual health insurance market. So, the gov’t is currently denying the rights of it’s citizens Bernie. Do something about that.

  103. If a single payer healthcare system is such a great idea, I think Senator Sanders should focus his efforts on working with his home state of Vermont to try it out there first. Let’s see if Vermont can come up with sustainable and affordable financing to cover the uninsured, replace employer provided coverage with state coverage, develop a fee schedule that providers can live with and convince Medicare and Medicaid to adhere to its rate schedule. While they’re at it, they need to control fraud as well. The biggest thing Vermont has going for it in this context is its small population which will minimize the number of people who are hurt or inconvenienced if they get it wrong. It’s not easy, but if Vermont thinks it can improve on the healthcare system it has now without resorting to explicit rationing, I say go for it but don’t even think about trying to impose it on the whole country.

  104. “This is true but not relevant to this conversation.” The statement about relevance is your personal opinion and you’re entitled to it. People travel to the US to receive medical care from the nation’s physicians and surgeons that are usually affilliated with ‘high value’ organizations such as M. D. Anderson, Mayo Clinic,and Johns Hopkins, to name a few. Typically, the patients pay cash and the total cost is negotiated in advance.

    “They also come to the US to get treatment or medicine they don’t have access to in their country due to rationing.” This is true. Sadly, the single payer system in England has a significant DIQ statistic, the by-product of a failed system orginally framed by Lord Beveridge in the mid-1940s. The NHS is not sustainable in its current configuration and is undergoing reorganization.

    “Or they come to the US from UK because even paying for the new cancer drug out of their own pocket the NHS will stop treating them.” There are ways to recoup your costs from the NHS if your travel to the USA for medical care.

    ” …by academic prudes more interested in the form of debate then substance. If your first concern is spelling, punctuation, or form instead of what is being said then your [sic] usually defending such a weak argument your only hope is to change the topic.” How things are said affect meaning, hence language rules.

  105. It’s a nonstarter as an argument. There are enough affluent canadians close to rochester and canadian snowbirds close to Scottsdale and Jacksonville. It proves that Mayo has an excellent reputation and is able to attract affluent people from all over the world (mostly Rochester), and even more people from close by canada. It’s silly to even bring it up.

  106. Mayo is over 120 years old. When they say “over the years”, they are talking about a century, and then some.

    Mayo has a singular worldwide reputation. People from Canada or other countries don’t come seeking care from the US system. They seek miracles from Mayo specifically.

  107. The problem with editorials such as Senator Sanders is that is he envisions a solution without indentifying or even acknowledging how extraordinarily complex and entertwined the health care issues and problems are. Instead he offers soundbites intended to inflame and outrage the populace.

    For instance, he envisions a nation under a single payor because the administrator costs with private insurers are too high. Yes, there are health plans which charge administrative costs in excess of 30%, but a majority are in the neighborhood of 10-12%. The often quoted administrative percent for Medicare is about 5-8%.

    But why is Medicare so low? I would argue that Medicare’s administrative expenses are not low at all. Rather, the expenses are passed to other areas in government or are artifically deflated by Medicare’s “take-it-or-leave-it” approach. For example; they are not forced to negotiate with health care providers. The Medicare fee schedule is set at the national level and only varies by geographical prices indicators. Secondly, in the Medicare world, the contracting expense is not in securing an agreement for a provider to participate, but rather with those providers requesting to opt out. Thirdly, enrollment is handled by the Social Security Administration, not requiring a separate billing, accounting and marketing department. Lastly, contract compliance in governed by federal statute not common law. This means the expense of investigating and litigating violations is an expense for the OIG and FBI rather than Medicare directly.

    Imagine the decrease in administrative expenses of private insurance companies if all health care providers were forced into accepting a single reimbursement schedule, such as Medicare. Are hospitals and physicians prepared to become, in essence, government contractors?

    Senator Sanders also mentions that pharmaceutical costs are lower in Canada and overseas. It’s pblic information, but not to many people are aware that foreign governments and foreign entitlement programs are large investors in US healthcare. For example, look at the investments in pharmaceuticals from the Canadian Pension Plan. http://www.cppib.ca/files/PDF/Foreign_PublicEquityHoldings_March312011.pdf

    The CPP is equivalent to US Social Security. In addition, the CPP is a major investor in at least one hospital network in the US (Legacy Health Partners).

    I find it ironic that the deficiencies in US health care is a source of revenue for foreign governments.

    The final argument I would like to point out with respect to the single payor option is the millions of jobs that would be impacted in the transition. Now, I’m not saying this should prevent consideration of the single payor option, but it’s worth noting that any potential saving would be offset by an increase in unemployment rates and decrease in tax revenues.

    Dan

  108. http://www.ctv.ca/CTVNews/Health/20110509/mayo-clinic-insurance-110509/

    Turn this comment around;

    “”We see insurance companies trying to expand their markets all the time in Canada. It’s very lucrative to sell private insurance, as we see in the United States,” Eggen said Monday from Edmonton. “It’s part of a disturbing trend that I think we should protect Canadians from, quite frankly.”

    Eggen said such companies profit by spreading the idea that Canada’s universally accessible system is irrevocably broken and that the care provided is somehow inferior to American private-sector health services.”

    Its very lucrative to take over private healthcare and make it public, as we see in other countries and with Medicare. Politicians profit by taking over large parts of the economy. They do this by spreading the idea that the US system is broken…blah blah blah.

    “Dr. David Hayes, a cardiologist at the Mayo in Rochester, Minn., said tens of thousands of Canadians have sought testing and treatment at the clinic’s three locations over the years.”

    10s of thousands, and thats just Mayo, I thought you and Margalit and Matt said only a couple dozen(see how I put words in your mouth) came here.

    Notice how protective they are of the concept of Universal coverage, like our Medicare they are scared of people seeing options becuase they know they will want and expect more if they see in comparison how terrible they are.

  109. Your comment isn’t trolling because….?

    Personal attack…check
    strawman argument…check

    anger, where is there anger? Thats the little brother argument to just calling then a racist or sexist.

    “no one on earth wants the US health care “system”, excpet for a few people with unlimited resources.”

    Really so the billions of people in China and India and Africa with no healthcare don’t want our system. If your going to make stupid comments we aren’t going to have a very productive debate. UMC in Las Vegas has a problem with illegal immigrants using dialysis, they apparetnly want the system, they aren’t going home for treatment.

    And what does all your European references have to do with this discussion of Canadian Tourism?

    People go where the resources are available. Why would a german with access to private insurance come to the US for services he can get in Germany? Now an English citizen denied a cancer drug is going to go where the drug is available. A Canadian on a waiting list is going to go where they can quickly get the treatment at an affordable price.

    Step up the Quality of debate and stop the trolling

  110. Nate, I regret that you are getting into trolling mode again, just throwing things out with anger. I read enough about the Canada to US traffic (incl phantoms in the snow) which is largely a myth, I trained in Europe and practice, for family reasons, in the US, I read multiple polls and also talk to relatives and friends on both sides of the pond, and I can tell you what you probably already know: no one on earth wants the US health care “system”, excpet for a few people with unlimited resources.

    And you are unaware of the cognitive dissonance that you create by usually stating that individuals want too much from 3rd party payors, and yet you cite that some people with money and certain health problems travel to the US as proof for … yeah, for what exactly?

    Mayo Clinic and some other tertiary care facilities are very good and have a consistent level of excellence, but they offer not much that European tertiary care cannot offer (and vice versa, European center have to offer some things that Mayo cannot). And if they spoke French or German in Rochester, they probably would get only a fraction of international visitors.

  111. since you brought it up lets discuss this “study”

    First couldn’t you find anything older? Socialized health systems always perform great at the beginning, Medicare was great when it first passed, its the way they quickly deteriot that is the problem.

    Next the number of people crossing the border compared to total spending seems like a pretty pointless measure. in a population half your people wont have any care, then factor in emergency care and that care you don’t have the opprotunity to make a decision to go elsewhere and this study is worthless from the beginning, just propoganda.

    Of the trillions we spend how many people went to India 10 years ago? Next to no one so we must not have a healthcare problem?

    Good thing I wasn’t around in 2003, your post is terribly written. For example;

    ” The latest comparable numbers have the US spending roughly 14% of GDP on health care while that number is around 11% in Canada. So at a macro level, the Canadians pay less as a share of their income to cover more of their people. ”

    That 14% of GDP includes all spending including care that isn’t paid for so in fact all people are covered, some by insurance some by safyet net.

    “recall that Canada has a single payer in each province that provides uniform health insurance to all its citizens.”

    With a significant private insurance component.

    “They asked consumers’ views in several countries,”

    Wow can you get less scientific? Ask an englishmen how to drink beer they say warm, ask an American they say cold, who’s right? You can’t conduct meaningful opion pools across different cultures.

  112. “Sadly for Nate the BS about hordes of Canadians”

    Come on Matt, nothing better to do on a Friday then killing strawmen? When did anyone say hordes or reference any measure of the number of people comming here? Sorry I let you get back to arguing with yourself.

  113. This new smartphone keyboard stinks. (Beware anyone moving from an iphone to an atrix.) I meant to say that it has nothing to do with multiple payers and everything to do with government capture by industry as well as a culture that doesn’t know when to say “no.”

  114. Sadly for Nate the BS about hordes of Canadians coming here for their healthcare is just that and was proved as such by an exhaustive study in Health Affairs called Phantoms in the Snow http://content.healthaffairs.org/content/21/3/19.long

    But that’s OK, you keep repeating a lie long enough and who cares what the truth is.

    For a real balanced look at this crossborder topic not much has changed since my excellent (because it’s old and I used to care then) essay called Oh Canada published on THCB back in 2003

    https://thehealthcareblog.com/blog/2003/11/11/policy-oh-canada/

  115. The US pays more for brand name drugs in large part because Medicare and to a lesser extent private plans can’t credibly threaten to drop a drug from the formulary if the price isn’t lowered. The systems in other nations that “ration” can do so. Why do we have to wait for single payer to let Medicare negotiate? We don’t, but we wont because of special interest lobbying and Republican support for big pharma.

    This has nothing to do with the existence of multiple layers and

  116. you managed to make Bernie look well informed.

    ” Because it costs too much.”

    Your first error is not knowing or ignoring that cost vary across the US. If your visiting from a foreign country and cost is an issue yoru not going to go to MA or NY. You can go to Iowa or Kansas and get surgeries for a fraction of the cost. Insurance cost in UT is comparable to the rest of the world.

    Plenty of middle class people are treated from all sorts of countries.

    “It costs so much that there is little left for the rest of us, ”

    Pure ignorance. Medicare sonsumes 30%+ of our spending are you claiming they are all poor?

  117. For all those arguing that people are coming to the US for the excellent care not available anywhere else – I agree.
    However, just know that unless your financial fortunes are comparable to those of foreign dignitaries coming here in desperation, you, like the overwhelming majority of Americans, do not have access to the same excellence.
    Why? Because it costs too much. It costs so much that there is little left for the rest of us, and nothing at all left for those of us who happen to be poor. I sure hope that delaying the death of some dictator from some rare form of cancer provides you with adequate comfort and happiness.

  118. Someone should also tell Bernie we have the cheapest generic drugs. And if he is really concered about the cost of brand name drugs why has the current administration steped up seizures of drugs imported from other countires? Classic example of liberals/socialist talking out both sides of their mouth. They create the problem with one hand so they can solve it with the other.

    Every problem with our current healthcare system is government created.

  119. “Answering a question with a quetion(sic) is considered to be poor form.”…

    …by academic prudes more interested in the form of debate then substance. If your first concern is spelling, punctuation, or form instead of what is being said then your usually defending such a weak argument your only hope is to change the topic.

    “People journey to the USA to get the ‘best’ medicine offers.”

    This is true but not relevant to this conversation. They also come to the US to get treatment or medicine they don’t have access to in their country due to rationing. For example they come to the US from Canada and UK because they don’t or can’t wait 18 weeks or more. Or they come to the US from UK because even paying for the new cancer drug out of their own pocket the NHS will stop treating them.

  120. Answering a question with a quetion is considered to be poor form. People journey to the USA to get the ‘best’ medicine offers. They go to other venues to get lower prices, accepting different, frequently lower, quality standards, a ‘satisficing’ exercise.’

  121. http://www.bbc.co.uk/news/health-13130678

    Can’r wait, pun intended, for more government care. Seeing as how 90% of our problems are from Medicare and Medicaid why can’t liberals every explain how more of it will fix things? If you can’t run mini Medicare for all how do you expect Medicare for all to work?

    The fact that the Senator can’t even make a rational argument for single payor shows we shouldn’t trust them with any of our healthcare.

    ” yet we still rank 26th among major, developed nations on life expectancy, and 31st on infant mortality.”

    Both terrible measures of a nations healthcare system. His best argument on why to change our healthcare system has nothing to do with our healthcare system.

    “It boggles the mind that approximately 30% of every health-care dollar spent in the United States goes to administrative costs,”

    How sad is it that someone with the staff and resources of a US senator falls for propoganda like this?

    He doesn’t care about healthcare he cares about trillions he can control and blow, the current SS and Medicare slush fund is running low and Bernie is worried he won’t have anyone’s money to spend.

  122. How does it explain that patients from all over the world travel to the US for care? We have far more patientrs comming here then we do going outside of the country.

  123. I live in upper Michigan. I have patients going over to Canada for their medical care and their medicines all the time. Also, see pcp above. Yay Socialized medicine! yay Physicians for a National Health Plan!

    Walt Valliere = pwnd

  124. And also explain why the citizens of the USA travel to Mexico, Singapore, and India for medical care.

  125. How sad it is, albeit expected, to see an elected official place political self interest over reality. The government administered is broke but you and your colleagues don’t really want to fix it; you want to get re-elected. It is frightening that you believe and support socialist pablum. Please namea ccountry that has succeeded with a single paye system, and when you do, please explain the reasons citizens of those countries with such wonderful medical sysems journey to the USA for medical care.

  126. My deepest admiration, and wishes for success, Senator Sanders.

  127. Hi Senator Sanders,

    I completely agree with you. Living in Canada, I can’t imagine the access issues your citizens face. It’s disgusting. For-profit health seems to have terrible consequences for citizens. Community Health Centers (or Centres in Canada) help increase access to care. They help people in Canada, too with dental healthcare, food security, etc.

    -Ashley Ashbee

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