Democrats and Health Care

Jacob Hacker on the Clinton and Obama health plans:

Are You Confused Yet?, by Jacob S. Hacker, Commentary, NY Times: Polls show that health care ranks near the top of voters’ concerns, especially among Democrats. ... And yet, voters must be awfully confused about where the Democrats stand on health care. ...

So what’s the main story: (1) a basic Democratic consensus about what should be done, or (2) a widening policy divide fueled by presidential ambitions? The answer is (1), but unfortunately, the reality of (2) is increasingly upstaging this welcome development. And, unfortunately, this unnecessary and self-defeating conflict could ultimately derail efforts at reform, confusing and turning off the very voters Democrats need to woo.

To see the basic consensus, we need to go back to its immediate source: John Edwards’s campaign proposal. Mr. Edwards’s plan, released in early 2008, had ... a requirement that employers either cover their workers or help pay to cover those workers through a public framework (an approach known as “play-or-pay”). The second core element ... would give workers whose employers didn’t provide secure coverage a choice of public or private insurance. The third core element was a requirement that everyone have coverage (a so-called “individual mandate”). ...

.The cornerstone of both candidates’ plans ... is the play-or-pay requirement: employers cover their workers, or their workers are automatically enrolled in a single insurance pool to which employers are required to make contributions. (Both candidates have said they would exempt small businesses from this requirement, which could pose a big hurdle to universal coverage, since most of the uninsured work for small firms.)

Done correctly ... a play-or-pay requirement makes covering people much less complicated. The more than 90 percent of non-elderly Americans (and more than 80 percent of the uninsured) who live in a family in which someone works would be enrolled automatically... Many of those missed are already covered through public programs, and aggressive outreach could reach those who still remain without coverage. Thus, Mr. Obama’s plan could well cover almost everyone even without the individual mandate.

But, of course, that hasn’t stopped the individual coverage requirement from becoming a flashpoint of disagreement. Hillary Clinton has savaged Barack Obama for leaving out an alleged 15 million Americans — an oft-repeated estimate, the precision of which belies the huge uncertainty about how an individual mandate would be enforced and how many people it would actually cover. ...

For his part, Mr. Obama has repeatedly charged that Mrs. Clinton will force some people to buy unaffordable coverage, an incendiary charge. ... But Senators Obama and Clinton’s proposals are so similar it’s hard to see how Mr. Obama can suggest that everyone will voluntarily sign up under his plan while Mrs. Clinton’s will impose unbearable costs on middle-income folks.

The truth is that the overall costs of the two plans, their essential structure, and their overarching logic are all but identical. Neither would force people to give up employment-based plans they’re happy with. Both would give people without coverage from their employer a menu of different plans, including a predictable, simple and attractive public plan modeled after Medicare. And both could cover all or virtually all Americans for a relatively modest cost. ...

But unfortunately, the fierce debate has pushed both candidates toward rigid positions and extreme pronouncements, elevating a modest disagreement into a confusing melee. .... Meanwhile, John McCain ... has gotten a free ride.

The overheated attacks serve neither Democratic candidate. Rather than impugning each other, they should be saying how they would ensure affordability and enrollment. Mrs. Clinton took an important step in this direction by committing to a limit on how much Americans will have to pay for insurance. Mr. Obama should make a similar commitment, and make clear he will automatically enroll employees and their dependents through the workforce...

Most important, Senators Clinton and Obama should be talking less about how they would cover the uninsured as an isolated group and more about how they would provide health security to all Americans, ensuring that everyone has affordable coverage that doesn’t disappear if they are laid off or change jobs. That’s, after all, what matters to most voters... Senators Obama and Clinton have a health care prescription for these folks that’s much more attractive than John McCain’s skimpy tax credits for coverage — if only they would speak about it in clear, simple and attractive terms.

While their plans may be very close overall, there may be a key difference - their willingness to make implementation of a health care plan a top priority after taking office.

Comments

[save_the_rustbelt]

Having been through every word of both plans, the differences are not that great.

As to intentions after election, who knows?

The Democrats form a circular firing squad, and we could get President McCain. Oh swell.

[kharris]

"...a predictable, simple and attractive public plan modeled after Medicare."

That was Edward's great innovation. Since it was his, I think we could have had some faith in its implimentation in a "predictable, simple" way in an Edwards' presidency. It is also the part of the formula that aims at forcing private insurers to compete by limiting premia and providing quality (simple, predictible) service. That is not in their interest, and they will do everything they can to prevent the creation of a simple, predictible plan. The public is going to need to keep the pressure on to assure that neither of these politicos strays away from this most important facet of the Edwards' plan. Competition from the public sector is the source of cost containment in this plan.

[markg]

The problem with health care is not insurance. If everyone had insurance but there was only one doctor in the country would everyone have health care? The focus should be on how to provide health care services to everyone. I favor a system of health care spending accounts funded by tax credits that are phased out above an income threshold. Of course catastrophic insurance would be necessary. Let individuals and doctors determine health care options - not insurance companies or government. This system would ensure everyone can afford health care. And free markets will work to provide adequate supply of health care services. And rebates of unused money in an individual account would promote healthier lifestyles.

[acerimusdux]

I have seen no evidence of any difference in willingness to implement a plan. I do see some difference in the practical ability to do so.

The biggest difference in the two plans has been over the issue of individual mandates. Hillary argues that forcing those who don't want coverage to buy it makes it a bit less expensive for everyone else. It is plain from the research, however, that it is less costly to cover these individuals because on average they are less likely to use these health services. Those who would refuse coverage tend to be younger and healthier.

Of course things are a bit less expensive when we have others pay for them for us, but perhaps we also ought to sometimes consider the cost to our liberty of such proposals. Here, it is not even a case of those who can afford subsidizing those who can't; it is as likely to be the young and poor subsidizing the old and rich.

I do agree with the commentary above that Obama ought to clearly endorse automatic enrollment, while allowing the choice to opt out. This seems to be the best bet for a plan which both moves us very near to universal coverage, while avoiding a costly political fight over "mandates" which don't seem to add much in practice.

Other nations which have done mandates have already gotten to 97% coverage or better first. At that point they perhaps become more politically palatable. Fix the affordability problem first, and people will be less worried about mandates.

[kharris]

markg,

The problem with just about all proposals to fund public policy initiatives through tax credits is that many people don't pay taxes. Those at the low end of the earnings scale, or with no job at all, are left out when programs are funded through tax credits. If we tack on a publicly funded benefit to those at the lower end of things, that might help. Making the transition absolutely smooth, in a money-value sense, would avoid creating a disincentive to work (on the books) at the point at which the publicly funded benefit would fade.

[Mark]

Any "mandate" (e.g., auto or health insurance, ambient air emissions, etc.) without enforcement provisions is not a mandate but rather an exhortation.

[robertdfeinman]

For those interested in this topic over a more extended period, I suggest visiting health journalist Maggie Mahar's blog
http://www.healthbeatblog.org/

The entries posted go beyond discussions of the individual candidates proposals to the causes of our expensive system. As was pointed out above, the issue is not insurance, but care. The US provides worse care at higher cost than other industrialized countries, changing how premiums are collected will not get to the root of the problem.

The "American Prospect" magazine also has a special section devoted to health care in the current issue with contributions from many experts in the field.

Some problems which currently seem intractable include:
1. Excess profits by insurance companies
2. Over priced, patented, drugs
3. Misallocation of doctors into high priced fields rather than into family medicine and preventive care which are under compensated
4. Over treatment, especially when outcomes are not supported by evidence. Overuse of statins is a good example
5. Harmful lifestyles. Some estimates are that 40% of health problems could be prevented by living better
6. Corruption of the medical profession and basic R&D by payments from drug and medical equipment makers
7. Inadequate enforcement by a gutted FDA

I could go on, but you get the idea...

[Rate of Increase]

"Fix the afford-ability problem first..."

This is the one. My insurance premiums went up about 14% last year, 20% the year before, and 17% the previous 3 years. No wonder people are terrified of mandates, including employers. How many can afford these rates of increase? A mandate that everyone pay for something few can afford solves nothing. At least McCain offers to help citizens pay for it with tax credits, however inadequate that is. Democrats are doing their party no favor with their current strategy on this issue.

[OhNoNotAgain]

"A mandate that everyone pay for something few can afford solves nothing. At least McCain offers to help citizens pay for it with tax credits, however inadequate that is. Democrats are doing their party no favor with their current strategy on this issue."

You're not paying attention, or purposefully not understanding the proposals that are out there. A public plan will be offered to all people that don't have a plan through their employer, and it would be significantly cheaper due to the lower administrative overhead and not-for-profit aspect. Furthermore, I would assume that, at some point, a Democratic administration would have no problem allowing Medicare, or whatever the public plan is called, to negotiate with providers on behalf of its members. That is what will ultimately bring down the prices. So far, the health insurance companies, and this administration, have been content to just keep passing the costs on to the customers/members in the form of higher premiums.

[Rate of Increase]

"...it would be significantly cheaper due to the lower administrative overhead and not-for-profit aspect..."

Unfortunately, Medicare deals with the cost problem by mandating prices so low that providers lose money treating patients. Many doctors now refuse to accept any new Medicare patients. I find the prospect of having insurance that virtually no one will accept almost as unsettling as current rates of increase.

The few states that have adopted mandates/semi-mandates have found that insurance premiums are far higher than originally predicted. This is also unsettling. I hope you are right that the problem will be solved soon, but nothing said so far has inspired much confidence.

[Wags]

I would love a national healthcare plan but I am not naive. To make any National Healthcare plan work would require major salaries reductions for doctors, nurses, and people who work in that industry. You can state cut back Big HMOs salaries(agreed), but that won't even make much of a a dent. Non profit sounds great but look at the ramifications for the hundreds of thousands who work in the industry. In France Doctors and Nurses make so much less, in Germany Drs have, at times, gone on strike because they are not making enough. Don't think we have seen the end of that problem in Germany. Things like this take a long time to develop. Students make choices to be a doctor or a nurse, what happens know reflects in 10 years. Think about Doctors & Nurses taking a 30-50% pay reduction, politically are you kidding? HMOs came about for a reason, we never solved the problem of soaring Healthcare costs internally, we still haven't.

I want National Heathcare, but frankly I can't see it happening. I am all for some solution, believe me I understand the personal pain. However the only solution for me is to take care of myself. I am afraid we are 40 years too late. That ship sailed long ago. The best we can do is start balencing the budget and get our finanacial ship in order, then maybe re-visit it.

If someone has better idea I am all for it, but it better be real, not just a get me elected campaign promise that no one will keep.

[Bruce Wilder]

To me, the politically disturbing thing about how similar the Democratic candidate plans are is how little discussion ensues about alternative architectures for health care.

My own view is that health care costs are the core issue. Mandating and subsidizing insurance is, at best, a band-aid, and at worst, bleeding with leeches.

A Mandate without a generous subsidy is going to be a cruel joke for many of the uninsured. The uninsured are composed of various populations, including those with existing, costly conditions, and the young-and-healthy-but-not-able-or-eager-to-take-on-a-five-figure-expense, as well as a lot of marginal people, who are not going to be easy to find, let alone enroll.

We need substantial tax-financing, in place of the employer-based system. And, we need some radical cost-control measures that are not based on some fantasy version of consumer sovereignty. But, we are quibbling over mandates.

We are not going to get out Iraq by obliterating Iran.

We are not going to solve the problems of peak oil and global warming and a chronic trade deficit with an 19 cent tax holiday for oil companies.

And, mandates are not going to solve our health care problems, or make it any easier to enact comprehensive reform.

[anne]

Oh No:

"A public plan will be offered to all people that don't have a plan through their employer, and it would be significantly cheaper due to the lower administrative overhead and not-for-profit aspect. Furthermore, I would assume that, at some point, a Democratic administration would have no problem allowing Medicare, or whatever the public plan is called, to negotiate with providers on behalf of its members. That is what will ultimately bring down the prices. So far, the health insurance companies, and this administration, have been content to just keep passing the costs on to the customers/members in the form of higher premiums."

Precisely.

[OhNoNotAgain]

"Unfortunately, Medicare deals with the cost problem by mandating prices so low that providers lose money treating patients. Many doctors now refuse to accept any new Medicare patients. I find the prospect of having insurance that virtually no one will accept almost as unsettling as current rates of increase."

Well, I'm for universal coverage from the get-go, so I do understand that anything that doesn't start there is going to be chock full of problems that can't be addressed in any other fashion. As someone else has said, doctors and other healthcare providers are going to have to take a big pay-cut, for starters. There's no other way around it, and frankly I really don't have a lot of sympathy for someone that is complaining about *only* making 70-80 grand a year instead of 200+. One way to make it more palatable might be to subsidize med school educations and provide tax credits for those that have already shelled out for their educations. We're going to have to get really creative and try to learn from others like Germany, UK, Taiwan, Switzerland, and Japan that have gone through this.

[Nick]

Why is it that people always think that something they want to do will have different outcomes than every other person who has done that thing? Like housing: "it's going to go up forever, it's a new and different situation". Or the stock market: "we're in a new market era, P/E of 100 is the new normal forever". Or socialism: "when the government is running it, it will cost less because it's not for profit". Or "progressive" taxation: "it won't hurt anything to just tax the rich people more this time". Or government interference in markets: "a government mandate will reduce costs and not harm quality this time".

Is it some psychological flaw in the human brain which causes people to believe these things, over and over, in various forms, with no historical precedent to justify the beliefs? Are some people just wired to think that way? Is there any way we can prevent those people from contributing their destructive influence to our society? Is our education system falling down on teaching critical thought?

Maybe we should think about solving that problem, before we go on another misguided crusade of idiocy destined to leave us worse off than we currently are, eg: socialized health care... just a thought.

[save_the_rustbelt]

"...it would be significantly cheaper due to the lower administrative overhead and not-for-profit aspect..."

There is little evidence to suggest this is true.

Physicians do not acutally lose money on Medicare patients, they just have a lower margin. Very few physicians actually understand their cost structure, a problem I work tirelessly to correct.

[Cynthia]

Anyone with just one remaining brain cell oughta realize that McCain's tax credit for health care will only add to the sickness of our healthcare system.

McCain's way of fixing health care is nothing more than a supply-side tactic to keep not just wealth (but also health) concentrated in the hands of the very few!

Oh, it just sickens me to no end how GOPers are smelling more and more rotten each day like a bunch of banana republicans!

[anne]

Over and over, the point of the comments seems to be to make sure there will be no universal health care. Tens of millions will continue with no insurance, health care deficiencies will become an increasing problem for young and old, and we will be unique among developed countries in denying what is a basic right, a human right, to so many we care nothing at all about. But, we are becoming increasingly practiced in not caring for others.

[anne]

"As someone else has said, doctors and other healthcare providers are going to have to take a big pay-cut, for starters."

Rubbish, but do continue to undermine any hope for universal health care; for starters.

[OhNoNotAgain]

"Maybe we should think about solving that problem, before we go on another misguided crusade of idiocy destined to leave us worse off than we currently are, eg: socialized health care... just a thought."

Other countries have already done the homework, and are much better off because of it (6-7% GDP less than us). The fact that you choose to ignore this empirical evidence is more indicative of a political bent than the merits of such a system.

[anne]

Cynthia:

"Anyone with just one remaining brain cell oughta realize that McCain's tax credit for health care will only add to the sickness of our healthcare system."

Simple, but the point is to be sure to deny that what is a basic right is a right at all. For Republicans, health care is no right of ours. So rising infant mortality may be sad, but no concern beyond sadness. Shortening life spans of poorer women may be sad, but no human rights matter.

[don]

The biggest problem with public health care, it seems to me, is the difficulty in aligning incentives. Patients should weigh costs against benefits so they don't order more in medical treatment than the cost warrants. However, what if someone cannot pay? We believe they should nevertheless have access to medical care. But if those who can't pay are given access to free or highly subsidized care, they face inappropriate incentives to use scarce medical resources, just as subsidized, cheap gas encourages overconsumption of gasoline. The larger the portion of the market facing inappropriate incentives, the greater the waste, until the point is reached where nonprice rationing is the only viable alternative.

"Everyone should have access to 'adequate' medical care. It is a basic essential that no one should be denied." Sounds good, doesn't it? So does "To each according to his needs, from each according to his abilities." But economics is a stern arbiter that has little patience with such ideologies. So now, we have some people going to the doctor for ordinary colds, while costs prevent some children with more pressing needs from getting medical care. Would we do better with nurses triaging all requests for medical services?

[OhNoNotAgain]

"There is little evidence to suggest this is true."

Links please. Everything I've read indicates this is the case. And the only thing I've seen in opposition amounts to quibbling, like saying that Medicare administrative costs don't take into account premium collection via taxes. Of course it doesn't - the IRS collects taxes for all government agencies and therefore Medicare is not adding any further administrative costs to something that already exists, whereas private insurance has to replicate the premium collection over and over again for each insurer. In trying to make a case for more administrative costs for Medicare, they're actually making the opposite case.

[OhNoNotAgain]

"Rubbish, but do continue to undermine any hope for universal health care; for starters."

Well, it's true. If the government starts to negotiate prices on behalf of its constituents, then doctor services are going to be negotiated down also, meaning less profit for the doctors. I don't have any problem with that, and neither should the doctors. Either way, their salaries are going down. Either the customers can't afford to pay the prices anymore and stop showing up, or the government negotiates them down. Those are the two options at this point, because I don't see wages for the general population increasing enough any time soon to cover the shortfall.

The doctors are simply going to have to reign in costs like everyone else has to. For starters, stop paying exhorbitant rents to developers by locating their offices in glorified "medical" office parks, go back to using old residential houses, etc. with very low overhead, automate their systems further, add value to their services with house calls, etc., and on and on. What we've had over the last 30 years is basically a protectionist racket that benefits the doctors and skewers everyone else.

[OhNoNotAgain]

"So now, we have some people going to the doctor for ordinary colds, while costs prevent some children with more pressing needs from getting medical care. Would we do better with nurses triaging all requests for medical services?"

Go watch the PBS Frontline special on healthcare in other countries:

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

Japan uses its healthcare facilities *much* more than the US, yet still has lower healthcare expenditures as a percentage of GDP. And many of the healthcare systems like Japan's do not use "gatekeepers" to triage patients. You can go directly to a specialist without consulting a GP.

[anne]

"Patients should weigh costs against benefits so they don't order more in medical treatment than the cost warrants."

The new and improved immoralism, but the immoralists are definitely winning. All that can be done is to point out the impossible meanness, I suppose.

[anne]

http://www.nytimes.com/2008/04/27/weekinreview/27sack.html

April 27, 2008

The Short End of the Longer Life
By KEVIN SACK

THROUGHOUT the 20th century, it was an American birthright that each generation would live longer than the last. Year after year, almost without exception, the anticipated life span of the average American rose inexorably, to 78 years in 2005 from 61 years in 1933, when comprehensive data first became available.

But new research shows that those reassuring nationwide gains mask a darker and more complex reality. A pair of reports out this month affirm that the rising tide of American health is not lifting all boats, and that there are widening gaps in life expectancy based on the interwoven variables of income, race, sex, education and geography.

The new research adds weight to the political construct popularized by former Senator John Edwards of North Carolina, that there are two Americas (if not more), measured not only by wealth but also by health, and that the poles are growing farther apart.

The most startling evidence came last week in a government-sponsored study by Harvard researchers who found that life expectancy actually declined in a substantial number of counties from 1983 to 1999, particularly for women. Most of the counties with declines are in the Deep South, along the Mississippi River, and in Appalachia, as well as in the southern Plains and Texas.

The study, published in the journal PLoS Medicine, concluded that the progress made in reducing deaths from cardiovascular disease, thanks to new drugs, procedures and prevention, began to level off in those years. Those gains, as they shrank, were outpaced by rising mortality from lung cancer, chronic obstructive pulmonary disease and diabetes....

"Some people are actually sinking," said Majid Ezzati, one of the report's authors. "The line of excuse that we can live with inequality as long as no one is getting worse is just no longer there."

The researchers found statistically significant declines for women in 180 of the 3,141 counties in the United States and in 11 counties for men. In an additional 783 counties for women and 48 for men, there were declines that did not reach the threshold of statistical significance.

Of particular concern is that the gap in life expectancy between top and bottom counties expanded by two years for men and by about 10 months for women. In the worst-performing counties, all in southwestern Virginia, the drop in life expectancy over the 16-year period was nearly six years for women and two and a half years for men....

[anne]

http://www.nytimes.com/2008/04/22/health/research/22life.html

April 22, 2008

Life Expectancy Is Declining in Some Pockets of the Country
By NICHOLAS BAKALAR

Life expectancy has long been growing steadily for most Americans. But it has not for a significant minority, according to a new study, which finds a growing disparity in mortality depending on race, income and geography.

The study, published Monday in the online journal PLoS, analyzed life expectancy in all 3,141 counties in the United States from 1961 to 1999, the latest year for which complete data have been released by the National Center for Health Statistics. Although life span has generally increased since 1961, the authors reported, it began to level off or even decline in the 1980s for 4 percent of men and 19 percent of women.

"It's very troubling that there are parts of the wealthiest country in the world, with the highest health spending in the world, where health is getting worse," said Majid Ezzati, the lead author and an associate professor of international health at Harvard. It is a phenomenon, he added, "unheard of in any other developed country."

Counties with significant declines were concentrated in Appalachia, the Southeast, Texas, the southern Midwest and along the Mississippi River. Life expectancy increases were mainly in the Northeast and on the Pacific Coast.

The researchers also compared the 2.5 percent of counties with the lowest life expectancies and the 2.5 percent with the highest. The disparity between those two groups rose to 11 years for men in 1999, from 9 years in 1983, and to 7.5 years from 6.7 in women.

The study found that from 1961 to 1983, there was little difference in average income for the counties where life expectancy rose at rates above and below the mean. But after 1983, life span rose with wealth. Race may also be a factor. In counties where life expectancy declined, the proportion of African-Americans was higher.

From 1961 to 1983, no county had a statistically significant decline in life expectancy, and reductions in cardiovascular disease led to a generally increasing length of life for both sexes. But after 1983, life expectancy declined an average of 1.3 years in 11 counties for men, and in 180 counties for women....

[anne]

http://www.nytimes.com/2008/03/23/us/23health.html

March 23, 2008

Gap in Life Expectancy Widens for the Nation
By ROBERT PEAR

WASHINGTON — New government research has found "large and growing" disparities in life expectancy for richer and poorer Americans, paralleling the growth of income inequality in the last two decades....

One of the researchers, Gopal K. Singh, a demographer at the Department of Health and Human Services, said "the growing inequalities in life expectancy" mirrored trends in infant mortality and in death from heart disease and certain cancers....

Dr. Singh said last week that federal officials had found "widening socioeconomic inequalities in life expectancy" at birth and at every age level....

[anne]

http://www.nytimes.com/2007/04/22/health/22infant.html

April 22, 2007

In Turnabout, Infant Deaths Climb in South
By ERIK ECKHOLM

HOLLANDALE, Miss. — For decades, Mississippi and neighboring states with large black populations and expanses of enduring poverty made steady progress in reducing infant death. But, in what health experts call an ominous portent, progress has stalled and in recent years the death rate has risen in Mississippi and several other states.

The setbacks have raised questions about the impact of cuts in welfare and Medicaid and of poor access to doctors....

"I don't think the rise is a fluke, and it's a disturbing trend, not only in Mississippi but throughout the Southeast," said Dr. Christina Glick, a neonatologist in Jackson, Miss., and past president of the National Perinatal Association.

To the shock of Mississippi officials, who in 2004 had seen the infant mortality rate — defined as deaths by the age of 1 year per thousand live births — fall to 9.7, the rate jumped sharply in 2005, to 11.4. The national average in 2003, the last year for which data have been compiled, was 6.9. Smaller rises also occurred in 2005 in Alabama, North Carolina and Tennessee. Louisiana and South Carolina saw rises in 2004 and have not yet reported on 2005.

Whether the rises continue or not, federal officials say, rates have stagnated in the Deep South at levels well above the national average.

Most striking, here and throughout the country, is the large racial disparity. In Mississippi, infant deaths among blacks rose to 17 per thousand births in 2005 from 14.2 per thousand in 2004, while those among whites rose to 6.6 per thousand from 6.1. (The national average in 2003 was 5.7 for whites and 14.0 for blacks.)

The overall jump in Mississippi meant that 65 more babies died in 2005 than in the previous year, for a total of 481....

[anne]

http://delong.typepad.com/sdj/2007/04/falling_indicat.html

April 23, 2007

Falling Indicators of Human Development in Mississippi
By Brad DeLong

There are 2.8 million people in Mississippi. About 15% of the non-elderly population--make that 350,000--were on Medicaid.

Cut Medicaid enrollments by 50,000, by 1/7.

42,000 babies born in Mississippi each year.

For the share who die to jump from 0.97% to 1.14%... That's a less than 1/3000 chance.

That's worth saying.

[Patricia Shannon]

Nick says...

Why is it that people always think that something they want to do will have different outcomes than every other person who has done that thing?

I'm sure it's just an accident that you overlooked such things as lack of regulation of business leading to medicines that don't work or even kill patients, pollution that causes brain damage and cancer, skipping of plane inspections to save money, unsafe cars, rivers so polluted they catch fire, etc., etc., etc.

[anne]

Not to worry though, Congress is even now readying another $178 billion appropriation for the war in Iraq. * Of course, spending $7 billion to protect the health of 3.8 million needy children has been proven too much, but I think if we can teach parents to take kiddies to the doctor less often, simply teaching them the value in suffering quietly, all will be well.

* http://www.democracynow.org/2008/4/29/headlines#2

[OhNoNotAgain]

"Not to worry though, Congress is even now readying another $178 billion appropriation for the war in Iraq. * Of course, spending $7 billion to protect the health of 3.8 million needy children has been proven too much, but I think if we can teach parents to take kiddies to the doctor less often, simply teaching them the value in suffering quietly, all will be well."

Depressing, isn't it ? The wife and I had a "Bring our Troops Home, Vote for Kerry" sign on our front lawn back in 2004, and it was vandalized once and finally stolen. I'm doubtful that those that were responsible have reconsidered their opinions. It's all about "the team" with some people.

And imagine how depressing it must be for those in needy countries that used to look to the US as their salvation in times of need. We can't even take care of our own people anymore.

[anne]

"And imagine how depressing it must be for those in needy countries that used to look to the US as their salvation in times of need. We can't even take care of our own people anymore."

Agreed completely; darn.

[hari]

It is amazing the amount of time and energy you guys waste on a subject which has been more or less - from a policy framework perspective - established inside EU.

Why does one need to (always) reinvent an American *brand* when there are *reliable* and *tested* empirical brands in opeation - administratively advanced - in OECD countries.

[OhNoNotAgain]

"Why does one need to (always) reinvent an American *brand* when there are *reliable* and *tested* empirical brands in opeation - administratively advanced - in OECD countries."

Because a small portion of our population has hijacked the discourse and convinced a larger portion of our population that our government cannot do anything worthwhile and should be dismantled. Although, recently it looks like these same people are starting to regret buying into that snake oil, so hopefully we're on the brink of some changes for the good.

[JRossi]

Ohnonotagain,
As a family doc, I can tell you your idea of paying docs 70-80k per year is way off base, at least if you actually want to have docs, as opposed to mid-level providers. We're currently recruiting for a physician assistant ( 6 yrs education after high school)--salary 65k for 9 months work per year. My brother-in-law is an electrical engineer with an MBA (6 years edafter hs) and he earns 85k. My sister-in-law has a master's in biomed engineering (6 years ed after hs) and earns 90k. An board-certified MD has a minimum of 11 years of ed after hs as well as a much more difficult work environment. And, on average, med students have higher academic abilities and qualifications than the others above. How are you going to attract them at 70-80k per year when the average salary now for the lowest-paid primary care specialties is 160k per year and there's a shortage? Absurd. Primary care salaries need to go up, not down. And don't give me that nonsense about opening to borders to foreign docs. It's already being done.
That said, some specialties are probably overpaid in the sense that you could likely get docs to do the work for less. Dermatology and radiology come to mind.

[JRossi]

I second robertfeinman's suggestion about going to healthbeatblog. Maggie Mahar is definitely worth reading on health care.

[OhNoNotAgain]

"As a family doc, I can tell you your idea of paying docs 70-80k per year is way off base, at least if you actually want to have docs, as opposed to mid-level providers."

I just threw that figure out there without really looking into it too much, so my apologies for confusing the issue with an un-researched figure.

However, my point still stands. Many other highly-educated occupations in the US have had to deal with global wage pressures, and those in the medical profession have, for the most part, not been subject to these same pressures.

And, as I said, there may be ways of compensating doctors in ways that are "non-traditional", such as a free or subsidized education.

[acerimusdux]

I have no objection in principle to markg's health care spending accounts suggestion, but it does very little to address the overall problem. The problem with solutions that depend entirely on the unregulated free market, is that this is mostly what we are doing now and it isn't working. I have no objections to using market based incentives where practical, but in some places more significant intervention is clearly needed to address market inefficiencies.

One common market failure in health care is that most patients lack the expertise to make rational buying decisions on their own. Free market efficiency depends on an arms length transaction between equally informed parties. We rarely get this in health care. Without some guidance, patients on their own would be inclined to spend too little on preventive care, and too much on expensive brand name treatments aggressively marketed to doctors by pharmaceutical companies.

I think Don is correct that "Patients should weigh costs against benefits so they don't order more in medical treatment than the cost warrants" (and I'm not sure I understand why Anne finds this "immoral"). But they don't always do a good job of this without help. I think we should look to the French model here, which has done a very good job of creating the proper incentives by fully reimbursing the most cost effective treatments and drugs, and providing lesser reimbursement for less effective treatments.

I agree with Bruce that "We need substantial tax-financing, in place of the employer-based system." Shifting cost mandates onto employers doesn't seem to improve efficiency any. I would like to see taxation financing of a medicare like system providing at least most basic health care, preventive care, and catastrophic care.

I would also alter medicare, and the new system, so that reimbursements are paid to the patient rather than the provider. This gives the patient more incentive to control costs, but at the same time the freedom to see any doctor desired. Reimbursements would be at a scheduled rate, but the patient is free to choose to spend her or his own money in addition if desired.

If you now add those medical spending accounts on top of this, maybe they would be useful. Patients could make payments out of these counts and get reimbursements paid into them.

[JRossi]

Ohnonotagain, Well, of course MDs haven't been subjected to the same wage pressures as, say, software engineers. Medical services are local, fer krissakes! You gotta be there, man, just like the plumber. This is pretty basic stuff, bud. Do yourself a favor and spend some time at Mahar's blog.

[OhNoNotAgain]

"Ohnonotagain, Well, of course MDs haven't been subjected to the same wage pressures as, say, software engineers. Medical services are local, fer krissakes! You gotta be there, man, just like the plumber. This is pretty basic stuff, bud."

I understand that very simple point very well, thank you. However, you're missing my point, which is that this fact is causing a disparity in what doctors are earning vs. what the patients can actually afford to spend. Any way you slice it, the plumber and the doctor are going to see their earnings go down, either by losing customers or by having to finally cut their fees to adjust to the realities of the situation. In recent years people have been able to use debt to "cover the spread". That money spigot is now gone, and all of the "local trades" are going to start feeling the pinch also. You're seeing the beginning of it right now with reports that healthcare insurers are losing customers by the thousands. I've personally had to do it with my business and move from a normal plan to a high-deductible plan. In other words, myself and my employees won't be seeing the doctor unless it is absolutely necessary, and we will be paying out of pocket to do so.

[mik]

Primary care salaries need to go up, not down. And don't give me that nonsense about opening to borders to foreign docs. It's already being done.

You do know that French health system is rated superior to ours (US) in virtually all ratings?
By all indications French docs on average are just as good as their US counterparts. It certainly was my experience.

French docs make about $55K/year (www.businessweek.com/magazine/content/07_28/b4042070.htm) and largely OK with that.

Was it in constitution somewhere that says that US docs must make much more money than any other docs on the planet?

[JRossi]

mik, I think you have the constitution confused with the forces of supply and demand. Re: the French experience, cultures differ, my friend, cultures differ. It would be great for pts and payers if we could get docs to work in this country for 55k, but we can't, and wishing that we could won't make it so. In the English NHS GPs earn 200k( admittedly at current exchange rates )per year, so there is a least one other place on the planet where generalists earn more. I don't know what specialists earn there.
I'm not saying that docs here are not overpaid. I think many are. I am saying that 70-80k per year is not realistic in the US.

[robertdfeinman]

Doctors might be willing to earn less if there were compensating adjustments. Three of the most obvious are making medical school (and perhaps all higher education) free as in many European countries. Next change the liability system so that insurance is not so burdensome and compensation for malpractice can be dealt with more efficiency. I expect some combination of impartial arbitration and tort reform. Finally remove record keeping and chasing after payment from private insurance companies out of doctor's offices.

There is nothing wrong with the average family doctor making $200K per year. In my neighborhood policemen make $100K. Beginning lawyers on Wall Street commonly make $140K. If you feel doctors earn too much then you need to look at compensation in the rest of society. The former head of United Health made $1.3 billion. Fix that and we can start to worry about doctor's earnings.

[OhNoNotAgain]

"There is nothing wrong with the average family doctor making $200K per year. In my neighborhood policemen make $100K. Beginning lawyers on Wall Street commonly make $140K. If you feel doctors earn too much then you need to look at compensation in the rest of society. The former head of United Health made $1.3 billion. Fix that and we can start to worry about doctor's earnings."

For the record, I don't personally begrudge anyone the ability to make as much as they can, especially doctors. I want the best and brightest advising and treating me, and fabulous pay is usually, but not always, a good incentive.

My point in the comments has, and will always will be, that the current trend in the wages of health professionals is unsustainable given the wage situation in the US general population. However, I do wholeheartedly agree that the first place to start cutting would be exactly where you state.

[don]

Anne:

"Japan uses its healthcare facilities *much* more than the US, yet still has lower healthcare expenditures as a percentage of GDP.

The second part of the sentence directly contradicts the first, unless you are arguing that U.S. services are overpriced. Could that be partly a result of services provided to people who have no incentive to monitor costs?

"'Patients should weigh costs against benefits so they don't order more in medical treatment than the cost warrants.'
The new and improved immoralism, but the immoralists are definitely winning. All that can be done is to point out the impossible meanness, I suppose."

Unfortunately, attempts to resist the fundamental principles set forth by Adam Smith usually result in even greater meanness.

[Patricia Shannon]

I have noticed that comparisons of money between countries are often not reflective of the reality of the cost of living.
Eg., if you live in a country where most people have a garden where they grow much of there food, or if they have nationalized health care, they don't need as much money for the same "quality of life". And definitions of "quality of life" often don't count important factors such as leisure time and time for close personal relationships.

[OhNoNotAgain]

"The second part of the sentence directly contradicts the first, unless you are arguing that U.S. services are overpriced."

I'm saying that the Japanese people use their health care facilities at a higher rate than the US, yet still manage to spend a lot less than us. And yes, the natural conclusion to draw is that our health care is way overpriced.

"Unfortunately, attempts to resist the fundamental principles set forth by Adam Smith usually result in even greater meanness."

Please. Adam Smith would be considered a socialist by today's standards - progressive taxation anyone ?

[Patricia Shannon]

Maybe the Japanese get problems diagnosed and treated at an earlier stage because they use their health care facilities at a higher rate than the US. Eg., I'm sure it costs a lot less to treat high blood pressure than to leave it untreated, and have to pay for the care for a heart attack or stroke.

says...

Universal health care will be awesome. All the libs can go stand in line like the post office and get treated by doctors making 80k a year with their community college medical degrees and the rich republicans will be getting gold plated med care from doctors that have set up practices for non-government plans.

The usual morons on this blog will be blogging in 10 years about Medical Inequality.

Welcome to the medical equivalent of Amtrak.

Take care of your self and your family. Get rid of the cell phone, the cable, and the two car payments and buy your own insurance like an adult is suppose to do.

You people are like a bunch of spoiled teenagers bitching about what mommy and daddy don't buy you.

[mik]

It would be great for pts and payers if we could get docs to work in this country for 55k, but we can't, and wishing that we could won't make it so.

Plenty of, many probably are mediocre, docs from around of world would gladly come and work for $50K/y.

How about increasing number of med schools in US and increasing numb of slots in existing schools?

How about removing guild priviledges American Med Ass has in licensing and control of doctors supply?

I'm all for free market setting wages, but health care is a strange market where supplier (doctor) decides how much service a customer (patient) will get and payer will have to pay for.

Imagine retail car business run this way. All buyers would end up with cars loaded with all available extras.

[BJ Feng]

And would you complain when those mediocre doctors screw up more often? Of course that'll be the perfect time to whine about "two health care systems" as one of the posters above alluded to.

The market for doctors is no different than that for lawyers, or anyone else requiring some level of competence. Get rid fo the AMA? Fine, but then I'm sure there'll be more calls demanding for patient protection and the guarantee of good service. You want a government entity instead? I'm not sure how they would do better, plus they would likely cost a lot more.

It takes years of training and skill to become a doctor, these people have to be compensated, or else they'll choose another profession, you can't get around that. If you'd settle for lower quality, then fine, but don't pretend that the problem can be solved by artificially reducing doctors' pay.

The inconvenient truth is that services and goods have to be paid for by someone in the real world. So these fantasy solutions just aren't going to work no matter how much you want them to. I'm reminded of a situation where an adult has to tell a child to stop crying and whining because their demands aren't reasonable and they can't get what they want.

What's scary is that the posters on this board actually try to come up with real arguments and solutions. They seem to be intelligent. Yet no one can come up with an universal health care proposal that will work when examined closely. That speaks for itself.

[BJ Feng]

"Next change the liability system so that insurance is not so burdensome and compensation for malpractice can be dealt with more efficiency"

I believe this is the one statement we all have agreed on in the past. Incredible how every attempt to limit the liability doctors face has been defeated in Congress thanks to the lawyers' lobby, and we all know which party has the support of trial lawyers and their association. Where is the outrage?

[anne]

"What's scary is that the posters on this board actually try to come up with real arguments and solutions. They seem to be intelligent. Yet no one can come up with an universal health care proposal that will work when examined closely."

Lie, lie, lie, lie, lie; scary monster.

[anne]

"Incredible how every attempt to limit the liability doctors face has been defeated in Congress thanks to the lawyers' lobby, and we all know which party has the support of trial lawyers and their association."

Lie, lie, lie, lie, lie; scary monster.

[anne]

http://select.nytimes.com/2007/02/09/opinion/09krugman.html

February 9, 2007

Edwards Gets It Right
By PAUL KRUGMAN

What a difference two years makes! At this point in 2005, the only question seemed to be how much of America's social insurance system — the triumvirate of Social Security, Medicare and Medicaid — the Bush administration would manage to dismantle. Now almost all prominent Democrats and quite a few Republicans pay at least lip service to calls for a major expansion of social insurance, in the form of universal health care.

But fine words, by themselves, mean nothing. Remember "compassionate conservatism?" I won't trust presidential candidates on health care unless they provide enough specifics to show both that they understand the issues, and that they're willing to face up to hard choices when necessary.

And former Senator John Edwards has just set a fine example.

At first glance, the Edwards health care plan looks similar to several other proposals out there, including one recently unveiled by Arnold Schwarzenegger in California. But a closer look reveals extra features in the Edwards plan that take it a lot closer to what the country really needs.

Like Mr. Schwarzenegger, Mr. Edwards sets out to cover the uninsured with a combination of regulation and financial aid. Right now, many people are uninsured because, as the Edwards press release puts it, insurance companies "game the system to cover only healthy people." So the Edwards plan, like Schwarzenegger's, imposes "community rating" on insurers, basically requiring them to sell insurance to everyone at the same price.

Many other people are uninsured because they simply can't afford the cost. So the Edwards plan, again like other proposals, offers financial aid to help lower-income families buy insurance. To pay for this aid, he proposes rolling back tax cuts for households with incomes over $200,000 a year.

Finally, some people try to save money by going without coverage, so if they get sick they end up in emergency rooms at public expense. Like other plans, the Edwards plan would "require all American residents to get insurance," and would require that all employers either provide insurance to their workers or pay a percentage of their payrolls into a government fund used to buy insurance.

But Mr. Edwards goes two steps further.

People who don't get insurance from their employers wouldn't have to deal individually with insurance companies: they'd purchase insurance through "Health Markets": government-run bodies negotiating with insurance companies on the public's behalf. People would, in effect, be buying insurance from the government, with only the business of paying medical bills — not the function of granting insurance in the first place — outsourced to private insurers.

Why is this such a good idea? As the Edwards press release points out, marketing and underwriting — the process of screening out high-risk clients — are responsible for two-thirds of insurance companies' overhead. With insurers selling to government-run Health Markets, not directly to individuals, most of these expenses should go away, making insurance considerably cheaper.

Better still, "Health Markets," the press release says, "will offer a choice between private insurers and a public insurance plan modeled after Medicare." This would offer a crucial degree of competition. The public insurance plan would almost certainly be cheaper than anything the private sector offers right now — after all, Medicare has very low overhead. Private insurers would either have to match the public plan's low premiums, or lose the competition.

And Mr. Edwards is O.K. with that. "Over time," the press release says, "the system may evolve toward a single-payer approach if individuals and businesses prefer the public plan."

So this is a smart, serious proposal. It addresses both the problem of the uninsured and the waste and inefficiency of our fragmented insurance system....

[OhNoNotAgain]

"Yet no one can come up with an universal health care proposal that will work when examined closely."

There are several universal health care frameworks in place in modern, industrialized economies around the world (Germany, Japan, UK, France, Switzerland, Canada) and, horror of horrors, they actually work !!!! In fact, we're unique in that we're one of the few OECD countries that *doesn't* have universal health care. *We're* the oddball, not them, and it's all because of people like you that want to defend the broken, corrupt, and immoral system of health care that currently exists here.

[anne]

Oh No:

"There are several * universal health care frameworks in place in modern, industrialized economies around the world (Germany, Japan, UK, France, Switzerland, Canada) and, horror of horrors, they actually work !!!!"

* Many.

[acerimusdux]

The problem with changing the liability system so that malpractice compensation is dealt with more efficiently, is that any truly fair and efficient system is likely to be more costly than what we have now.

Under the current system, only 1 in 8 patients who are injured through medical negligence file claims, and only 1 in 16 receive any compensation through litigation. link

So, while a system of no-fault malpractice insurance might be a good idea (and one which trial lawyers might oppose), any efforts to reform the existing tort system should probably be directed first at improving (rather than limiting) access and responsiveness to those who have actually suffered injury.

[anne]

Interesting:

http://query.nytimes.com/gst/fullpage.html?res=9C0CEFDE1E30F932A35750C0A966958260

March 1, 1990

No-Fault for Doctors Is Called Feasible
By KEVIN SACK

A system of no-fault medical malpractice insurance, which would compensate victims of medical injury without a judicial finding of negligence, would not cost significantly more than the existing liability system, according to a state-sponsored study of malpractice in New York hospitals that was released yesterday.

The study projects that a no-fault system in New York State would cost a little more than $1 billion, approximately the same amount currently being spent by New York doctors and hospitals for malpractice insurance premiums.

The study conducted by a team of Harvard University researchers is considered by health-policy experts to be the most thorough survey of malpractice conducted in the nation.

It also concludes that the incidence of negligence in public hospitals is 50 percent higher than in private nonprofit hospitals and three times higher than in for-profit hospitals.

The researchers speculated that the severity and complexity of cases at public hospitals, where illness is often complicated by drug abuse, AIDS and poverty, increases the likelihood of negligence.

Some preliminary results from the study, including the rates of injury and negligence, were reported by news organizations in late January. But additional results were released yesterday, including the conclusions about the cost of a no-fault malpractice system and the comparative rates of negligence at different hospitals....

The study, which analyzed the cases of 31,429 patients at 51 hospitals, found that eight times more patients suffered an injury because of medical negligence than filed malpractice claims and that 16 times as many suffered negligence than received compensation through litigation.